HIV and ID Observations

Labor Day amusement, 1940.

There’s so much interesting ID material out there.

The only solution — an ID Link-o-Rama, especially curated for the long Labor Day weekend.

(Actually, not really, but that sounded good.)

Off we go!

• Even if it doesn’t provide 100% protection, the flu vaccine may reduce the severity of influenza. Good to have this paper handy as clinics start to ramp up immunizations.
• Here are several sensible observations about Lyme Disease from a local physician. Not surprisingly, the first comments from readers are various forms of criticism. Sigh.
• The FDA approved meropenem-vaborbactam (Vabormere) for complicated urinary tract infections. Based on the clinical trials of this agent, however, its true indication should be treatment of carbapenem-resistant enterobacteriaceae (CRE). Take it from Brad Spellberg (who emphatically will not be in charge of marketing this drug):

FDA indication only relevant to control marketing. This is a CRE drug & that's what it should be used for. Any other use borders on criminal

— Brad Spellberg (@BradSpellberg) August 31, 2017

• One person died, 9 others were sickened by botulism from gas station nachos. As if we needed any other reason to avoid gas station nachos. Yuck.
• The incidence of Zika in endemic areas is dropping rapidly. But it’s not gone, and Zika’s permanent departure cannot be counted on. This is a nice quick summary of the mysterious coming and going of an epidemic, with the best explanation for its decline the effects of “herd immunity” — many got infected, never got sick, and are now protected from reinfection. As a result, they don’t pass Zika on to mosquitos or other people.
• With Zika incidence down, one company has pulled its plans to develop a vaccine. Difficult to test a vaccine’s efficacy when people are no longer acquiring the infection — how do you prove it’s working? And of course the market will be uncertain, to put it mildly.
• Blowing out birthday candles increases bacterial transfer to the cake by 1400%. The findings from this study represent either an unrecognized major health hazard or, conversely, a perfect example of why ID doctors are sometimes the deserved subject of ridicule. And in case you want another “germs are everywhere” study, which are irresistible click-bait, here’s more:
• 

  SpongeBob SquarePants, thrilled by latest microwave study.

  Microwaving your sponge increases the growth of potentially harmful bacteria. Not only that, it’s terrible for browning — to get good, crisp, golden-brown sponge skin, I suggest roasting or pan-searing.

• Ceftaroline may be an effective option for severe MRSA infections. This is a welcome review (disclosure, done by colleagues of mine), especially since there are no prospective studies of ceftaroline for this indication. A ceftaroline plus daptomycin vs vancomycin comparative study for MRSA bacteremia would be optimal — though doubt it will ever happen.
• Does switching to a dolutegravir-based regimen cause weight gain? This is the second published paper implying such an effect (the first is here). Hard to come up with a plausible mechanism. Still, weight gain from HIV therapy in general remains a knotty unsolved problem.
• In candidemia from a urinary source, early drainage improves outcome. A reminder that the vast majority of these cases relate to obstruction of some sort that needs remediation (surgical, percutaneous, or endoscopic).
• A researcher contracted HIV in a laboratory despite no known breach of infection control. Exactly how this happened remains unclear, but the phylogenetic analysis of the virus supports this was a lab-based isolate. Transmission of HIV in the lab or hospital setting is (fortunately) so rare that any such event deserves special scrutiny.
• Compared to 1990, global deaths due to communicable diseases are down substantially. The only condition showing an increase is HIV/AIDS — and if we looked at death rates since the expansion of ART in the early 2000s, these are down too.
• Taking responsibility for treating opiate addiction is a natural fit for some ID doctors. It’s not easy, and requires additional training, but among the various medical subspecialists, who better than ID? This follow-up piece in the Boston Globe makes the excellent point that, like treating HIV, our field is taking on a highly stigmatized illness (opiate use disorder) — one with numerous infectious complications.
• Martin Shkreli, the guy responsible for increasing the price of pyrimethamine 5000%, isn’t well liked.  I know, shocking. Still, reading this transcript from his recent jury selection is quite something. Imagine if this were your legacy.
• Maybe doxycycline doesn’t cause dental staining in children after all. It’s a small study (n=38), but the results are reassuring — especially in a highly Lyme- and anaplasma-endemic region like this one!
• Clofazimine has a growing role in treating non-tuberculous mycobacteria. Unfortunately, obtaining clofazimine for each patient who needs it is the very definition of burdensome. Time to change this difficult access problem!
• Gunshot-related spinal cord injuries and infected pressure ulcers — a highly complex, dangerous, and expensive combination. In this perspective, the authors state that people with this condition experience “slow but irreversible and expensive death sentences,” sadly all too true. They call for a multidisciplinary approach, meaning investing resources upfront to avoid complications and costly hospitalizations.

And now, a non-ID section, some medically related, some not:

• “Admit to observation” can saddle a patient with enormous uncovered hospital or rehabilitation facility charges. This is an excellent example of the strange incentives in our healthcare “system”. Check out the reader comments to get a sense of how difficult it can be when someone “admitted” to the hospital actually isn’t considered admitted at all.
• Is our national obsession with football fading? Longtime columnist George Will and I don’t always see things the same way, but with this piece he’s hit a real home run (metaphor chosen intentionally). The opening sentence alone will bring smiles to English majors and football haters across America.
• So long, Walter Becker, co-founder of Steely Dan! The band’s jazz-influenced rock and slick studio sound have always polarized my friends, eliciting rapturous praise, active dislike, or complete indifference. Count me as part of the cheering section.
• In a recent game, Joey Votto of the Cincinnati Reds went 0 for 0 with 5 walks. Joey Votto is the best baseball player you’ve never heard of. In case you’re wondering what makes him so good, the most important skill a hitter can have is getting on base. So 0 for 0 with 5 walks is a very good game indeed — it’s just a quirk of baseball scoring that it’s not called 5 for 5.
• Most of the dietary advice we got growing up was wrong. That’s the inevitable conclusion of this large cohort study, which found that high carb, low fat diets were associated with a higher risk of death, while total fat intake was related to lower mortality. Doesn’t it always come back to Michael Pollan’s brilliantly simple formulation? Eat food. Not too much. Mostly plants.
• If you want to know what makes wine fanatics tick, “Cork Dork” is an interesting, funny, and entertaining read. Terrific title, too. Warning — ordering wine at a restaurant will never be the same!

For Steely Dan fans out there, a personal favorite, this relatively obscure track: