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A gorilla walks into the operating room …

An emerging concept in medicine is the One Health movement that says human health is inextricably linked to the health of animals & the environment. And that human & veterinary medicine will unite as one discipline. For example, it’s been shown that MRSA travels back & forth between owner & pet.

The following story illustrates the idea. But that’s not really why we’re running it. It’s because it’s so darn heartwarming. And in this time of politically-driven pathology we need stories that remind us of our common humanity. In addition to the video, there’s a neat backgrounder piece – it’s brief – in the Atlantic about the surgeon who delivered the baby gorilla & her day at “the office.” Be sure to read it to the end where there’s a nice surprise waiting.

Johns Hopkins study: 1 in 5 patients harmed by antibiotics

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Question: What is the likelihood of developing an antibiotic-associated adverse drug event (ADE) for a hospitalized patient receiving antibiotic therapy?

Answer: 1 in 5 patients experienced at least one antibiotic-associated ADE.

Researchers looked at the medical records of 1488 adult inpatients at Johns Hopkins Hospital & found a total of 324 ADEs overall. The most common one’s were gastrointestinal, renal, and hematologic abnormalities, accounting for 78 (42%), 45 (24%), and 28 (15%) 30-day ADEs, respectively. Of those, 186 (57%) happened within 30 days, and 138 occurred within 90 days. Of the 138 ADEs occurring within 90 days, 54 (39%) were cases of the life-threatening Clostridium Difficile Infection, and 84 (61%) were Multi-Drug Resistant Organism infections, such as MRSA.

The researchers suggest the 1 in 5 figure is probably an underestimate because the study did not include patients seeking out-of-network care or those receiving prolonged or inappropriately broad antibiotic therapy.

The authors didn’t say this, but keep in mind that the study was done at Johns Hopkins – perennially ranked as one of the best hospitals on the planet.

Conclusion: “Although antibiotics may play a critical role when used appropriately, our findings underscore the importance of judicious antibiotic prescribing to reduce the harm that can result from antibiotic-associated ADEs,” said one researcher.

Decrease the Demand Please

Here’s a helpful video on antibiotic-resistant infections from Time. The key message is that we’re misusing antibiotics in 2 ways:

(1) We use them for the flu which isn’t affected by these drugs. And according to the CDC, antibiotics can’t cure the common cold or viral pneumonia, are almost never needed for bronchitis, are not recommended to treat many ear infections, and are typically not needed to treat a sinus infection (sinusitis).

(2) 80% of antibiotics are used in our food animals to keep infections at bay (i.e. they’re used on the animals when they aren’t even sick), and as a way to encourage chickens, pigs, cattle, turkeys, and (farmed) fish, to grow larger and produce more meat.

The upshot is that with so many antibiotics circulating in people and in animals, bacteria mutate to find ever more clever ways of becoming resistant to the drugs. The answer is to put the brakes on how we use antibiotics: we need to decrease the demand. Treat them more as a drug of last resort & limit their use in industrial farming to the treatment of sick animals.

 

Oops: The U.S. spends $3.4T a year on healthcare. And look what they get for it

From the Stanford School of Medicine’s conference on Big Data last week, the following graphic has emerged that’s attracting a lot of attention on Twitter. And as sobering as these numbers are, there was a report out of Johns Hopkins last year that said medical error is actually the 3d leading cause of death in the US – and that probably underestimates the scope of the problem.

This is from the Twitter feed of Eric Topol, MD, who was the opening speaker at the Stanford conference:

 

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The G20 enters the fray

German Chancellor Angela Merkel poses for a group picture at a meeting of the G20 health ministers in Berlin

While this guy is being lambasted for his approach to science & medicine, we can be thankful that the true leader of the free world, Angela Merkel – who holds a PhD in chemistry – is going about things quite differently.

