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May 21st, 2017

The Curious Case of M184V, Part 1

Thanks to our sophisticated research team here at NEJM Journal Watch, we have an excellent idea who reads this thing for its scintillating ID/HIV content.

Most of you are clinicians — doctors, nurses, PAs, PharmDs. A smaller proportion are researchers, lab-oriented types who wandered over here unexpectedly after an errant search, expecting the latest in CRISPR-Cas9 gene editing and instead getting an ID Link-o-Rama, a rumination on vintage medical photos, and a mysteriosis about listeriosis.

But another divider is whether you consider yourself an HIV specialist or not. A grab bag of ID (mostly), primary care, and other subspecialty clinicians, HIV specialists know and ruminate over lots of the same stuff even though there’s no formally designated HIV specialty by the American Board of Internal Medicine.

And today’s topic is most definitely an HIV-focused one, triggered by an email I received last week from one of my colleagues:

Subject: M184V

Paul,

What’s your go-to regimen in the setting of a solo M184V?

Jon

For the non-HIV specialist readers, allow me to decipher the code in the above question. “M184V” is the shorthand for methionine replacing valine at position 184 in reverse transcriptase. It is by far the most commonly encountered nucleoside reverse transcriptase inhibitor (NRTI) mutation after failure with regimens containing lamivudine (3TC) or emtricitabine (FTC).

And with that single paragraph, I’ve hinted why HIV drug resistance — and genotypes in particular — baffle some of even the most astute and brilliant ID clinicians. It’s like reading about the coagulation cascade or the complement system. You have to work with this stuff frequently to understand the lingo.

But for those seeing HIV patients on a regular basis (especially as outpatients), this question — what should be done after M184V? — is both quite relevant clinically and, surprisingly, not readily answerable from the literature.

Remember, M184V is a special mutation — it does some very weird things:

  • Viruses that harbor M184V don’t replicate well. In virology parlance, they’re “less fit.”
  • M184V causes marked phenotypic resistance to 3TC/FTC, but this doesn’t translate clinically. Or, to cite the invaluable Stanford HIV Drug Resistance Database, “M184V/I are selected by 3TC/FTC and reduce susceptibility to these drugs >100-fold.” For an analogy, think of high-level gentamicin resistance in an enterococcus isolate — but then ignore it and use gentamicin anyway. Because unlike these enterococci, where gentamicin would be useless, studies show that 3TC still exerts significant antiviral activity despite this loss of phenotypic activity. I’ve cited these studies before, but they deserve emphasis: Virologic rebound occurred after stopping 3TC in patients who already had developed M184V; and 3TC alone slowed CD4 decline more than no treatment despite M184V being present in all patients.
  • M184V influences the in vitro susceptibility of certain other NRTIs in a favorable way.  Yes, with M184V, susceptibility to tenofovir, zidovudine, and stavudine improves. In other words, an M184V containing virus is more susceptible to tenofovir than a wild-type virus, a phenomenon referred to as hypersusceptibility. Someone much smarter than I can explain the molecular mechanism of this phenomenon (it certainly won’t be me).

Because of these odd effects, and because both 3TC and FTC are so well tolerated, there’s a practice (not universally observed) of continuing 3TC or FTC even after M184V has been selected. But should this be done?

And with that background, let’s get back to the question in Jon’s email — what to do after M184V?

Imagine this case — a patient who failed a regimen of dual NRTIs plus an NNRTI (let’s say TDF/FTC/EFV) some time in the past. He had a genotype then showing M184V and K103N (conferring resistance to efavirenz), and then was lost to follow-up for a few years.

He now shows up saying he wants to start treatment again. Let’s give him a CD4 cell count of 250 and a viral load of 50,000. He of course wants as few side effects, and as few pills, as possible.

What would you choose as his antiretroviral regimen?

 

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May 14th, 2017

Poll: Which Feature of Electronic Health Records is Most Important to Patient Care?

The first electronic medical record I used regularly — called “BICS” — initially had one purpose. It was a tool to look up a patient’s lab results.

Simple, reliable, and blazingly fast, it did one thing remarkably well.

Later, one of our Emergency Department doctors, who happens to have impressive coding skills, worked with a team to add a simple ambulatory medical record (medications, allergies, a problem list, progress notes).

Soon after, they released an astonishingly efficient inpatient order entry system, one that relied on keyboard shortcuts. Use of the mouse was definitely for amateurs.

