Swipe right to connect young people to HIV testing

Midway through her sophomore year of high school, my patient told her parents that she had missed two periods and was worried she might be pregnant.

Stunned to learn that she was sexually active, her parents took her to the pediatrician, who had another surprise: She wasn’t pregnant but she did have H.I.V.

To learn more - including how my patient could have been protected from late H.I.V. diagnosis by a cool mobile app - check out my new post up at The New York Times. Many thanks to support from Dartmouth Public Voices Fellowship, a chapter of the Op-ed Project.

 

Will this new diagnostic test help us prevent antibiotic misuse?

Clinicians seeing a miserable patient with the sniffles or a cough commonly face a challenging choice: give them antibiotics on the off chance they help, or educate a patient who feels gross why those antibiotics won't work. More of than not, clinicians take the easy way out and reach for the prescription pad. 

The problem of course is that this leads to millions of unnecessary antibiotic prescriptions every year. It's one major driver of epidemic antibiotic resistance, and also why the epidemiology of the antibiotic-associated infection C diff is worse than ever. 

This problem doesn't persist because clinicians are stupid or uncaring. Rather, it is their best intentions that lead them astray. Faced with a concrete potential benefit for the patient in front of them versus an abstract risk down the road, often times clinicians choose that concrete potential benefit over a hard-to-imagine intangible risk like antibiotic resistance or future C diff. Even if the risks FAR outweigh any potential benefits.

A point-of-care test that could tell both docs and patients that those symptoms are definitively from a virus could really change that whole dynamic. And, it could save us from a lot of antibiotic misuse.

A new study out today brings us closer to that reality. Researchers out of Duke found gene expression combinations that were nearly unique to viral vs bacterial vs non-infectious illnesses. To learn more, check out this new post by Eric Boodman in STATnews. I was proud to be quoted in it. See also this very thoughtful post by the ever- excellent Judy Stone at Forbes.

This is not the first test to try to tell bacterial and viral respiratory infections apart. Other similar tests have tried the same thing, and seemed promising at the outset but ultimately flamed out. Take procalcitonin testing, for instance. The reason so many tests have failed before is that the promising diagnostic data found in early studies conducted amid artificially distinct clinical populations and implausibly controlled lab circumstances looked much worse once applied to the messy real world of clinical medicine. That's the next hurdle this new technology has to surmount: to show convenient quick utility in real patients in the real world.

I have my fingers crossed that this new technology will be better!

Posted on December 9, 2015 .

New science shows how loneliness makes older people frail

Every Monday during the summer, some of the residents of Lyme, New Hampshire, gather up fruits and vegetables from their gardens to donate to Veggie Cares, a program that distributes local food to people living alone. Volunteers collect, sort, and package the produce, then head out in separate directions to deliver the food to some Lyme's most vulnerable, isolated residents.

While the stated goal of the program is to provide people with healthy food, Veggie Cares volunteers also deliver companionship. Visits are often more than a quick drop-off—they may involve a shared cup of tea, an offer to replace burned-out light bulbs, or a chance to check in on sick or elderly neighbors.

Nine million elderly people currently suffer from food insecurity in the United States, and the produce provided by Veggie Cares is one way to safeguard the health of Lyme residents who may be at risk. But recent research supports the idea that the companionship the volunteers provide may be physically nourishing in its own way.

Read more in my new article (with the lovely and talented Jessica Lahey) over at The Atlantic

Why we shouldn't over-hype the use of PrEP to prevent HIV transmission

Recently we got great news from a real-world study of HIV pre-exposure prophylaxis (PrEP).

Researchers at San Francisco's Kaiser Permanente Medical Center reported on the real-world experience of 657 people who started PrEP between 2012 and 2015. Over 99% were men who have sex with men, 84% reported multiple sexual partners, and 30% had HIV-positive partners. Together they were observed for over 388 person-years of PrEP use.

The big news: Exactly zero patients contracted HIV infection! That's huge.

The problem is, the popular conversation about it has been over the top. From The Washington Post to FoxNews and the Huffington Post, people have been saying it's "100% effective" and lots of other undeserved superlatives.

PrEP works, this study was great, but there is real danger in all of this over-hype.

Read more in my new post over at TheBodyPro

Posted on September 19, 2015 .

Is the new Ebola vaccine too good to be true?

Ebola is on the run: the number of cases dipped below ten a week recently, and a few days ago investigators announced in the prestigious journal The Lancet that a new Ebola vaccine was “100% effective.”

