An ongoing dialogue on HIV/AIDS, infectious diseases,
October 1st, 2008
Deadlines of Note
Just a reminder of some interesting deadlines/events out there, in case you were too wrapped up sharpening pencils for tomorrow’s Vice Presidential debate:
- As of today, Medicare will no longer reimburse hospitals for medical errors — which includes some hospital-acquired infections. According to this article, several other payors (including private insurers) are using this as a precedent for them to do the same. No doubt the desired outcomes — fewer errors, better outcomes, lower costs — are something we all want, but could it be that insurance companies view these outcomes with slightly different motivations than the people actually experiencing and delivering the health care? (Just a hunch.) Plus, some of these errors are more amenable to systems and behavioral changes than others. Mistakes such as wrong-limb surgery, retained devices during operations, or transfusions of the incorrect blood type are simply not the same as a nosocomial infection in a highly debilitated or immunocompromised patient. Great review of the complexity of this issue here in this week’s JAMA.
- Abstracts for the 16th Retrovirus Conference (CROI 2009) are due today at 5:30pm. As a regular attendee of HIV/ID conferences over the years (and, darn it, frequent rejectee of submitted abstracts), I can state unequivocally that the standards set by CROI for abstract acceptance must be the highest in our field. Moreover, once accepted, abstracts face an incredibly high hurdle to be chosen for oral presentations. Notable examples of this from the 2008 conference include the abacavir/DAD/cardiovascular disease study (published as a major paper in Lancet just a week later), and a large randomized clinical trial comparing abacavir/3TC with tenofovir/FTC. Both of these studies were posters, not oral presentations! This is a tough club to get into, that’s for sure.
- (Warning, no ID/HIV content to follow.) Tonight at 6:30 PM EST, the Chicago Cubs — the best team in National League this year — start their “quest” for their first World Series title since 1908. Yes, that’s a hundred years! Can there be any baseball fan with a pulse out there who isn’t rooting for them at least a little?
September 29th, 2008
Required Reading: The Value of ID Specialists
In the most recent issue of Clinical Infectious Diseases, there’s a comprehensive review of the value of an ID specialist from the perspective of non-patient care activities.
Covered in particular are:
- Antibiotic stewardship
- Infection control
- Monitoring rates of nosocomial infections
- Managing health care worker “well-being and exposures”
Also included are tables listing dozens of studies quantifying the value of these activities. It’s an impressive paper, running 12 pages long and including over a hundred references.
What might be most useful, however, is a section entitled, “Putting the Data to Use Effectively in a Negotiation.” Here, in best Business School 101-ese, is a step-by-step approach to making the case for our value to hospitals or other health-care centers. Such negotiating skills are not taught in medical school, residency, or fellowship, and suspect that many of us could use this nice primer.
So if you can’t define “BATNA” (hint: it’s got nothing to do with rabies), I highly recommend this paper.
September 27th, 2008
Crunchy Frog?
One of the ID fellows just received this curbside consult:
A primary care doctor paged me because a patient of his just discovered a dead frog in the salad she was eating, and wanted to know what to do.
How about, “Don’t eat it!”
But there are definitely some things in our field you just can’t look up — not even in UpToDate. And as a nerdy male of a certain age, I had the immediate impulse to ask if the salad dressing on this salad was lark’s vomit, but refrained.
You think Cardiologists get questions like these? I think not. They don’t know what they’re missing.
September 18th, 2008
C. diff: The cure for antibiotic abuse
Even with market doom-and-gloom dominating the news, there’s a good article in yesterday’s Wall Street Journal on Clostridium difficile (C. diff). It gives an accurate summary (in lay language) of the problem, several pertinent clinical anecdotes, and quotations from national experts.
But this part in particular caught my eye:
She says that among other measures, the hospital has cut its post-operative antibiotic doses for all joint-replacement surgeries to two from three to avoid C. diff infections.
No offense intended, but anytime “routine” antibiotic use is reduced on surgical patients, it’s notable. Practically reportable. (One might question why any post-operative antibiotic doses are given at all — but we’ll take this small victory anyway.)
Human beings love antibiotics — all of us are guilty of this love affair, health care providers and patients alike. (This is a great cartoon!) My first introduction to this phenomenon was during a medicine rotation in medical school, when the esteemed senior physician on rounds obviously had a bad cold. After a particularly noisy bout of sneezing (and what was he doing in the hospital, one might wonder), he confessed that the cold he could deal with — but the nausea from the erythromycin he’d prescribed for himself “just in case” was driving him crazy.
But this new “hypervirulent” C. diff has changed the equation, in a way that warnings about antibiotic side effects and risk of resistance never could. One of my friends, a maxillofacial surgeon, thinks long and hard about every antibiotic prescription ever since one of his patients had severe C diff — requiring a colectomy and prolonged ICU stay — after a brief outpatient course of clindamycin.