After a brief learning period that took the interns around a nanosecond, all the clinicians loved it. It was so popular that the medical housestaff even held a party in its honor, something they called “OlymBICS,” with teams competing to see who could enter orders the fastest.

Much of its success, I’d argue, had to do with the simplicity — it didn’t overreach. Today, of course, all the big EHRs (or EMRs, or whatever you want to call them) try to do all things for all people — doctors, nurses, patients, administrative staff. I wouldn’t be surprised if there are features for the hospital cafeteria and catering services.

And because the range of these activities is so broad, EHRs have become bloated, complex, and inefficient. The complexity steals attention away from our patients as we try to satisfy the insatiable screen, keyboard, and mouse.

There’s just so much to do (and so many opportunities to do it wrong), it’s hard to concentrate.

In a piece called “Death By A Thousand Clicks,” some local colleagues write the following:

It happens every day, in exam rooms across the country, something that would have been unthinkable 20 years ago: Doctors and nurses turn away from their patients and focus their attention elsewhere — on their computer screens … EMRs have become the bane of doctors and nurses everywhere. They are the medical equivalent of texting while driving, sucking the soul out of the practice of medicine while failing to improve care.

Yes, we all recognize that feeling!

These problems notwithstanding, it’s clear that not even the crankiest EHR critic would propose that we go back to the days of paper charts, radiology film libraries, or having to call the lab to get patient test results.

Part of what makes the problems with EHRs so frustrating is that there is so much potential for excellent, intuitive, and interoperative systems. EHRs already do some things very well indeed.

The British struggled when their EHRs went down in the recent WannaCry cyberattack, and not just because they were still using an unpatched version of Windows XP.

(XP? Seriously? Yikes.)

So to detail the EHR benefits, and in honor of BICS (may it R.I.P.), I list below several widely available EMR functions.

You, dear reader, will choose the one feature you would miss the most during patient care if it suddenly were no longer available. In the comments section, feel free to elaborate why you chose what you did.

And I’m pretty sure I can predict the loser of this poll.

What function of electronic medical records would you miss most if it were unavailable?

View Results

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May 7th, 2017

CRISPR and HIV “Cure,” Zinc for Colds, New AIDSInfo Site, CROI Dates, Vanco Pricing, and More: I Can’t Believe It’s May ID Link-o-Rama

A few Infectious Diseases/HIV items to consider as we wait (and keep waiting!) for the warm weather to arrive in chilly, and often wet, New England:

OK, now for a quick non-ID section:

Hey, I started with CRISPR/Cas9, so here’s the big finish. Take it away, A Capella Science!

 

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April 30th, 2017

Celebrating the Invaluable Knowledge and Expertise of ID Specialist PharmD’s

Since expression of gratitude makes you happier — hey, I read it on the internet — and whining does the reverse, I’ve decided to turn what was going to be a typical rant about dealing with insurance companies into an expression of thanks to a remarkable group of professionals.

Namely, the Doctors of Pharmacy (PharmD’s) who specialize in Infectious Diseases. About whom I am extremely, exceedingly grateful.

And I’m not alone in holding that view — you’ll find it’s universal among ID doctors who are lucky enough to work with one or more ID PharmD’s, whether it’s as part of an antibiotic stewardship program, an HIV or transplant clinic, or on the inpatient ID consultation service.

Although I could cite numerous examples of how the two primary ID PharmDs help us out (thank you Dave and Brandon!), here’s a recent case from my outpatient practice.

A patient of mine, receiving TAF/FTC, darunavir/cobicistat for HIV treatment, needed a nasal steroid inhaler for seasonal allergies. For the non-HIV specialists, recall that when inhaled, injectable, or even topical corticosteroids are given with these potent cytochrome p450 inhibitors, systemic levels of cortisol can dangerously increase.

Result:  Full-blown hypercortisolism (Cushing Syndrome), which usually takes months to resolve and can leave permanent damage. This ritonavir/cobicistat-inhaled steroid interaction is emphatically not one of those EHR alerts to ignore.

So this isn’t a simple matter of telling him to go grab whatever over-the-counter spray is on sale at his local CVS or Walgreens. As a result, I sent a prescription to his pharmacy for beclomethasone because it can be safely given without interacting with cobicistat or ritonavir.

