Polio Re-enters Equatorial Guinea

The eradication of the poliovirus suffered another setback. In the past, I have discussed the number of countries still harboring the virus and the threat that spill over events pose to neighboring nations. 

So in recent weeks, Equatorial Guinea, a country that hasn't had a polio case in over a decade has reported one.

The sequence of the virus isolated indicates it came from Cameroon (where 3 cases have occurred in 2014). The threat of these spillovers is reinforced because the Cameroon cases which began in 2013 were the result of spillover from cases in Chad which were themselves spillovers from Nigeria, where the disease remains. 

So, the current scoreboard is 37 cases--a case count higher versus this time last year--in 5 countries. The Big Three: Afghanistan, Pakistan, and Nigeria remain the heads of the polio hydra that urgently need decapitation.

Patients, BYOS (Bring Your Own Stethoscope)

The admonition to physicians and other healthcare workers to wash their hands before and after patient contact is well established (thanks to Ignaz Semmelweis) and has become part of professional conduct. By engaging in this process the transmission of pathogens--carried on the hands of a provider--between patients is diminished. 

However, even if hands are washed there may be other mechanisms pathogens can exploit to find new individuals to infect. A study, just published in the Mayo Clinic Proceedings, assessed the ability of a physician's stethoscope to be a vehicle of bacterial transmission. 

The study showed that the rate of stethoscope contamination was comparable to that of unwashed hands. 

The implications of this study are many. Stethoscopes are the tools of the trade of medicine and many physicians exhibit their own "flair" with their stethoscope (color, style, electronic features, engraving, etc). Just like it's been difficult to diminish the prevalence of physician white coats, despite evidence that they may also be routes of contagion, personal stethoscopes may be hard to dislodge.  Disposable patient-specific stethoscopes may be somewhat helpful but I believe total disruption of stethoscopes, by hand-held ultrasound devices, is likely to provide the best solution.

Sepsis: ProCESS shows Progress

The treatment of severe sepsis, colloquially known as blood poisoning, has underwent a real revolution in the last 10+ years largely on the basis of a seminal paper by Emanuel Rivers.

The Rivers study, conducted at one center, demonstrated impressive morality reductions when septic patients were treated to reach specific physiologic goals (that were essentially set to reflect normal physiology). The study protocol required the insertion of a central venous catheter.

Since that paper, early goal-directed therapy (EGDT) has become the paradigm and is the cornerstone to the sepsis management bundle. 

However, some debate has occurred over which goals are most important to achieve and whether the bundle can be de-bundled.

A major study on this topic, known as ProCESS and led by Pitt, was recently published in The New England Journal of Medicine.

The aim of this study was to determine whether EGDT with or without a central venous catheter for sepsis in emergency departments was superior to routine care. The results of the study, somewhat surprisingly, did not demonstrate any difference in mortality amongst the groups. 

The implication, to me, of this study is that early recognition and prompt treatment of severe sepsis is the key step that must be performed. I think part of this result is explained by the widespread diffusion of the general principles exemplified in the Rivers trial. Whether or not a formal protocol or central venous catheter is in place does not matter if one is treating severe sepsis appropriately. However, not everyone can function without a protocol so smaller hospitals may still fare better under a protocol-driven approach--as the accompanying editorial notes. 

Would a Caveman Observe the 5 Second Rule?

I think the recent study regarding the "5 Second Rule", which states that an item of food dropped on the floor is dropped is okay to eat so long as it is picked up within 5 seconds, is really unnecessary.

We literally reside in a world of microbes. They reside everywhere on the planet, including within the body. How are plates and forks immune to bacterial growth? Clearly, they aren't. 

How many seconds does food sit on a bacterial-laden plate?

One caveat, however. If food is visibly soiled after being dropped, say on a farm pasture, it's probably best not to eat it. But, the carpet in your living room or the kitchen floor? What would a caveman do? 

The Needle vs. The Nose

Of vaccine delivery methods, the needle is the one that brings the most apprehension to adults and children alike. Few alternate methods are currently available and include oral (e.g. oral polio vaccine) and, importantly for influenza, nasal mist. 

The nasal mist flu vaccine not only is easier to administer, not only does it mimic the means in which influenza sets up infection, it is a live but weakened--not killed--version of the flu. Data show that this version of the vaccine is preferred for children as it provides the more robust immunity than the ordinary vaccine. 

It was recently reported that the pioneering innovator who developed this vaccine, Hunein Maasab, died.

Commenting on his breakthrough vaccine, Dr. Maasab said: "I feel in a sense that I have accomplished my life’s dream." The secondary consequence of pursuing his life's dream--as it is for all innovators--was the bequest of a life-enhancing augmentation of man's armamenetarium against infectious disease. Thank you, Dr. Maasab.