For example, this past weekend under the leadership of Chancellor Merkel, Health ministers of the G20 leading economies met for the first time and agreed to work together on the growing problem of drug-resistant infections and to start implementing national action plans by the end of 2018. In a joint statement the Health ministers stressed the need to:

  • Combat antimicrobial resistance (AMR) through appropriate monitoring and surveillance of antimicrobial resistance and consumption in G20 countries
  • Raise awareness on AMR prevention and control across multiple stakeholders
  • Prioritise the need for infection prevention, control, sanitation and vaccination across health systems
  • Promote judicious use of antimicrobials through education and training of health professionals
  • Foster research and development for new antimicrobials, alternative therapies, vaccines and rapid-point-of care diagnostics

But why is the G20 – whose mandate is the promotion of international financial stability – making antibiotic resistance a priority? Here’s what economist & former chairman of Goldman Sachs, Jim O’Neill (who wrote a highly persuasive report on antibiotic resistance commissioned by then Prime Minister David Cameron) said last September:

As [drug-resistant infections] renders established antibiotics ineffective untreatable infections will make relatively routine procedures such as organ transplants or cancer chemotherapy increasingly risky. The human and economic toll of rising [drug-resistant infections] could easily spiral out of control: left unchecked, drug-resistant infections could claim ten million lives annually by 2050, with the cumulative cost in terms of global GDP reaching $100 trillion. [My emphasis.]

In other words, as the G20 said at the same time as the O’Neill statement, “AMR poses a serious threat to public health, [economic] growth and global economic stability.”

 

The other problem with antimicrobial resistance: We don’t know what the words mean

If you don’t understand the term “antimicrobial resistance,” don’t feel bad  —  neither does anybody else. In a commentary & interview this month with the leading science journal Nature, infectious disease specialist Marc Mendelson said the term “antimicrobial resistance” is not understood by the public and should be abandoned, replaced with “drug-resistant infection” and “antibiotic resistance.” Dr. Mendelson:

The studies … highlighted the fact that the main term … that is used … “antimicrobial resistance,” less than 50% of people have heard of the term; that it’s abbreviation which is commonly used, which is AMR, less than 20% have heard of this term; and there’s a complete blank look on people’s faces often when you discuss these terms. So, without understanding of the problem, use of … terminology … that people don’t understand can have serious impact on your ability to try and take the discussions and, more importantly, the actions, further.

This matters because the problem of drug-resistant infections requires more than just scientists to solve. Mendelson: “It requires engagement from a much broader array of players, from governments, regulators and the public, to experts in health, food, the environment, economics, trade and industry. People from these disparate domains are talking past each other. Many of the terms routinely used to describe the problem are misunderstood, interpreted differently or loaded with unhelpful connotations.” Hence the need to get everyone on the same language page.

Mendelson offers a cogent example of the benefit of adopting the right words: The decision to name the cause of AIDS as human immunodeficiency virus (HIV) in 1986  —  instead of human T-cell lymphotropic virus (HTLV-III) or lymphadenopathy-associated virus (LAV)  —  helped people to understand that the disease was caused by a virus that harms the immune system. “As such,” he says, “it was crucial in tackling stigma and phasing out terms such as ‘the gay plague’, which had previously dominated communication around AIDS.”

The following video was made for the public and nicely explains what a drug-resistant infection/antibiotic resistance is. In brief, it’s a 3-part harmony between the bug, the drug, and you. As bugs like staph aureus or E. coli get increasingly exposed to our drugs (antibiotics) through rampant misuse and overuse, the bugs fight back by successfully resisting the drug’s effect, & thus we stay sick. The media coined the term “superbug” to refer to bugs that have evolved this resistance.

Et Tu Canada? Like their U.S. counterparts, Canadian doctors are handing out antibiotics like candy

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We’re getting it wrong almost half the time: 46% of Canadian seniors who saw their doctors because of a nonbacterial respiratory infection were nevertheless prescribed an antibiotic, says a study published this week in Annals of Internal Medicine.

