App Updates

November 29th, 2018

The IDPodcasts Team appreciates all the interest we receive on a regular basis for our smartphone and tablet apps. Although we premiered an all new web site in 2018, our app updates have lagged behind. A few months ago, our Android app stopped working due to software compatibility. Our IOS app continues to function, but is sorely in need of new updates.

Fortunately, in 2019, the IDPodcasts platform will welcome new Android and IOS apps! We hope that these new generation apps will include additional functionality that all of our users will enjoy. Specifically, we wish to integrate:

1. Standalone audio podcast compatibility for listening in environments where an audio podcast is appropriate (such as in the car) and where you need your phone for other purposes.
2. Feedback comment capability within the app.
3. More comprehensive indexing.
4. News, blogs, and other features we have added to our web site this year.

While we bring our new apps to completion, for (especially Android) smartphone and tablet users who cannot use our apps, please note that our website is mobile device friendly and should play in any browser. Also, all of our podcast content is still available at our youtube channel at http://www.youtube.com/idpodcasts.

Thank you for supporting our content now for over ten years!

IDWeek 18: Reflecting on a terrific meeting at the foot of the Golden Gate

October 23rd, 2018

Richard L. Oehler, MD
Professor, USF Division of Infections Diseases
Editor, IDPodcasts platforms

Since 2004, I have tried to make IDWeek (formerly known as the “IDSA annual session”) a regular annual event on my professional meeting calendar. Usually held in October, I find this scientific meeting to be a terrific way to connect with long lost colleagues and former fellows, update myself on new science in the form of freshly published abstracts and recently published research, and to refresh my core knowledge in infectious diseases by attending state-of-the-art symposiums and other conference sessions.
This year, IDWeek 18 was held in San Francisco, California from October 2 through October 7. Though the Moscone Center is currently undergoing renovations, making getting around the convention center and Yerba Buena area somewhat more difficult, the pleasant fall San Francisco weather made up for some of the city’s inconveniences.
Conference days at IDWeek can be busy–it is possible to attend as many as 11 hours of scientific sessions each day, and even more if you participate in some of the affiliated (i.e., industry sponsored satellite) meetings. As much as I tried to attend as many sessions as I possibly could, I found my few days at IDWeek to be a balance of scientific meetings, poster sessions, industry exhibits, and connecting (and reconnecting) with friends and colleagues.

As far as the scientific sessions I attended, I needed a few days to reflect on what I had learned before I could put it together in my mind. Now, after being back for a couple of weeks, my chief takeaways from IDWeek are as follows:

Non-tuberculous mycobacterial (NTM) Infections
There was an excellent session on nontuberculous mycobacterial (NTM) infections featuring information on both Mycobacterium avium complex (MAC) and rapid grower mycobacterial (RGM) infections (chiefly Mycobacterium abscessus complex). The presenters made clear the importance of achieving the clinical and microbiologic diagnosis of nontuberculous mycobacterial disease. Traditional diagnostic criteria, of course, emphasize the importance of clinical symptoms, radiographic changes and the exclusion of other diagnoses. The session emphasized the value of a microbiologic diagnosis afforded by either two positive sputum specimens, one BAL specimen and/or appropriate histopathology. The presenters mentioned the need to consider surgical resection of NTM lesions in the presence of geographically discrete disease or when there is failure to respond to medical therapy. Aminoglycoside therapy with amikacin continues to be a critical component of induction therapy in patients who are initiated on an antimycobacterial regimen, but toxicity concerns with aminoglycosides should always be kept in mind. Patients with extensive structural lung disease, resistance to macrolides, and/or persistent smear positivity all are likely to experience poor response to treatment. Similarly, in Mycobacterium abscessus complex disease, the importance of the erm (41) gene as a factor in the treatability of lung disease was emphasized. A significant predictor of progression is low BMI and either bilateral and/or cavitary disease. Some promising new therapies for refractory disease include clofazimine, bedaquiline, and the oxazolidinones; inhaled amikacin and inhaled nitrous oxide therapy may show some promise. Nontheless, NTM lung disease continues to be a frustrating disorder to treat in many severely affected patients.

