Recent Posts

May 5th, 2008

Brush with Greatness: Paul Farmer

Perhaps you caught this week’s 60 Minutes, featuring the work done by Partners in Health, the group founded and run by Paul Farmer.

(If he reads this, he’ll no doubt want to correct my description of him as playing these major roles, eager to give equal credit to his impressive colleague Jim Kim and his mentor Howard Hiatt. Ok, done.)

But if you missed the interview, no matter — in all likelihood you’ve heard of him. Maybe you’ve read the fine book about him or seen his smiling face in a variety of newspaper or magazine images. In the Infectious Diseases world, Paul Farmer is a true rock star — our equivalent of Paul McCartney, Mick Jagger, and Bono all rolled up into one guy.

He also was an Infectious Diseases fellow in our program and a clinical attending on our inpatient Infectious Diseases consultation service for several years.

And that’s what I’m going to write about — Paul Farmer here in the resource-rich USA.

April 30th, 2008

Young Doctors “Get a Life” — Whither ID/HIV?

A front-page article in yesterday’s Wall Street Journal says that younger physicians (definition:  younger than I am), “intent on balancing work and family,” are choosing specialties that allow them to control their hours.  The content of the article will be familiar, including:

  • The rise of the hospitalist movement
  • A decline in those entering primary care fields
  • The pros and cons of this change (a better-rested, more-balanced doctor vs. the inevitable lack of patient continuity — gone is the “hero model of the lone ranger who is there 24/7, 365”)
  • Ways that specialties with unpredictable call (such as obstetrics) are adapting to this trend

April 23rd, 2008

Antiretrovirals in the Pipeline: And Then There Were … None?

The flurry of drug approvals that began in 2005 with tipranavir – followed rapidly by darunavir, maraviroc, raltegravir, and most recently etravirine – has been nothing short of astounding. Every experienced HIV clinician now has many patients who are on successful (read: suppressive) treatment for the first time ever. The Vancouver HIV program — wonderfully called “Centre for Excellence” (why couldn’t our clinic have chosen that name?) — reports that the incidence of drug resistance is declining “drastically.” And their experience is not unique, even though their “excellence” moniker might be.

All good news, right? Well, mostly.

April 17th, 2008

Required Reading: Bat-Related Human Rabies

A group of researchers in Canada have done infectious diseases experts a big favor — they’ve summarized a staggering amount of useful data on bat-related cases of human rabies in a paper just published in Clinical Infectious Diseases.

(Note to non-ID specialists: infectious diseases doctors spend a lot of time answering questions about rabies in general and the vaccine and bats in particular. I’m fairly certain that being a bat expert was not listed in my job description when I signed up for this field, but maybe that’s because there was no job description.)

This paper should be required reading for all ID docs. Whether the news is reassuring or terrifying will depend on whether you’re a glass half-full or half-empty type of person. Here are some of the key points:

April 10th, 2008

Needed: Something Better than “HAART”

dutch springI think we all have pet peeves, and so I’ll confess one of mine: I hate the term “HAART.”

(I work with someone, by the way, who hates the term “viral load,” preferring “virus load.” Go figure.)

Standing for “highly active antiretroviral therapy,” HAART first surfaced in the mid-1990s in order to distinguish potent anti-HIV treatment from the older, not-so-active form of antiretroviral therapy that preceded it. Writers often will use the phrases “era of HAART” or “advent of HAART,” both of which sound to me like essays on Dutch history.

But HAART has never been very precise — what exactly does it mean? 

March 31st, 2008

FDA Investigating Safety of Abacavir and Didanosine — Old News or New?

The FDA has issued one of its new “early communications” indicating that it has opened an investigation into the safety of abacavir and didanosine based on analyses showing higher rates of myocardial infarction with these drugs than with other NRTIs in the Data Collection on Adverse Events of Anti-HIV Drugs (D:A:D) study.

The pace of our field is sometimes remarkably fast: Immersed in HIV care or research or policy, we think of this as old news — after all, it was presented over a month ago at the Retrovirus Conference. These D:A:D results linking abacavir and ddI to increased MI risk have already been the subject of extensive discussions in clinics, conference rooms, and meetings. But I have to remind myself that no, it’s not old news at all — the full paper has not yet been published, although it will be soon — and that we still need some time to process the data, and to consider the questions raised by the findings. Is this a causal relationship, or just an association? Why has it not been seen in other studies? What is the mechanism? Would it still be the case with HLA-B*5701 screening? Why is the risk not cumulative? When will we be seeing data on tenofovir? (I suspect soon, given when tenofovir was approved.) What do abacavir and ddI have in common that would cause this? What should we be doing with our patients on abacavir who are doing well? I confess my answer to all of these questions is the same: I just don’t know.

D:A:D is an extremely important study that has already provided enormous insight into HIV treatment. But as the D:A:D investigators no doubt would agree, there are limitations to ascribing toxicities to treatment based on observational data. So I guess I’m proposing that as of today (March 31, 2008) we view these results as suggestive, and hypothesis-generating, rather than defining standard of care right now.

UPDATE

The D:A:D data have now been published in the Lancet. There is also an accompanying editorial here (subscription required).

March 20th, 2008

How to Solve at Least One Part of the Healthcare Mess: ADAP for All

The presidential elections have once again made our Byzantine healthcare system a regular feature in the news. A recent film also made quite a splash, and though Michael Moore offered no plausible solutions (Cuba? c’mon!), he certainly made me wonder what I’d do if I had two severed fingers that needed to be reattached and only enough money to cover one procedure.

Everywhere, you hear the usual complaints: increasing numbers of uninsured, highly variable (but mostly mediocre) quality of care, “skyrocketing” (interesting how often that adjective is used) costs, misaligned incentives leading to overuse of expensive procedures and medications, greedy insurers denying coverage, and (always) unfavorable comparisons with outcomes in other industrialized countries. Reading the various candidates’ solutions to this quagmire, I get that same heavy-lidded feeling I had in medical school when lecturers tried to “explain” how the immune system works — yes, you have a theory and a lot of nice figures, but could anything so complicated really work? Many of those immunology theories have long since been discarded, and it would not surprise me a bit to see the same happen with the presidential hopefuls’ proposals.

It is with great magnanimity, therefore, that I offer the candidates — free of charge — a model of how to fix one aspect of our healthcare mess, the high cost of prescription drugs.

March 19th, 2008

How long have I got, Doc?

Some aspects of seeing a patient newly-diagnosed with HIV haven’t changed much over the years — for example, the emotions in the room remain a mix of fear, shame (note to world: this is still a highly stigmatized disease), incredulity, and ultimately relief in finding a clinician who is comfortable with the condition.

But a lot has changed, of course, due to the availability of effective antiretroviral therapy. To illustrate, here’s a commonly-asked question, especially from newly-diagnosed patients and their loved ones — in fact, I heard it just last week:

How long can a person live with HIV these days?

HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

Biography | Disclosures | Summaries

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