In response, global health authorities are starting to sound a little giddy. “We believe that the world is on the verge of an efficacious Ebola vaccine,” said Marie Paule Kieny, the World Health Organization’s assistant director-general for health systems and innovation (and a senior author on the paper). “It could be a game changer.”

She’s right: this is wonderful news, and a great testament to human ingenuity. A genetically engineered hybrid of the benign vesicular stomatitis virus and the Zaire strain of Ebola, together called rVSV-ZEBOV, was tested in a multi-site clinical trial conducted amid a massive aid response in Guinea, one of the poorest countries in Africa. The scientific and logistical acrobatics required to pull this off boggle the mind.

Yet, for three reasons, we cannot know if the vaccine really worked, or how well. 

To read more, check out my new post over at The Conversation.

New challenges of an aging epidemic

The AIDS activist Larry Kramer once said,

AIDS was allowed to happen. It is a plague that need not have happened. It is a plague that could have been contained from the very beginning.

The past 10 years we have witnessed innumerable incredible advances in HIV science and HIV treatment, but Mr. Kramer's words still ring true. We could have done more to stop it, and we still leave a lot of the work left undone.

This is particularly poignant since new challenges have now joined the old scourges of poverty and stigma and the wily habits of a historically pernicious virus. 

These new challenges include what one of my patients called the "Peter Pan Syndrome" and an uptick in injection drug use in many areas of the United States. The Peter Pan Syndrome is when patients told they did not have long to live at the beginning of the HIV epidemic now grapple with the accelerated effects of aging, a phase of life they never thought they would face. Additional challenges include complacency in youth who didn't grow up losing friends from HIV, and donor fatigue, and the short-term thinking of budget-conscious legislators who cut funding to HIV prevention programs that save lives.

These and other modern realities of the 2015 HIV epidemic are on full display in a new article in the Concord Monitor in which I was proud to be quoted, including:

The most pernicious myth in the HIV epidemic today is that people infected with HIV contracted the virus because they are somehow different – that in some way people with HIV deserved to get infected. This is hard-hearted and ill-informed, but I understand how the finger-pointing can be a defense mechanism against fear. The truth is, we are all vulnerable to this wily virus, and the only way we will win against HIV is to band together in compassion.

Twenty years from now will we look back and say we learned from our early mistakes, or will we rue the mistakes we made again and again?

The Placebo Gene

Scientists from Harvard Medical School recently published a persuasive summary of evidence behind a revolutionary idea: that the placebo effect has genetic origins.

Although their work is preliminary, it raises some fascinating questions.

Might people with a genetic predisposition to larger placebo effects skew the results of small clinical studies if they're unevenly allocated to one or another of the study groups?

Should clinical trials stratify their analyses by placebo genetics?

The most fascinating use of this observation, I think, could be the development of novel therapeutics that leverage the mechanisms underlying the placebo effect. Forget the underlying pathophysiology - perhaps we could just focus on wellbeing. 

Proud to be quoted in a nice story by Lisa Rappaport in Reuters. Here's another nice summary and the original article on which they were based.

Posted on April 16, 2015 .

Protecting patients from employee drug diversion

In May 2012, Exeter Hospital in Exeter, New Hampshire, announced it would temporarily close its cardiac catheterization lab after dozens of patients were diagnosed with acute hepatitis C infection.

In time, a multi-state investigation revealed that every case was linked back to a lab technician who was using patient drugs himself, and then putting contaminated vials back into use.

Further, there were multiple opportunities for the hospitals in which this technician worked to protect patients from him - but none were taken.

In a new article, ethicist Bill Nelson and I propose a nationwide reporting system that would help protect patients from the risks of drug diversion-related outbreaks like this one. 

Posted on March 13, 2015 .

Why it's getting harder to know if someone is dying

We tried our best, but CPR, an injection of epinephrine, and 360 joules of electricity all failed to restart Mrs. Melnyk’s heart. When everybody on the resuscitation team agreed that we could do no more, I said the words: 

“Time of death, 9:32.”

As we cleaned up, a young nurse began to tuck a clean white sheet around Mrs. Melnyk’s body—and then suddenly stopped. 

“Wait!” she shouted, pointing at the heart monitor. There on the screen, an electrical impulse registered and quickly disappeared, replaced by a flat green line. “It’s too soon to give up!” the nurse said. 

It turned out the young nurse had been fooled by a stray electrical discharge on an EKG machine. Together with her supervisor, we talked it through, and did not prolong the code blue.

That kind of confusion is getting more difficult to clear up, though. With newer technologies like PET scans and ECMO, the dividing line between life and death is getting harder to define. 

To read more, check out my new post in The Atlantic.