Tuesday, December 16, 2014

GBV-C Co-Infection Associated with Improved Ebola Survival

GB virus C (GBV-C or Human Pegivirus - or even Hepatitis G) is associated with high viremia but there is little evidence that it causes disease in humans. Back in 2001, Jack Stapleton and colleagues (including Dan) showed that GBV-C co-infection significantly improved survival in HIV+ patients. The thought behind this association is that GBV-C attenuates aberrant immune activation.

Given that GBV-C infects between 10-28% of individuals in the three countries that have experienced the highest level of Ebola infections in the recent outbreak, Michael Lauck and colleagues in Madison wanted to examine the influence of GBV-C co-infection on Ebola outcomes. Using a cohort of 49 Ebola infected patients with outcome, age and gender data available they assessed the association of GBV-C co-infection on mortality.

Overall, mortality in the cohort was 69%. However, while mortality was 78% (28/36) in GBV-C negative patients, it was "only" 46% (6/13) in GBV-C co-infected patients. The unadjusted and adjusted analyses are in the Table below. The higher p-value with unchanged OR in the multivariable model likely represents a loss in power and not age-related confounding as the authors claim. Minor quibble - they presented a case-control (OR) analysis for this cohort of patients with a significant p-value. Analyzed as a cohort study, the RR=0.59 (0.32-1.09), p=0.0950. Either way, if I had Ebola, I'd also want GBV-C.

Monday, December 15, 2014

Guest Post: IDSA’s Take on the Match Results

This is a special guest post by Dr. Stephen B. Calderwood, MD, FIDSA, President, Infectious Diseases Society of America (IDSA)

The first annual IDWeek Mentorship Lunch, IDWeek 2014    

The IDSA community is over 10,000 doctors strong, and we’re all concerned with the match results for this year. But the dumpster fire metaphor is only half right: Yes, it’s a crisis, but we aren’t shrinking from it. Everyone at IDSA is fighting for our specialty, and we need our whole community to join in. 


HAI Controversies has talked before about this, and Mike Edmond put the blame squarely on the economics of being an ID doctor. The Society continually advocates for better compensation for ID services and how to value their input differently under health care reform. This past year, IDSA has pushed hard for ID specialists to be required for hospital stewardship programs. To help individual doctors with compensation, several IDSA veterans compiled The Value of the ID Specialist, a comprehensive study that documents how ID consultations result in better outcomes and lower costs.  And for IDSA members, we offer a Value Toolkit (login required), which collects presentations, videos, and documentation to help ID doctors make the case to their own employers, hospital administrators and health plan executives.

Funding for Research and Public Health

Funding cuts in research and public health affect all of us, not just ID specialists, and IDSA joined hundreds of other professional societies to Rally for Medical Research. In addition, our policy and government affairs team works tirelessly, advocating for more research funds for HHS agencies and encouraging the White House and Congress to commit more of the federal budget to infectious disease research and public health.

We actively encourage our members and the public to join these efforts. In three minutes, you can let your congressional representatives know that budget cuts hurt the infectious disease community, and ultimately the patients we serve. Of course, you can also contribute more directly: the IDSA Education and Research Foundation supports medical students and young investigators with fellowships, travel grants, and research funding to help recruit more people to our specialty and to help with their early career development.


Mike Edmond’s post led with a moving tribute to the mentor who inspired him to choose ID. IDSA is dedicated to expanding our mentorship efforts. In addition to our two Fellows’ meetings every year and our scholarships for medical students, we launched a new Mentorship Program at IDWeek 2014. Students, residents, and fellows were teamed up with seasoned ID professionals and explored the meeting together. We’re actively trying to expand our mentorship programs, and encourage our members to volunteer for these efforts.

Responding to the match is a community effort that will require a multi-pronged approach. We at IDSA are all thankful to have an active, involved, and passionate community of ID doctors in our Society who want to see the specialty thrive and expand; we welcome all thoughts individuals may have in better addressing this issue. We certainly want to ensure that we continue to attract the very brightest and committed individuals to our specialty. We’re committed to ensuring that the future workforce brings the clinical expertise and new knowledge needed to address the many problems we face, including the enormously important areas of antimicrobial resistance and stewardship, HIV, TB, emerging infectious diseases (such as Ebola!), and all the other key areas our specialty contributes to so uniquely on a daily basis.  

Friday, December 12, 2014

What is Healthcare Quality Improvement?

Dr. Mike Evans, a staff physician at St. Michael's Hospital in Toronto, and his team at the Evans Health Lab have released another excellent whiteboard video. This time they cover QI in healthcare.  Brilliant and clear as always.

Thursday, December 11, 2014

The world will end in 2050 because...resistance

UK Prime Minister David Cameron requested a review of the health and economic burden of antimicrobial resistance in July. Quicker than you can say supercalifragilisticexpialidocious, economist Jim O'Neill has delivered his report and the results are surprising (at least for those who don't follow this blog). Utilizing commissioned studies from KPMG and Rand Europe, the Review estimates that the economic losses attributable to antimicrobial resistance will total $100 trillion and 10 million excess deaths will occur annually by 2050. In fact deaths do to resistance will surpass other major causes of death even the 8.2 million due to cancer. (see figure on right) Of course, cancer deaths might rise due to the fact that we can no longer safely give chemotherapy without effective antibiotics. The report covers these issues in a sobering section titled: "The secondary health effects of AMR: a return to the dark age of medicine?"

