By Hannah Park, MD
Peer Reviewed
The winter storm Jonas was a much buzzed about topic for days leading up to its arrival this past weekend, and it truly lived up to its billing as an extraordinary weather event. Jonas now claims status as the second-largest storm in New York City history, with 27 inches of snowfall having rapidly accumulated during Saturday (1). Along with the declaration of state of emergency, Jonas single-handedly paralyzed NYC transit, prompting a complete travel ban on road traffic. As a result, the normally bustling and boisterous NYC sounds were eerily diminished by the lack of traffic, replaced instead by muting heavy snowfall, gusty winds of more than 40 mph, and intermittent laughs of NYC residents who braved the elements to engage in impromptu snowball fights. Jonas not only stunned NYC by storm, but traversed the Mid-Atlantic to the Northeast, leaving an impressive trail of cities buried in snow.
This week in Primecuts we will touch upon a smattering of medical topics from the rise of the Zika virus to global views on antibiotic resistance. We will also peek at a new prospect for treatment of refractory Clostridium difficile infections, and an NYU-based study on how physicians personally face end-of-life decisions.
Zika virus, the most recent arbovirus to strike the Americas:
Though snowstorm Jonas has most recently impacted the east coast of North America, the Zika virus has been the most recent arbovirus to sweep through the more temperate Southern America. The threat of the Zika virus, a virus transmitted by the Aedes mosquito, is reviewed in a recent article published in the New England Journal of Medicine (2). Estimates of 440,000-1,300,000 cases have been identified in Brazil alone. Similar to its predecessors including dengue fever and chickungunya, Zika can often cause a flu-like syndrome including arthralgias, and lacks a definitive treatment. Zika virus has also been concomitantly tied to specific and devastating neurological sequelae. Zika virus has been linked to a 20-fold increase in the incidence of microcephaly in Brazil, which is thought to be caused by mosquito bites during pregnancy. Furthermore, there is a reported increased incidence of Guillan-Barre syndrome in the French Polynesia with 70 cases reported in a population of 270,000.
Thus far, prevention of mosquito bites with repellant and other such mechanical barriers have been identified to help prevent the spread of this disease (3). However, these are not the most amenable methods for a mostly impoverished urban population. It is imperative that more interventions are pursued, especially in light of the coming Olympics being hosted by Brazil this August 2016.
Global views on antibiotic resistance:
A multi-country survey conducted by the World Health Organization that included 10,000 participants across twelve countries uncovered widespread misunderstanding about antibiotic resistance (4). Of note, two-thirds of participants (nationally representative samples of adults over the age of 16 years) expressed awareness of the issue of antibiotic resistance and that it would affect themselves and their loved ones. However, there were also salient misunderstandings divulged in this study. One third of participants thought once they felt well on antibiotics, they could self-discontinue the medication. Three-quarters of participants believed that “antibiotic resistance” described the people becoming resistant to the medication, versus the bacteria. In addition, 25% of the participants stated that they believed using leftover antibiotics from friends or family was acceptable for experiencing similar symptoms.
Take away messages include the need for improved and more widespread public education on a variety of crucial points. This includes the importance of taking antibiotics for the entirety of the duration recommended, recognizing the customized nature of a prescription written by a medical professional and understanding the fact that antibiotics address bacterial, not viral infections.
Frozen vs. fresh fecal microbiota transplantation for refractory clostridium difficile infection:
Clostridium difficile infection (CDI) is a prevalent infection in the hospital setting. Refractory CDI has become an issue of significant concern and though fresh fecal microbiota transplantation (FMT) has arisen as a potential intervention, it has not become easily accessible (5).Whereas fresh FMT has been proposed previously, a recent study published in JAMA examines the prospect of frozen FMT for the treatment of refractory CDI. In this randomized, double-blind trial, patients were randomly allocated to receive fresh or frozen FMT treatment via enema. Outcomes were measured by resolution of diarrhea with no relapse within 13 weeks and no adverse effects. Overall, the resolution of diarrhea was 83.5% for those who received frozen FMT vs. 85.1% for those who received fresh FMT (difference, −1.6% [95%CI, –10.5% to ∞ ]; P = .01 for noninferiority). Frozen FMT may offer wider accessibility for treatment, as the stool preparation protocol utilizes disposable equipment and frozen FMT is administered through less invasive means than fresh FMT. Finally, compared to fresh transplantation, frozen FMT provides further protection from potential transmission of pathogens between donor and recipient.