Per his insurance pharmacy benefit manager, however, they wouldn’t cover the beclomethasone. They sent along an annoying notice about “formulary alternatives”, specifically:

… flunisolide spray, fluticasone spray [hey guys at insurance company, this is the WORST POSSIBLE SUGGESTION!], mometasone spray, or triamcinolone spray.

So what to do? Obviously fluticasone would be a terrible option. Furthermore, I’ve seen iatrogenic hypercortisolism several times after triamcinolone injections, so cross that one off the list too.

What about mometasone? UpToDate has an easy-to-use drug interaction program, and it showed no significant interaction. However, the invaluable University of Liverpool HIV Drug Interactions checker disagreed, and did so strongly (that’s their report to the right).

This left flunisolide, which for some reason isn’t listed on the Liverpool site. At this point, I needed help with determining whether flunisolide would be safe to administer with cobicistat. Cue up the query to our ID PharmD’s.

Shortly after sending an email, I received the following incredibly helpful response:

Hi Paul,
Beclomethasone is the only corticosteroid that has been shown to have no clinically significant interaction, likely due to the fact that it is not primarily metabolized by CYP3A4. Flunisolide is also not primarily metabolized by 3A4 and has similar physicochemical properties as beclomethasone (less systemic absorption and more highly protein bound) — here’s a good review. Theoretically it would have the lowest likelihood of an interaction out of the alternatives they recommended, but there are no studies or case reports of flunisolide use with ritonavir or cobicistat. If you decide to prescribe flunisolide, you could start at the initial dose of 2 sprays in each nostril BID, which is half of the maximum dose of 8 sprays in each nostril daily. Let me know if you have any further questions.
Brandon

Thank you, Brandon!

And to the other ID PharmD’s out there, thanks for the advice on the innumerable other drug interactions, for guidance on dosing in renal failure, for questions about formulations (about which doctors know shockingly little), for interpretation of voriconazole, vancomycin, and aminoglycoside levels, for researching adverse drug effects — and for the whole gamut of expertise you bring to our specialty.

 

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April 22nd, 2017

If United Airlines Ran Your Doctor’s Office Practice

Man Dragged from Doctor’s Office Exam Room; Investigation Ongoing

April 22, 2016

MIDDLETON, MINNESOTA — Mr. Thomas Anderson was scheduled to see Dr. Wilson Smith yesterday for evaluation of low back pain.

He left his appointment with considerably more than that.

In a bizarre series of events that Middleton law enforcement officials are still investigating, Anderson sustained facial injuries and bleeding when he was forcibly dragged out of Smith’s office by security guards when he refused to leave voluntarily.

Meanwhile, startled patients in the waiting room filmed the disturbing event on their cell phones. The videos were posted on Facebook and Twitter, quickly eliciting a chorus of outraged comments, all supporting Anderson’s right to stay.

“I’d been waiting for this appointment for weeks,” said Mr. Anderson from his hospital room, where he is being treated for facial injuries and a concussion. “They had already put me in the exam room, collected my co-pay, and asked me to change into this skimpy gown. No way I was going to leave.”

The problem began when Dr. Smith, who works for United All Life (UAL) Health Corporation, was contacted by the CEO of the company stating that four UAL employees needed to be seen urgently. But when Dr. Smith checked his afternoon schedule, he noted he was completely booked.

Based on policies outlined in a 5,000 word document that UAL patients sign when agreeing to care, the company has the right to deny services based on overbooking — or, in the case involving Anderson, when UAL employees require care.

The policy does say UAL must offer compensation to patients in exchange for being “bumped” from their scheduled visit. Three of Dr. Smith’s other patients agreed to reschedule their medical appointment when told they would receive a $25 Amazon gift card and a $10 discount at Panera (provided they spend at least $20 on food or beverages).

When Mr. Anderson refused the same offer, UAL upped the compensation to include 2 matinee passes to see Smurfs:  The Lost Village. “Those passes are good at any theater,” said Ms. Jenna Gormley, a spokesperson for UAL. “We take our company motto — ‘Get the Friendly Care of United’ — seriously.”

But Mr. Anderson, who is 66, said he had little interest in seeing the latest Smurfs movie and still refused to leave. That’s when Dr. Smith called the security guards, who made the term “bumped” literal.

Middleton law enforcement is now investigating the criteria UAL uses to choose which patients are to be “re-accommodated” under these circumstances.

