Professor Clement Alfred Finch: hematologist, humanist, and mentor for many (July 4, 1915 - June 28, 2010)

Clement Alfred Finch was a physician, researcher and educator who helped advance the scientific basis and practices of diagnosis and treatment of anemia since the time when little was known about the disease. He was born in New York, USA and graduated from medical school in 1941. He had a 60-year tenure at the University of Washington and published extensively (more than 30) scholarly articles and close to 30 key reviews). He was instrumental in collaborating with key Thai hematologists, particularly at the premier Siriraj Medical School. His contribution on iron metabolization in the bloodstream has been a corner stone of hematology. It included seminalresearch which led to the widespread supplementation with iron in diets by women to avoid iron deficiency anemia.

The “Yellow Rain” controversy: are there lessons from the past?

A quarter century has passed since the “Yellow Rain” biological warfare controversy in Southeast Asia had become a major news item worldwide. The debate whether or not a biological warfare weapon was used at that time has never abated and was the subject of a recent PhD thesis. Starting in the late 1970’s, persistent reports of chemical attacks appeared originating from Hmong resistance forces in Laos fighting the Vietnamese and Pathet Lao forces. Soon, similar reports came from the Khmer Rouge as well as from the anti-communist Khmer Peoples National Liberation Front who also were engaging the Vietnamese army as well as the Khmer Rouge. The Soviet-backed Vietnamese army was held responsible for use of chemical and/or biological agents. Attacks were said to be in the form of gas or “yellow rain”-like toxic spray delivered by aircraft or artillery. Many rapid and more delayed deaths of domestic animals as well as humans were said to have resulted. The initial reports were in the form of interviews of refugees, usually originating from relief workers, missionaries and international news-service reporters. No reliable witness interrogation by professionals or forensic laboratory investigation was conducted and no “smoking gun” was found. Much of this seemed a repetition of similar accusations directed previously at the Soviets in Afghanistan. It was similar to what the US had been accused of during the Korean War and reminiscent of the more recent accusations against Saddam Hussein in Iraq which helped start the Iraq war. Chemical and biological weapons were banned by the Geneva Convention of 1925 which was signed by a majority of countries. It seems that this convention had been largely ignored. The author believes that valuable lessons can still be learned from reviewing these events.

Management of severe bites from orangutan (Pongo pygmaeus)

Background: Orangutans are critically endangered primates living in the shrinking virgin rainforests of Borneo and Sumatra. Two or more species of orangutan once inhabited a larger part of Southeast Asia. Attacks by these giants are extremely rare and we could not find any prior medical report of human injuries from an orangutan. This incident took place in Borneo in a primate rehabilitation station operated by Indonesian and international staff. Objective: This reports the management of severe bites by an orangutan.

Failures of post-exposure rabies prophylaxis

Rabies remains a public health problem in many developing and emerging countries. Virtually all is known in order to eliminate this scourge by controlling the disease in canine populations and by provision of WHO recommended postexposure prophylactic treatment. Nevertheless, true postexposure prophylactic failures do occur, though rarely. Most common are those due to deviations from WHO management recommendations and lack of quality biologicals. Presented are seven deaths where it appeared all was done according to current standards. Six additional examples of common management deviations that resulted in deaths are also shown. This is an uncomfortable topic which has received little attention at rabies conferences or in recent literature. However, each rabies post exposure prophylaxis [PEP] failure case may contain lessons that might be able to prevent new ones. Chulalongkorn University and the Thai Red Cross Society have had a long standing interest in rabies PEP failures but almost all that came to our earlier attention contained obvious defects in care1. It was in 1996 that we encountered the first case where all WHO recommendations had been carefully followed by experienced staff and yet the patient died of rabies 2. This is why this series of seven cases, of what appeared to be true PEP failures, are being presented. Each of these seven cases had what appeared excellent and prompt wound care, were administered immunoglobulin of equine [ERIG] or human [HRIG] origin at 40 IU/Kg or 20 IU/Kg respectively, and this was injected into and around the bite wounds. Six additional PEP failures with defects in management are also shown to demonstrate that much more educational efforts are needed to prevent more deaths

Rabies virus and pathogenesis of rabies

Despite increases in our understanding of rabies pathogenesis, it remains an inevitably fatal disease. Lack of awareness, low level of political commitment to rabies control, and failure to recognize and correlate clinical, laboratory, and neuroimaging features contribute to continuing deaths. Clinical symptomatology, once believed to be unique, may be variable, even in patients associated with lyssaviruses of the same genotype. This article discusses virus transport, the role of virus and host response mechanisms in relation to protean clinical manifestations, and mechanisms responsible for relative intactness of consciousness in human rabies. Differential involvement of the anterior horn cell in furious rabies and the peripheral nerve in paralytic rabies is summarized. Escape mechanisms from host defenses explain why a fatal outcome is unavoidable regardless of therapy. Neuroprotective treatment, using a coma-induction regimen, proves not to be beneficial. Survival of patients with excellent recovery relies on early innate and adaptive immunity plus adequate intensive care support

Microscopic diagnosis of rabies [Seller's stain compared with the fluorescent antibody test]

A retrospective study of 25,292 Sellers' stain and fluorescent antibody diagnoses of rabies revealed a sensitivity of 80.26% and specificity of 94.59% for the Sellers' stain compared with the fluorescent antibody technique. Several pitfalls in performing these tests have been pointed out. The fluorescent antibody staining method carried out by an experienced microscopist, using a high quality conjugate, should be the preferred method for laboratory diagnosis of rabies from neural tissue

Rabies in Asia: 2004

Rabies remains a public health problem in spite of the fact that we have the knowledge and tools to eliminate this disease as a human threat. Lack of motivation by governments, cultural issues and lack of funding are remaining barriers. This is amazing since the number of human rabies deaths worldwide is greater than that from polio, meningococcal meningitis, Japanese encephalitis, yellow fever, SARS, bird flu and other scourges that attract more public attention. Safe and effective tissue and avian culture vaccines are now widely available. Reduced dose WHO approved, effective and economical post-exposure treatment regimens have helped eliminate nerve tissue vaccines in Thailand, Philippines and Sri Lanka. Immediate wound cleansing and the use of a potent vaccine will save the majority of infected persons. Human or equine rabies immunoglobulin, injected into and around bite wounds, provides added safety for the severely exposed. The high cost of rabies biologicals is still a problem, but new manufacturers and the use of intradermal vaccination schedules should bring down expenses. Ultimately, it is the need to control rabies in dogs that should occupy most of our attention. Here, the tools are also available but attitudes must change before they can be applied. There have been many new developments since publication of the last WHO rabies expert committee report in 1992. This essay will review some that have practical applications