And those unfortunate patients who have had C diff have been thoroughly cured of any “just in case” mentality towards antibiotics for sniffles, colds, sore throats, minor sinus issues, and coughs. Alas, a case of C diff is more effective than “Your cold is caused by a virus; antibiotics don’t work for viruses,” which oddly has little traction at all.
September 10th, 2008
Yes, TNF blockers increase infection risk. Now what?
So the FDA has issued (another) warning about TNF (tumor necrosis factor) blockers and increased infection risk, this time focusing on fungal infections, in particular histoplasmosis. TNF blockers are used for treatment of rheumatoid arthritis, Crohn’s Disease, ankylosing spondylitis, psoriasis, and a wide range of other autoimmune diseases, both in approved and in off-label use.
ID/HIV specialists of a certain age can easily remember the first patients they had who, after starting PI-based combination therapy (note I don’t say “HAART”), literally got their life back. Went from imminent death to joining the living again. It was miraculous. A similar thing happened when TNF blockers entered clinical trials, then were approved by the FDA.
No, the TNF blockers don’t usually reverse a fatal illness like the antiretrovirals. But their effect, while perhaps not literally life-saving, is nearly as profound. It doesn’t much matter what the disease is; for patients with severe RA, or Crohn’s, or whatever, going from a life of chronic pain and disability to feeling normal again is, well, a miracle of almost comparable magnitude to the reversal of AIDS with antiretroviral therapy.
That’s why seeing patients with serious infectious complications from these drugs is so challenging. It’s not just about treating the infection. It’s also about managing the post-infection life.
And coming up with a sensible, compassionate answer to the inevitable question, “When can I start the Enbrel [or Remicade, or Humira, or Cimzia …] again?” — is certainly one of the hardest things I do.
September 5th, 2008
West Nile Virus and Friday Night Lights
The town of Braintree, just south of Boston, has cancelled Friday night high school football games until the first frost of the year due to concerns about West Nile. Apparently the campus has a lake and wetlands, good breeding grounds for mosquitoes. “This is all in the name of safety,” says the school headmaster.
(If someone were doing a presentation on “How Massachusetts Differs from Texas”, this move is Exhibit 1.)
When West Nile encephalitis first appeared in Boston in the Summer of 2000, there were newspaper articles about how parents would rush their children from house to car on summer evenings to avoid mosquito bites; lots of debate over the relative safety of various chemical repellents; people scrutinized their neighbors’ yards for suspicious bird baths or, worse, old tires with stagnant water.
This all seemed to me a variant on a commonly-observed inability for us humans to figure out relative risk. Which was more dangerous, a few mosquito bites on a summer evening, or the drive in the car? We fear what we can’t control — especially creepy microbes, bugs, germs, yuck — and if anything can be done to reduce this risk further, even if it’s from a 1 in a million to a 1 in 10 million chance, let’s do it. (See rabies prevention, for another example.)
By contrast, we have the illusion of control over things like car safety, when in fact most car accidents happen suddenly — no warning –- and we have no control at all over the driver trying to find his sunglasses while talking on the cellphone after having a few too many. People are more concerned with feeling safe than being safe — just try to convince the driver of a large SUV otherwise.
This is not to diminish the potential seriousness of West Nile disease — a colleague of mine’s father died of it in California several years ago — but the reality is that so far this year in Massachusetts there have been zero human cases; last year there were 6 (3 encephalitis, 3 fever). Less than 1% of people who become infected with West Nile virus will develop severe illness. Most people who get infected with West Nile do not develop any disease at all, and the elderly — not high school football players — are at the greatest risk for encephalitis.
As a 140-pounder when wet, I can think of lots of good safety reasons reasons not to play high school tackle football on Friday nights — but the risk of West Nile isn’t one of them.
August 22nd, 2008
We have met the enemy … and it is MRSA
In Jerry Groopman’s recent New Yorker piece on antibiotic-resistant bacteria, he quotes Dr. Louis Rice from the Cleveland VA, who uses the term “ESKAPE” bacteria: an acronym for Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumanni, Pseudomonas aeruginosa, and Enterobacter.
Nothing against the mostly gram-negative nasties in this list (and the focus of the New Yorker article), but in my opinion there is one bacterial King of Pain, and it is MRSA — methcillin-resistant Staph aureus. Already a hospital-based problem when I began medical school in the 1980s, MRSA is now absolutely everywhere, and I’ll go out on a limb and state that it is the most common and worrisome source of serious infectious suffering we have out there right now.