Most of the other patients on Dr. Smith’s schedule that day had “Elite” status based on paying a higher fee at the time they booked their appointments. This payment allowed them to bring one item (such as a purse or a backpack) and a coat with them to the doctor’s office without incurring extra charges.

Elite patients also had access to more comfortable chairs in the waiting room. Mr. Anderson, who chose not to pay this fee, says he was told by Dr. Smith’s receptionist that he had to sit on a hard stool in the corner, face the wall, and put on an embarrassing hat.

When asked further about these policies, UAL’s Gormley responded, “At UAL, our first priority is always our patients’ safety.”

She then was completely unable to explain how this statement could possibly be true.

 

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April 16th, 2017

Mark Wainberg and the Enduring Importance of 3TC

Last week, the HIV/ID research world lost one of its leaders and pioneers when Dr. Mark Wainberg unexpectedly died. An astute, thoughtful virologist — and a warm, engaging person — he led the HIV research program at McGill University in Montreal for years, contributing to the field both through his research and patient advocacy. A strong voice in the effort to expand HIV therapy to Africa in the early 2000s, Mark was also a vocal critic of HIV denialism.

If I had to single out one notable achievement, however, it would be this:

Then, in 1989, after studying the properties of a new antiviral drug called 3TC, or lamivudine, Dr. Wainberg found that it was effective against H.I.V. It soon became an important part of the so-called AIDS cocktail of drugs that is still used to treat infected patients.

This, of course, just hints at the critical role this drug has had in the success of HIV treatment. 3TC is the long-term superstar of the nucleoside reverse transcriptase inhibitor (NRTI) class, a characteristic it shares with the similar (and somewhat more potent) emtricitabine, or FTC.

Here are some of the highlights:

  • Triple-therapy consisting of AZT, 3TC, and indinavir demonstrated durable virologic suppression for the first time. The protease inhibitor indinavir got lots of the credit for the success of this strategy since it represented a new drug class, but in these AZT-experienced patients — many of whom likely had extensive AZT resistance — the addition 3TC was arguably just as important.
  • Resistance to 3TC improves susceptibility to AZT, d4T, and tenofovir. Having no resistance is clearly the best scenario, but if you have to have one resistance mutation, let it be M184V. This phenomenon could explain at least in part the results of the above study, or the ongoing benefit of recycled NRTIs in second-line trials (EARNEST, SECOND-LINE), where the activity of the NRTIs appears comparable to raltegravir — even though the latter is a new drug class.
  • Resistance to 3TC isn’t really resistance after all. Despite massive phenotypic resistance to 3TC measured in vitro with viruses harboring the M184V mutation, several studies have demonstrated the ongoing antiviral effect of the drug anyway. In one study, stopping 3TC in patients with M184V led to prompt virologic rebound. In this other study, 3TC monotherapy delayed CD4 decline and virologic rebound compared with complete treatment interruption. Is it that M184V reduces viral fitness? That our phenotypic assays are wrong? Does it matter?
  • Pretty much every “winner” in comparative clinical trials contains 3TC or FTC; conversely, strategies without these drugs often lose. There are so many examples it would take me a week to go through them all. Instead, I’ll just repeat the brilliant comment from Joel Gallant on this topic: “The best nuke [NRTI]-sparing strategy contains a nuke.”
  • 3TC might be the key component to successful 2-drug therapy. The GARDEL study of LPV/r plus 3TC was the first hint that this strategy could break the rule that combination therapy must contain three active drugs. This success has now been followed by studies in virologically suppressed patients “deintensified” to a boosted PI (LPV/r, ATV/r, or DRV/r) plus 3TC, each demonstrating ongoing virologic success when the third (non-3TC) NRTI was dropped. Since boosted PIs are no longer first-line therapy, an important question is whether the same success will be seen with DTG plus 3TC — studies are ongoing.

Of course none of the above success with 3TC or FTC containing regimens would be possible were the drugs not extraordinarily well-tolerated. This safety profile makes 3TC among the few drugs approved in the 1990s still in wide use today.

We will very much miss Dr. Mark Wainberg. His legacy lives on with the people he trained, his extraordinarily productive research career, the expansion of HIV treatment globally — and with the miraculous drug 3TC.