Physicians know the rule: antibiotics only work on bacterial-driven infections, not viral-driven ones, and the classic viral infections are the common cold & acute bronchitis. Yet in a sample of 8,990 Ontario primary care physicians and 185,014 of their patients who presented with a nonbacterial respiratory infection, typically the common cold or acute bronchitis, antibiotics were given to a whopping 85,106 people (46%).

So why the huge error rate? Lead researcher Michael Silverman MD, chief of infectious diseases at Western University in London, Ontario, told the CBC there are two main reasons: (1) the time pressure to see more and more patients, which is driven by financial incentives, and (2) “decision fatigue,” the idea that physicians who have to say no all day to patients asking for antibiotics just get tired of saying no. Which comports with US research suggesting doctors tend to prescribe more antibiotics later in the day, Silverman said.

Handing out antibiotics when you shouldn’t, says Silverman, matters because they have serious side effects such as diarrhea from C. difficile, a big issue in Canada and around the world; irregular heartbeats and sudden death; tendon rupture; adverse drug interaction; and antibiotic resistance, i.e. the more you use these drugs, the less effective they become.

While the study was conducted in Ontario with patients 66 years of age and older (because researchers had access to data on nearly all prescriptions for this age group), Silverman believes these findings generalize to all age groups and to the rest of the country.

Down in the Dirt: Say Hello To Your “Old Friends”

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Children now spend less time outside than the average prisoner. Adults spend 90-95% of their time indoors in their homes, work places, or cars. Living lives increasingly separated from the natural world comes with a cost, especially for kids, writes Paul Bogart in his new book The Ground Beneath Us. In an interview with National Geographic, Bogart says children need to be exposed to the microbes in the soil to build up their defenses against diseases that may attack them later:

“Kids these days are not being exposed to dirt because they’re not allowed to play outside. Their parents think dirt is dirty. But both the newest science and the oldest traditions tell us the same thing, which is that the ground is alive. The ground gives us life.”

The parents Bogart is talking about subscribe to the theory that dirt = microbes = germs (pathogens). This gave rise to the so-called hygiene hypothesis, the idea that early-life exposure to dirt/germs produces antibodies that protects us from disease – a sort of do-it-yourself vaccination program.

But there was a problem: Since the 1950s, in developed countries only, rates of multiple sclerosis, Crohn’s disease, type 1 diabetes, and asthma soared by 300% or more, and there were also spikes in hay fever and food allergies. And because scientists felt that our exposure to pathogens remained the same, they re-examined the hygiene hypothesis and discovered a problem: Yes, dirt = microbes; but no, microbes do not = germs. That’s because the vast majority of them are either necessary, helpful, or neutral. And by limiting our exposure to them we deprive ourselves of their health benefits.

A seminal article in the Proceedings of the National Academy of Sciences, titled “Cleaning up the Hygiene Hypothesis,” underscores Bogart’s view of the life-giving force of “dirt,” and argues we should replace the hygiene hypothesis with what they call the “old friends” hypothesis:

Today, epidemiological, experimental, and molecular evidence support a different hypothesis: Early exposure to a diverse range of ‘friendly’ microbes—not infectious pathogens—is necessary to train the human immune system to react appropriately to stimuli.

‘We realized human beings coevolved with a whole host of organisms, and it was far more likely what was going on was that we were being deprived of organisms on which we are dependent’ … early and regular exposure to harmless microorganisms—“old friends” present throughout human evolution and recognized by the human immune system—train the immune system to react appropriately to threats. It’s not that children … aren’t subject to enough infections when they are young, but that their exposure to the microbial world is far more circumscribed than it once was.

Young children continue amassing microbiota in every contact with family members, while playing outside in dirt, getting licked by dogs, and sharing toys with friends. The developing immune system takes cues from all of these encounters.

PNAS emphasizes that sequestering children away from the natural environment is one of several factors that reduces our exposure to necessary microbes. Others include the overuse of antibiotics (they kill good & bad microbes); the rise of caesarian sections (deprives the child of microbes found only in the birth canal); and the increased use of sanitizers that view microbes as signs of dirt to be destroyed.