HIV Disease and Pre-exposure Prophylaxis (PREP)
I was fascinated by a discussion regarding implantable devices useful in preexposure prophylaxis (PREP) for HIV infection. Such devices would be analogous to the Nexplanon contraceptive implant, which provides as much as 3 years of continuous pregnancy prevention. The implants would need to contain extremely potent long-lasting antiretrovirals given their compact size and anticipated life expectancy.
In other HIV news, the recent New England Journal study utilizing Ibalizumab (N Engl J Med 2018; 379:645-654.) in persons with multidrug-resistant HIV was discussed. In this phase 3 trial, 40 heavily treatment experienced patients with multi class antiretroviral resistance were included in the study. After a seven-day control period, a 2 g loading dose was given and functional monotherapy was observed for 7 days. The patients were then started on a regimen optimized to include ≥ 1 fully active agent. Eighty-three percent (83%) of the patients who completed the study achieved the primary endpoint ≥ 0.5 log drop in their viral load after the loading dose (statistically significant). About 43% at week 24-5 had undetectable viral loads. Other advanced therapies discussed during this HIV symposium included a phase 3 trial utilizing fostemsavir, a GP120 blocking agent that inhibits HIV attachment to CD4, PRO 140, a monoclonal antibody against CCR5, and Doravirine, a next generation NNRTI for treating HIV-1 infection. Doravirine has demonstrated non-inferiority to Ritonavir-boosted Darunavir and non-inferior efficacy to Atripla (week 48) in twin phase 3 clinical trials.

Staphylococcus aureus infections
In a symposium on the optimal management of Staphylococcus aureus infections, the authors attempted to answer several pressing questions regarding disease management. Regarding the optimal agent for invasive MSSA infections, the authors presented evidence suggesting that cefazolin therapy is probably better than nafcillin (McDaniel. CID 2017 Jul 1;65(1):100-106.) , but that some caution should be exercised with infective endocarditis and other deep-seated infections. In addition, some MSSA strains exhibited what was called the Cefazolin inoculum effect (CzIE), which resulted in the development of high MICs (≥ 16 ug/ml when the strains were incubated with high colony concentrations of MSSA (~107 CFU/mL) versus standard colony counts (~105 CFU/mL). The authors concluded that the clinical significance of CzIE is unclear. For treatment of MRSA bacteremia, the speakers presented data suggesting that for MRSA bacteremia with a vancomycin MIC ≥ 1.5, an early switch to daptomycin was associated with better outcomes. Furthermore, in a multicenter retrospective cohort in cases of MRSA bacteremia with a vancomycin MIC > 1, failure rates were similar and there was less kidney injury in the daptomycin group. Regarding whether combination therapy is useful in the treatment of Staphylococcus aureus bacteremia, data was presented (Thwaites, et. al. Lancet 2018;391:668-78.) suggesting that there was no 30 or 90 day mortality benefit in the addition of a beta lactam plus a second agent (typically, rifampicin, a fluoroquinolone, an aminoglycoside or fosfomycin) except for adding rifampin when there is prosthetic material. When considering oral stepdown therapy for the treatment of endocarditis, there have long been questions about how effective partial or fully oral regimens are for the treatment of Staphylococcus aureus endocardits. This is particularly true in cases where a prolonged course of IV therapy is not possible or carries significant safety risks. The recent NEJM POET study (Iverson. NEJM 2018) looked at 400 patients with left-sided gram-positive endocarditis and compared outcomes in those who received at least 10 days IV therapy and then were either switched to oral therapy or continued on intravenous agents. The most common oral regimens were either dicloxacillin plus rifampin or amoxicillin plus rifampin. The findings applied to MSSA only and in patients with no extracardiac complications. The study showed that in patients with endocarditis on the left side of the heart who were in stable condition, changing to oral antibiotic treatment was noninferior to continuing intravenous antibiotic treatment. However, the same results do not apply to MRSA cases. Lastly, regarding salvage options for highly resistant Staphylococcus aureus, data was presented suggesting some utility for the combination of daptomycin and ceftaroline based upon a recent multicenter observational study (Zasowski, et. al. AAC 2017).

