Here’s part two of my commentary on this ABIM issue. In this update, the current president of ABIM gets mad, says something he later regrets (maybe), apologizes (accepted, thank you!), but sticks to his guns anyway. After reading this, my ID colleague/pal John Badley kindly sent me an email stating, “Paul, you and your blog are not despicable.” Thanks for the reassurance, John! And let me be clear once again — I do believe that it’s essential physicians continue to learn, and to keep their clinical practice updated, but I’m increasingly aware that the recertification process as currently designed has major limitations.
Two investigational antivirals hastened time to recovery in people with COVID-19 compared to placebo. VV116 is a remdesivir oral analogue, and leritrelvir is a SARS-CoV-2 protease inhibitor given without ritonavir. Neither study reported significant safety concerns, and both would have fewer drug interactions than nirmatrelvir/r (Paxlovid), especially VV116. While the authors didn’t comment on rebound, recall that this issue does not happen with IV remdesivir. These two drugs (VV116 in particular) along with ensitrelvir all appear to have major advantages over our existing options for outpatients. As cases rise again this December (as they have every December since 2020), I eagerly — and confess impatiently — await better alternatives!
A synbiotic preparation called SIM01 improved certain symptoms of long COVID significantly more than placebo. These symptoms included fatigue, “general unwellness,” memory loss, gastrointestinal upset, and difficulty in concentration. There was a corresponding alteration in the treatment group’s gut microbiome. Confess I didn’t know what constituted “synbiotics” before this study — it means “a mixture of probiotics and prebiotics that beneficially affects the host by improving the survival and activity of beneficial microorganisms in the gut.” And in case you’re counting, this is the third COVID-19-related randomized clinical trial coming from China I’ve chosen to highlight.
A graphic designer provided a detailed account of her devastating symptoms from long COVID. This is a long, quite heartbreaking piece, beautifully depicted, painful to read. Clinicians will appreciate that for some patients, the meticulous record keeping provides some solace, the sheer volume of it starting in 2020 no doubt correlating with the severity of her symptoms. She writes, “I thought that if I collected enough data, I would eventually figure out what was going wrong. But no matter how much data I collected or how many correlations I tried to draw, answers eluded me. Still, I couldn’t stop tracking. My spreadsheet was the only thing I could control in a life I no longer recognized.”
A detailed pharmacokinetics study evaluated bictegravir/FTC/TAF in 29 virologically suppressed pregnant women with HIV. The main findings were that while concentrations of all three drugs during the second and third trimester were lower than postpartum levels (roughly 40-80% of postpartum levels, biggest reduction for bictegravir), the mean bictegravir exposures were still more than 6.5-fold greater than the protein-adjusted 95% effective concentration. No virologic failure or infant transmissions occurred. This regimen — the most commonly used in the U.S. right now — is still listed as having “insufficient data” in pregnancy guidelines. I wonder if this small study will change that category.
Latent infection with Toxoplasma gondii was associated with increased mortality. Note that I wrote “associated” and not “causes”, as this large observational study found marked demographic differences between those who were seropositive and seronegative. One also wonders why the tests were sent to begin with — certainly it’s not a commonly ordered test, done only in very specific clinical circumstances. Nonetheless, it’s worth remembering that even latent infections can have consequences, as is increasingly evident with studies on CMV.
A Mostly Non-ID Section:
The story behind the “booming business” of cutting under a baby’s tongue to improve breastfeeding. Although well intentioned, this procedure has minimal evidence to support its now growing use despite being widely recommended by certain lactation specialists. It also takes advantage of parents during a time of great emotional vulnerability when there is already enormous pressure to breastfeed. Here’s what we do know: it’s very profitable for the doctors and dentists doing the procedure, and it can have serious complications. I’ve been listening to wise pediatricians — especially one very close to me! — express concerns about this procedure for years, so it’s gratifying to see this exposed.
A general internist wrote about the patients who fired him. In this excellent account of a difficult subject — and the valuable things he learned through the process — he tells the story of four such patients who left his practice. He concludes by writing: “To keep this reflection under 2000 words, I leave out the stories of two other patients. I am also not sure I could have tolerated writing more.” We need more of these stories in clinical medicine to balance out the “I came in and saved the day” anecdotes — which not surprisingly are much more common!