PNAS also says that relaxing hygiene standards would not reverse this trend of rising rates of MS, Crohn’s, etc., but only serve to increase the risks of infectious disease. For example, they say, one can teach children to wash their hands after handling raw chicken but also encourage them to play outside in the dirt: “If your child has been out in the garden and comes in with slightly grubby hands, I, personally, would let them come in and munch a sandwich without washing,” says Graham Rook, an emeritus professor of medical microbiology at University College London.

 

The Humor Page: Comedian Kitty Flanagan advises doctors how to handle patients who demand antibiotics

Antibiotics have zero effect on the cold virus, yet patients keep insisting on them and doctor’s keep caving in to those requests. So how do we stop this? The C.D.C. has one approach. And Australian comedian Kitty Flanagan has quite another. In the video below (~ 3-min. mark) she role plays a doctor who sees a patient demanding antibiotics. This is how “Doctor” Flanagan handles it:

The heat is on: Anthrax has already escaped from our melting permafrost. It probably will again, with other pathogens to follow.

Anthrax is a deadly bacterium. Inhaled, it will kill 8 in 10 people if not treated in time. That’s why, in the wake of the 9/11 attacks, it was the microbial weapon of choice sent through the mail to Capitol Hill and media figures. It affected 22 people, closed down the Hart Senate Office Building for months, disrupted mail delivery, took billions of dollars to fix – and terrorized a nation. Imagine, then, what would happen if Nature were to melt the earth’s layer of permafrost, thereby causing the release of centuries-old stored anthrax into our atmosphere.

The drip, drip, drip of Nature’s involvement in pathogen release began, perhaps, last summer in northwest Russia when it was reported that a 12-year-old boy was killed by anthrax and 90 others were sent to hospital. Officials said the outbreak was caused by an unusually intense summer heat that melted the permafrost, exposing a reindeer carcass containing anthrax that spread to the local population. The regional governor imposed a quarantine on the Yamal Peninsula – the affected area – and insisted that the situation was under control. In the Yamal, it probably was.

But the melting permafrost problem we’re left with wraps around the global north – which includes the upper areas of provincial Canada – and is growing. For example, Inside Climate News reported in February that a massive permafrost thaw is underway in Canada: that 52,000 square miles are in rapid decline and this is potentially accelerating global warming.

Permafrost acts like a giant freezer. More than 1,000 feet deep in places, it has captured, stored and kept alive bacteria and viruses for a very long time. But as the permafrost thaws those infectious agents such as anthrax will come back to life and eventually infect people and animals. That’s in addition to the more publicized effects such as methane gas emission – which warms the planet by 86 times as much as CO2 – and a heaving landscape strewn with impassable undulating roads, drunken trees, and collapsing homes & buildings.

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Physician Birgitta Evengård, who heads the infectious disease unit at Sweden’s Umea University, studies how climate change alters the spread of diseases. She told NPR there’s likely to be more cases of anthrax resurfacing because climate change is causing the temperature in the Arctic Circle to rise very quickly.

EVENGARD: It’s about three times faster than in the rest of the world. And this means that the ice is melting, and the permafrost is thawing.

NPR: A hundred years ago, there were repeated anthrax outbreaks in Siberia. More than a million reindeer died. Now there are about 7,000 burial grounds with infected carcasses scattered across northern Russia.

EVENGARD: It’s not that easy to dig to bury these animals, so they are kind of very close to the surface.

NPR: Wow. So there could be these outbreaks happening every summer?

EVENGARD: Yes, this is serious.

NPR: People and animals have been buried in permafrost for centuries. There could be bodies infected with all kinds of viruses and bacteria, frozen in time. [Evengard] says scientists are just starting to look for it.

EVENGARD: So we really don’t know. This is Pandora’s box.

NPR: There’s also likely smallpox buried up there and the bubonic plague. So the question for researchers is, could these pathogens, like anthrax, ever be reactivated?

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