 

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April 5th, 2017

Here’s What Happens When You Search “Infectious Diseases” on a Stock Photo Site

Everyone knows a stock image when they see one. The people don’t look real, the activities are staged, and everything has an air-brushed, frozen quality that screams, “This is not a real thing, but we need some copyright-free graphics and this is the best we can do.”

Strangely depersonalized group photos, animals in human activities, and computer-created illustrations just one step up from Clip Art dominate the stock image sites.

Take this one, for example:

Who are these people? They’re in a boring white room, so why are they so happy? The woman on the far left, where did she get that hat? Is that dog as uncomfortable as it looks? The jeans — are they truly worn out like that, or is this a Photoshop acid-wash effect? What’s with the guys and the tongues?

Anyway, thanks to the largesse of the the generous publishers of this site — who are far more famous for their signature product, abbreviated N-E-J-M, than for this silliness — I have access to tons of stock photos. Literally 69 million, if you believe the banner on my (secret) source.

Now 69 million images is a lot to get through, especially if you have to milk the cow, pick up the kids after school, make dinner, and save that poor little dog from that black-hatted woman’s evil clutches.

Fortunately, there’s also a search box to help narrow down things a bit.

And just for fun, I searched “Infectious Diseases”. Here are a select few from the 10,737 that popped up with this query.

Let’s lead off with one for the children:

  • Hmm, what have we here? Two kids (assume they’re kids) playing outside on grassy lawn, sharing … “infectious diseases” (lower-case). All in the same cartoon word balloon.
  • Is this a harkening back to the days of Chicken Pox Parties? Imagine the Evite.
  • Come to think of it, those virions look very influenza-like — let’s hope they’re not H7N9.
  • Of course the kids are happy because they’re developing a healthy immune system. More support for the “hygiene hypothesis”!
  • Note the hat on the kid on the right, who has chosen a very old fashioned way to dress up as a nurse.

On to Image #2, a workplace scene:

Scene:  Inside an office park, Somewheresville, USA. Three young, attractive professionals are walking down the hall reviewing a very important contract, which is kept in a red folder. The topic shifts to their colleague Matt, whom they spot in the distance.

KARLA:  Hey, there’s Matt! Can we hide? He has the nastiest cold.
JEFF:  I know. I have the cubicle next to him, it’s disgusting. I hear him expelling gunk from his sinuses every five minutes.
CRISTIN:  Isn’t there anything we can do?
KARLA:  Remember when they thought a camel had MERS in our local zoo? I still have the masks they gave us.
JEFF:  Great idea, Karla!
CRISTIN:  Here he comes — quick, pass them out!

Matt approaches, and all three put on their surgical masks. He then sneezes noisily into his handkerchief. Screen fades to black. 

Now for #3, an educational graphic:

Courtesy of a graphic designer named “Roxanne”, I bring you this educational chart, described by her as a “Vector illustration intended for basic medical education (clinics & schools).” But before you use it, here are few important corrections, courtesy of a pedantic specialist in Infectious Diseases.

  1. Change the title to “Common Bacteria Infecting Human Beings” or “…Infecting People“. English, you know.
  2. For bacteria #2 and #3, it’s Streptococcus not Staphylococcus. C’mon Roxanne, you knew that.
  3. “Tetracoccus” and “Sarcina” as “Common Bacteria Infecting Human (Beings)?” You might need Dr. Google to help identify these two (I did), as both are exceedingly rare human pathogens. In other words, they will not be on your ID boards.
  4. If Bacillus tuberculosis is a name for Mycobacterium tuberculosis anywhere on the planet (besides this poster), this is the first I’m hearing of it.

And Roxanne, after you make those corrections, you can send the royalty check to my home address.

Wrapping up with #4:

… and #5:

Yuck. Highly unlikely we’ll be seeing either of these images on a T-shirt or mug anytime soon.

But maybe that’s just me.

 

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March 25th, 2017

HIV and Hepatitis C Are No Longer the Most Serious Infectious Threats to People Who Inject Drugs

I had dinner with my daughter Mimi the other evening, and was ruminating about how things have changed since I started work as an Infectious Diseases doctor around 25 years ago.

