An ongoing dialogue on HIV/AIDS, infectious diseases,
October 18th, 2008
Back to School, Day 2
During the course, often the best questions and anecdotes come during the breaks. Here are a few:
- Tons of questions about our favorite nemesis, MRSA. What works for chronic carriers? How do you manage family members who you suspect would be culture-positive (and the source of recurrences), but are not your patient? What if the vet won’t culture the family dog? What are the guidelines for infection control in the outpatient setting? What is the best non-linezolid (which still costs > $150/day) oral antibiotic? What’s the right dose of trimethoprim-sulfa? (Many advocates for two double-strength tablets twice daily.) Number of definitive answers to any of the above questions? None. I guess misery loves company.
- A primary care MD working at a college health clinic gave me some insight into just how far we still have to go to make those revised HIV testing guidelines a reality. In this campus-based practice, if one of the students requests an HIV test, or the clinician thinks an HIV test is indicated, several restrictions are in place that go way beyond the state-mandated requirement for written informed consent. First, extensive pre-test counseling is required; second, only one of the providers is allowed to order the test (so the student must return to see that clinician if he is not available that day); third, mention of HIV testing in the medical record is forbidden; and fourth, the results of the test do not appear in the student’s chart. (They are kept in some locked remote location, no doubt.) Hey, can we stop this madness already? Is there any evidence that such policies help anyone? (The MD at our course was complaining about them, not surprisingly.) Of note, the revised HIV testing recommendations — explicitly outlining the rationale for eliminating barriers to testing — are now over two years old.
- Only two course participants thought I was Paul Farmer. Interestingly, one of them thought I was Paul Farmer immediately after he gave his lecture, during the coffee break, when the real thing was standing right across the room. My clue she had the wrong Paul Edward was when she told me my work inspired her to apply to medical school when she was growing up in Port-au-Prince. There are definitely worse people one could be mistaken for — back when I had more hair (lots more hair), someone thought I was a dead ringer for this guy. Yikes.
October 15th, 2008
Back to School, Day 1
We offer two post-graduate courses each year, one entitled Infectious Diseases in Primary Care, and the other AIDS Medicine: An Intensive Case-Based Course. The Primary Care one started today, the AIDS course starts on Monday.
(Both are equally fascinating. I am entirely unbiased.)
What is so striking is that the participants — and content — barely overlap at all. Topics for primary care course:
- Antibiotics
- UTIs
- Pneumonia
- Sore throats/colds
- Immunizations
You get the idea. For the AIDS course?
- Acute HIV infection
- Management of treatment-naive patients
- Interpretation of resistance testing
- Metabolic complications of therapy
- Legal and ethical considerations of HIV care
I suppose I should not find the lack of overlap surprising, given papers such as this one, citing that 62% of family practitioners refer their AIDS patients to specialists immediately — a big change from 1994, when only 18% did. (Even 62% seems low …)
But the irony is that with improved antiretroviral therapy — the very thing that drove some generalists away from HIV care due to its complexity — HIV patients are living longer, and hence are in greater need of the kind of care delivered best by primary care clinicians.
So maybe what we really need is a primary care course for HIV specialists?
October 8th, 2008
The French Win This One
The 2008 Nobel Prize in Medicine goes to and
For the record, if you search the Nobel press release for the word “Gallo”, you won’t find it mentioned anywhere.
Why is this notable? Seems like ancient history, but actually two groups in 1983 claimed they discovered the virus that causes AIDS, both finding a human retrovirus — the one we now know as HIV. The French group called it “lymphadenopathy-associated virus” or LAV, and the Americans (led by Robert Gallo) “human T-lymphotropic virus III” or HTLV-III. We now know it was the same virus — indeed, due to “lab contamination,” sometimes literally the same — and that the French were first, but maybe (am being generous here) the Americans were a bit more practical (and certainly louder) about the implications of the discovery.
An academic truce of sorts ensued many years later — this was much less entertaining, but perhaps a good thing for international relations, at least until “Freedom Fries.”
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):
Paul E. Sax, MD
Contributing Editor
NEJM Journal Watch
Infectious Diseases
Biography | Disclosures | Summaries
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