Good times.

The independent Review will outline recommendations for an international response by 2016. In the meantime, I leave you with my favorite figure from the report below. Just for reference, $100.2 trillion is 6 times the size of the US GDP (2013). Perhaps this will wake up the world to antimicrobial resistance?

Additional Source: BBC

Sunday, December 7, 2014

Infectious Diseases and the Terrible, Horrible, No Good, Very Bad Match

Here we go again. Another internal medicine subspecialty “match day” and another record (bad) day for ID. How bad? The previous record (set last year) for unfilled ID programs was 54. This year 70 programs went unfilled, meaning that for the first time ever there were more programs that didn’t fill than that did. Almost 100 funded ID training positions unfilled in a single year!

We’ve blogged about this trend before, here and here, and discussed some of the reasons that ID is in decline as a specialty (along with some suggestions for how to turn this around). I don’t have any new insight, except to make the point that this is now beyond a crisis situation for our specialty. It’s a dumpster fire.

Saturday, December 6, 2014

Killed by an Abundance Of Caution?

Back in August, I wrote:
“most patients returning from the outbreak area with febrile illness (those meeting the Person Under Investigation (PUI) definition) will not have Ebola, but they may be very sick. If an overly stringent lab protocol prohibits or delays laboratory testing, substandard medical care may lead to adverse outcomes.”
In September, I wrote:
“the overwhelming majority of those with febrile illness upon return from the outbreak areas will not have Ebola—but they may well have something requiring urgent attention and appropriate therapy (malaria, typhoid, meningococcemia). Prompt laboratory testing will be essential, and potentially life-saving…..However, many hospitals plan not to let any samples from suspected Ebola patients cross the threshold of their laboratories. [This] could be dangerous for patients presenting with “severe non-Ebola infection” who happen to have been in an outbreak area in the prior 21 days.”
Well, the CDC has just released a report on their initial experience with “PUIs” in US hospitals, and there’s this disturbing little nugget buried within:
“At least two persons who tested negative for Ebola died from other causes. Based on reports from health departments and health care providers, in several instances efforts to establish alternative diagnoses were reported to have been hampered or delayed because of infection control concerns. For example, laboratory tests to guide diagnosis or management (e.g., complete blood counts, liver function tests, serum chemistries, and malaria tests) were reportedly deferred in some cases until there were assurances of a negative Ebola virus test result. In other instances, radiologic studies, such as computed tomography and ultrasound scans, or evaluation for noninfectious conditions, such as severe hypertension and tachycardia, were reportedly delayed while a diagnosis of Ebola was under consideration.”
Given the ratio of PUIs to actual Ebola patients presenting to US hospitals, it is quite likely that more patients will die in the US from AOC (“Abundance of Caution”) than die from Ebola. Back to CDC now:
“…it is important to recognize that the likelihood of Ebola even among symptomatic travelers returning from these countries is very low. In the hospital setting, where policies and procedures should be in place to safeguard health care workers, consideration of Ebola should not delay diagnostic assessments, laboratory testing, and institution of appropriate care for other, more likely medical conditions.”
In other words: diagnose and treat the patient, not your Fear of Ebola.

Image from The Keep Calm-O-Matic

Wednesday, December 3, 2014

Toilet lids for infection prevention

Back on clinical service again and having more thoughts on poor hospital design. Last month I wondered why there were no stethoscope wipes available outside of every patient room. This month while caring for patients with C. difficile and viral gastroenteritis infections, I looked over and noticed toilets without lids. Of course most toilets in hospitals (and many public spaces) lack lids. Reasons given for lack of lids are (a) lids might be hard to lift for some folks and (b) lids would be another surface to clean. But lids also prevent the aerosolization of pathogens into the environment, as Mike discussed three years ago.

Lack of toilet lids in hospitals is a patient safety issue and there should be no excuse for not having and using them. First, most patients can and will close the lid before flushing if reminded to do so. In fact, there should be public services announcements in the media that remind us all to close the lid and kids should be taught to do this in school. Second, if a small minority of patients can't or won't close the lid, it's not a reasonable excuse for going lidless in hospitals. This would be like not providing seat belts because some folks can't or won't use them!

So here are my recommendations:

1) Put a plastic, cleanable lid on every toilet and train hospital staff to clean the lid daily
2) Create education campaigns to get patients and staff to close the lid before they flush
3) Put a big "CLOSE BEFORE YOU FLUSH" sign on both sides of the toilet seat in every bathroom in hospitals, including public spaces
4) Help start local "CBYF" campaigns in your cities
5) If hospitals are worried about patients not being able to open or close the lid, they should spend $6400 on this toilet that automatically opens and closes, among other features. Given the cost of HAI and the amount we spend on other HAI prevention interventions, the $6400 will easily be cost-effective or there's even a touch-free sensor toilet seat for ~$100.

It's time we give a crap about having and closing toilet lids.

image source: http://www.dudeiwantthat.com/household/bathroom/friendly-toilet-seat-reminder.asp