Here’s an excerpt of our chat:

Me:  There are way more cases of endocarditis in young people than there used to be, a complication of injecting drugs. People in their 20s and 30s with life-threatening infections, getting admitted to the hospital, needing antibiotics for weeks, sometimes surgery … it’s awful. [I didn’t mean for this to sound like a cautionary speech to my 21-year-old daughter, but reading it now — guilty as charged.]
Mimi:  Endocarditis?
Me:  Infection of the heart valves. It’s an incredibly serious problem, much more difficult to treat than HIV and HCV. Even with our best antibiotics, some people need major heart surgery — their lives are never the same. And sometimes the infection spreads through the blood to the lungs, spine, brain… Some even die!
Mimi:  I’ve never even heard of it. And we never covered it in high school, and we had a ton of drug talks in health classes. It was all HIV and hepatitis. And overdoses, of course.
Me:  Trust me, it’s a terrible problem.
Mimi:  I bet if I asked 10 of my smartest friends, most would be like, “What?” Hey, I can’t even remember what you called it, and you just told me. Here, let me check something. What’s the infection called again?
Me:  Endocarditis.
Mimi [takes out her phone, does some rapid-fire tapping]:  Just did a Google search. “Endocarditis and injection drug use” has 179,000 hits, “HIV and injection drug use” has 1.6 million. And most of the endocarditis ones are in medical journals. Only doctors are going to read those.
Me:  How do we get the word out?
Mimi:  It needs a better name. Something like Zika — everyone can remember that.
Me:  Can I steal that line?
Mimi:  Provided there’s proper attribution, go right ahead!

For some context, Mimi is a college junior and, while not medical school-bound, is a smart kid. (Of course she is.) Having grown up with two doctor parents, she probably has a better than average fund of medical knowledge for her age.

But the above conversation exposes a major gap in the lay public’s understanding of the risks of injection drug use — one hinted at recently in a piece on the clinical and ethical challenges of heart surgery for people with addiction.

For whatever reason, endocarditis and other invasive bacterial infections are not nearly as feared as HIV and HCV, despite the fact that the former are far more immediately life threatening and way more difficult to treat.

It’s true even among those who have had endocarditis. One woman told me that the most upsetting part of her prolonged admission (complicated by cavitary lung lesions and spine infection at multiple levels) was not the days of fevers, the pain when breathing, the severe back pain from the infection, back pain that still plagues her.

It was when she found out her hepatitis C test came back positive.

Let’s compare:

  • Endocarditis due to Staph aureus:  Prolonged hospital stay; 6 weeks of intravenous antibiotics; metastatic infection in the lungs and spine; possible need for valve replacement surgery; possible death.
  • Hepatitis C:  12 weeks of one pill a day. Even if untreated, unlikely to cause problems for decades.

Of course HIV is incurable, unlike endocarditis — but it too is treatable with 1 or 2 pills a day, treatment that essentially eliminates the chance of getting sick from AIDS. And in the United States, rates of HIV due to injection drug use are way down despite the opiate epidemic, accounting now for only 6% of new cases.

So why do we have this strange paradox? And does endocarditis need a new, more memorable name? Suggestions welcome.

And remember, Zika is taken.

(Second image courtesy of Kelly Beverly, “Infective Endocarditis”.)

 

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March 19th, 2017

What Health and Human Services Secretary Tom Price Should Be Saying About Required Immunizations

In case you missed it, Secretary of Health and Human Services Tom Price said this past week that the states should make decisions about mandatory vaccination policies.

Here’s the actual clip:

What’s notable here isn’t the content of what he says — the states already make immunization policies — but that he seems to be so carefully parsing his words.

Of course, his reticence might be the result of his belonging to the Association of American Physicians and Surgeons, a group with strong opposition to mandatory immunizations. Or perhaps it’s the well-known views of his boss, who has publicly expressed he’s not so sure about vaccine safety, especially regarding the link to autism.

So in that spirit, if Price is feeling hesitant about expressing his own views, I’m going to offer him some alternative responses to Wolf Blitzer’s queries (plus a few more questions I’ve made up).

Price is, after all, an orthopedic surgeon. Some input from an ID doctor might be welcome, akin to how we assist them in managing a septic hip.