Relationship between occupation as physician and passing away in a hospital setting:
It has been reported that there are a higher percentage of people who would prefer to pass away at home compared to a hospital setting (6). Unfortunately however, this cannot always be anticipated, or easily facilitated. It has been brought up that physicians prefer to pass away after fewer interventions, and are more attuned to end-of-life goals. This may stem from firsthand exposure to goals of care situations and discussions that occur on a day-to-day basis within the workplace.
JAMA published a retrospective chart review study utilizing the National Longitudinal Mortality Study, a randomized sample based on the US census and stratified across demographics. Of the approximately 500,000 decedents chart-reviewed in this study, around 800 were physicians, 2600 in other health professions, and 15,000 of equivalent education level of physicians. Overall of the deaths in a facility, the lowest rate was that of physicians at 63.3%, compared to 65.4% of people in other health professions, 66.1% for people of comparable educational background as physicians, and 72.4% for the rest of the population. The groups other than physicians also had higher likelihoods of dying in any facility (other health professionals: AOR, 1.34 [95% CI, 1.32-1.37]; comparable higher education: AOR, 1.12 [95% CI, 1.11-1.14]; and all others: AOR, 1.34 [95% CI, 1.32-1.37]). Studies are currently lacking, but this may be a stepping-stone to more formally exploring the increased differentiation of goals-of-care in health care providers.
Mini cuts:
Other health-related tidbits to spur on further reading:
The Lancet delves into Cuba’s strength in preventative medicine- one that is particularly rooted in local communities based on “polyclinics”, creating primary care and public health models to be emulated by other countries (7)
The U.N. has identified 2016 as the “International Year of Pulses”, a global marketing plan for feeding a growing population. Pulse crops are legumes including beans, peas, lentils, and chickpeas, particularly within dry form. This food category is promising for food security in providing ample protein and dietary fiber, requiring less water to grow, and fairly available in different climates universally. (8)
Staph aureus infection has quite an impact within the hospital setting, and pLOS explores how susceptibility to and severity of Staph aureus infection can relate to host genetic variation, including at the clonal, gene, and SNP levels. (9)
Dr. Hannah Park is a 1st year resident at NYU Langone Medical Center
Peer reviewe by Karin Katz, MD, Chief Resident, Internal Medicine, NYU Langone Medical Center
Image courtesy of Wikimedia Commons
References:
- http://www.msn.com/en-us/news/us/massive-blizzard-paralyzes-new-york-and-washington-19-dead/ar-BBoCOeE
- Fauci, A and Morens, D. Zika virus in the americas- yet another arbovirus threat. N Engl J Med. January 13, 2016; in press online. http://www.nejm.org/doi/full/10.1056/NEJMp1600297
- Kamran, Khan et. al. Anticipating the spread of zika virus from Brazil. Lancet. January 14, 2016; in press online. http://thelancet.com/journals/lancet/article/PIIS0140-6736(16)00080-5/fulltext
- Antibiotic resistance: multi-country awareness survey. World Health Organization. 2015. http://apps.who.int/iris/bitstream/10665/194460/1/9789241509817_eng.pdf
- Lee, Christine et. al. Frozen vs. fresh fecal microbiota transplantation and clinical resolution of diarrhea in patients with recurrent clostridium difficile infection: a randomized clinical trial. JAMA. 315 (2):142-149. http://jama.jamanetwork.com/article.aspx?articleid=2481003
- Blecker, S et. al. Association of occupation as a physician with likelihood of dying in a hospital. JAMA. 315 (3): 301-303. http://jama.jamanetwork.com/article.aspx?articleid=2482317
- Loewenberg, Sam. Cuba’s focus on preventative medicine pays off. Lancet. 387 January 23, 2016; in press online. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)00155-0/fulltext
- https://www.washingtonpost.com/lifestyle/food/why-a-food-you-have-never-heard-of-could-be-key-to-feeding-the-world/2016/01/11/9e8f14da-b587-11e5-9388-466021d971de_story.html
- Messina, Julia et. al. Impact of Bacterial and Human Genetic Variation on Staphylococcus aureus Infections. PLOS Pathogens. January 14, 2016; in press online. http://journals.plos.org/plospathogens/article?id=10.1371/journal.ppat.1005330