In this past week alone, I have seen or heard about the following patients (some details slightly changed due to HIPAA, and even more importantly, this list isn’t even all-inclusive):
August 8th, 2008
More from Mexico City
A bit more travelogue from the XVII International AIDS Conference:
- It’s impossible to see everything you want at such a large, sprawling conference, sometimes because of conflicting meetings, sometimes because the room is full, sometimes because of a feeling analagous to being in a giant museum for too many hours — fatigue just takes over. But I’m sure glad I didn’t miss Myron (Mike) Cohen’s plenary session Tuesday AM on HIV Prevention. It’s easy to get cynical about HIV prevention efforts given the number of recent failures in the field (vaccines, acyclovir, microbicides …), but as Cohen pointed out, some things out there are working, and he outlined a very reasonable (and optimistic) strategy for how this epidemic could be controlled. Plus he did it in his typically energetic and entertaining fashion, all the while maintaining absolute academic rigor. Don’t miss his name-brand idea for a combination product containing tenofovir, emtricitabine, and maraviroc — brilliant. Some web casts are worth watching, and this is one of them.
- Missing from this International AIDS Conference were the phonebook-thick abstract listings. Instead, we received the abstracts on CDs, a move that definitely saved lots of trees, sore backs and shoulders, but made it very hard (ok, impossible) to flip through the abstracts. I´m sure this is a direction that more meetings will take, but will definitely take some getting used to. USB drives will be coming soon, as CDs as a storage medium are definitely on the way out.
- Speaking of USB drives, the speaker-ready room was shut down on Wednesday for a while due to — I´m not making this up — a computer virus acquired from some rogue USB drive. Many jokes followed about computer condoms, vaccines, and microbicides, but I´ll leave it right there!
- I’ve already written about food here in Mexico City, but only from the Infectious Diseases perspective. Now I’ll be my mother’s son (she’s a food writer), and say the restaurants have been terrific, the food fresh, interesting-tasting, and reasonably priced, and the service attentive and professional. But — there was one glaring exception, and unfortunately it was the food at the convention center, which consisted mostly of wilted salads, sandwiches with scary soft meat-like products (colored a disturbing faded gray), and (I think, don’t hold me to this) tuna salad. As lines for food during lunchtime were 15-30 minutes long, it became quite easy to skip the mid-day meal or subsist on potato chips, water, and coffee, probably not the healthiest diet on the planet. I got back to my hotel room absolutely famished every day.
- All of these conferences have a theme — this one is “Universal Action Now” (italics theirs). Pretty good. I suppose one could fashion a challenging trivia quiz, asking people to match the theme with the city and date: “Time to Deliver” (Toronto, 2006), “Access for All” (Bangkok 2004), “Knowledge and Commitment for Action” (Barcelona 2002), “Break the Silence” (Durban 2000), “Bridging the Gap” (Geneva 1998) … Good sentiments all, but Durban wins by a mile. Of course if they had the conference in Boston, the theme would be, “Let’s go Red Sox.”
(I guess I’m getting a bit homesick.)
August 4th, 2008
Mexico City: Drive on the right … most of the time
Some early and completely non-scientific observations from the XVII AIDS Conference, taking place now in Mexico City:
- Everyone said getting to and from the Banamex Convention Center would be difficult, and of course they were right. Mexico City is the largest city in the Western Hemisphere, has a road/traffic system that makes driving in Boston seem downright peaceful by comparison (that is hard to do), and of course none of the hotels are anywhere near the meeting. But it’s not as if we haven’t been through this before — namely, here in Bangkok and here in Rio, to cite some recent examples. So no big deal. But … I did experience something traffic-wise that was truly bizarre: On the drive in from the airport, the cab driver took a right turn onto a street and drove on the left for around a tenth of a mile, while the oncoming traffic was on the right — and it was actually planned that way, pefectly legal. To repeat (if that wasn’t clear): we were driving British style. According to the cab driver, it’s because left turns off some roads have become so congested that they simply moved that lane from the right to the left; after the busy intersection passed, we moved back to the right. I kid you not.
- What do Infectious Diseases specialists from the United States eat and drink when they’re in Mexico City? If my completely haphazard survey is any guide, we’re all over the map (ahem) when it comes to food safety while traveling. One colleague said she couldn’t live without salad, and the idea of visiting Mexico without a margarita (requires ice) was too depressing even to consider; another said he was sticking by the rules, eating only thoroughly cooked foods and drinking bottled beverages from “reputable sources,” whatever that means. (Maybe this.) One other said that the street food was one of the best reasons to visit Mexico to begin with. So far my approach has been pure pragmatism and selfishness: if there’s a tasty low E coli option available, great — but if not, and something looks too delicious to pass up, I’ll take my chances.
- The weather in Mexico City is wonderfully, delightfully cool in August. For some reason, I expected a summertime furnace, but it’s much cooler here than in Boston due to the altitude. Was I the only one in the world who didn’t know that?
Back with more later, maybe with some “real” content.
Paul E. Sax, MD
Contributing Editor
NEJM Journal Watch
Infectious Diseases
Biography | Disclosures | Summaries
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