Blitzer:  So you believe in immunizations, you believe all children should get a shot for polio, and other diseases?
Neo-Price:  Absolutely. We in the Department of Health and Human Services strongly support the state policies that require childhood immunizations. These policies have had a miraculous effect in reducing illness and death, particularly in children, and greatly improve public health for all. Some prevent cancer. They even save money! Talk about a win-win-win-win.
Blitzer:  There are some people who argue that it should be up to the parent or parents to decide what’s best for their child. What do you say to them?
Neo-Price:  When a policy is good for both the individual child and for society, we have to be firm that it’s enforced. And a critical component of vaccine effectiveness is herd immunity, especially with the most contagious infections such as measles. If we let immunity decline too much in the community, these infections will come roaring back. Let me show you this extraordinary short video:


Blitzer:  I hear there has been an increase in so called “nonmedical vaccine exemptions” in the United States. What are your thoughts on these?
Neo-Price: Frankly, each nonmedical vaccine exemption is essentially a misguided, selfish decision made by a parent at the expense of both the child’s health and public health. They should be more than strongly discouraged — they should be abolished.
Blitzer:  Well said, Secretary! I assume, then, that you do not believe in the link between vaccines and childhood autism.
Neo-Price:  Emphatically not. Vaccines are remarkably safe. After the fraudulent paper linking vaccines to autism was published, a torrent of scientific data subsequently found no such link. And the paper, as you know, was subsequently retracted by The Lancet. It’s garbage science.
Blitzer:  One last thing before you go — there are some who say the vaccine policies are being set by individuals who have hidden agendas — conflicts of interest with the pharmaceutical industry, or with insurance companies, or are just ivory tower academics who don’t understand “real” people.
Neo-Price: The Advisory Committee on Immunization Practices (ACIP) — which is organized by the Centers for Disease Control, a wonderful government institution — is a prime example of how doctors, scientists, and public health officials can come together for the public good. They carefully review the vaccine safety and efficacy data, and then issue policies that are broadly endorsed. It’s about as good an example as you can find for your tax dollars well spent. Makes me tear up a bit with patriotism just thinking about it.
Blitzer:  Thanks very much, Secretary. This has been most educational.
Neo-Price: Thank you for having me on. And let me know if you have any questions about your ACL repair. I am an orthopedic surgeon, after all.

My hunch is that Price will appreciate my articulating his position on vaccines more clearly. You’re welcome.

If not, I’d better watch out — orthopedists are much bigger than ID doctors.

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March 14th, 2017

Poll: Should We Allow 24-Hour Shifts Again For Interns?

Over on Boston’s NPR site, I wrote a piece about the decision by the Accreditation Council for Graduate Medical Education (ACGME) to allow 24 hour (or longer) work shifts again for interns.

My goal in writing the piece was to relay what I experienced doing these long shifts way back when during my internship — the good and the bad.

Not surprisingly, most of the comments I’ve received from non-MDs are highly skeptical that there could be anything good about working such a long shift. And if you listen to the linked radio segment on the site, you can sense the incredulousness of the hosts, neither of them doctors. Their tone is practically dripping with, “You’ve got to be kidding me.”

From my friends and colleagues in medicine, however, what I wrote seems to have resonated — here are a few of the emails I received:

“Great piece on 28 hour shifts!  Wonderful description of our days as interns. Forwarded to my daughter who is in her third year of med school.”

“Paul, I loved reading your piece. I had the same set of experiences and thought you captured the highs and lows perfectly. Thanks!”

“GREAT piece…I wish I could call you ‘old’ [ahem] but, alas, that was me in that description of internship too.”

“Your article – truly wise and wonderful, by far the best treatment of such a complicated topic that I have read, ever (I crossed out in years).”

Spot on, Paul! We learned the cycle of illness, both to recovery or to progression of disease. And, we were the patient’s doctor from day one.”

I don’t cite those just to toot my horn (obviously that’s a little bit of it), but also to emphasize that this experience we had with long shifts wasn’t exclusively terrible. Some good came out of it as well.

But did these positives actually outweigh the very substantial negatives, which I also outlined in that piece? I just don’t know, and hence am not sure if the ACGME should be applauded for allowing more flexibility in training, or — and this is the mainstream view — should they be criticized for bringing back work shifts that put patient safety in jeopardy?

Since I’m now back with this readership, I’m dying to know what you think. Based on the NEJM Journal Watch sophisticated reader metrics, you are predominantly practicing clinicians — doctors, nurses, PAs. And we also know that 22% of you have dogs, 14% cats, 6% both, and 0.0412% have ferrets. (Yuck.)

Please read the piece, vote in the poll below, and feel free to provide your comment or comments. We’ll stratify the results by pet ownership.

Thank you.

Should interns be allowed to work 24-hour shifts?

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HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

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