Opioid Use Disorder

Many clinicians attended a session on the importance that infectious diseases providers can play in the management of opioid use disorder when we intervene for infectious complications of their substance use. This discussion included information on so-called “supervised safer injection facilities” (SIS) where substance users can safely inject IV drugs under the nonjudgmental supervision of healthcare providers. Nearly 100 of these SIS facilities are in existence in Canada, Europe and Australia, but so far, are only apparently being considered or debated in the United States. The symposium presenters asserted that literature suggests that such supervised facilities reduce infectious diseases transmission, improve overdose morbidity and mortality, increase access to healthcare, do not increase crime or public disorder, and are cost effective. It remains to be seen if such facilities gain a foothold in U.S. communities (such as San Francisco) with significant IVDA populations.

Klebsiella pneumoniae, CRE, and HvKP
In a symposium regarding the “Big Beasts” of infectious diseases, two “Big Beasts” of Klebsiella pneumoniae were discussed, including hyper virulent Klebsiella pneumoniae (HvKP) and, Carbapenemase-producing Klebsiella pneumoniae (CRKP). First described in Taiwan in the 1980s as a cause of pyogenic liver abscess, HvKP is an emerging cause of community-acquired infections in immunocompetent hosts. This strain of Klebsiella can produce a variety of systemic manifestations, including necrotizing fasciitis, osteomyelitis, and meningitis. Fortunately, HvKP appears to be less likely to demonstrate multidrug resistance in comparison to “classic” Klebsiella pneumoniae. CRKP continues to become a more significant cause of hospital-acquired infections, most recently associated with duodenoscopes. Emerging treatments for carbapenemase resistant Enterobacteriaceae (CRE) include cefazidime-avibactam, plazomycin (a new novel aminoglycoside), meropenem-vaborbactam, imipenem-relabactam, aztreonam-avibactam, and cefiderocol. There is concern that these twin strains may share resistance factors via plasmid-related convergence, leading to hyper virulent MDR Klebsiella pneumoniae.

Febrile Neutropenia
The management of febrile neutropenia was discussed in a separate symposium with regard to bloodstream infections, particularly those with ESBL positive Enterobacteraceae. The recent MERINO trial (Harris, et. al. JAMA. 2018;320(10):984-94.) involved 26 hospitals worldwide and looked at 30 day mortality when Escherichia coli and Klebsiella pneumoniae ESBL positive bloodstream infections were treated with piperacillin-tazobactam versus meropenem. This study found that the 30-day mortality was significantly higher (12.3%) in the Piperacillin-Tazobactam group than in the meropenem (3.7%) group. Conversely, the mortality associated with carbapenemase-resistant gram-negative bacteremia was significantly greater, suggesting that carbapenem use should still be restricted to reduce the emergence of carbapenemase-resistant Pseudomonas, Acinetobacter and Enterobacteraceae. A study by the European conference on infections including leukemia published by Mikulska in the Journal of infection (Mikulska, et. al. J Infect 2018;76(1):20-37.) was also discussed. This review showed no reduction in mortality through the common use of fluoroquinolone prophylaxis in prolonged neutropenic patients (> 7 days), although rates of bloodstream infection and fever episodes were decreased. The review suggested that fluoroquinolone prophylaxis should be utilized in high-risk patients only and be dependent upon local epidemiology and practice.

Fun and Games
Unfortunately, IDWeek is far too large a meeting for the totality of its expansive and compelling scientific program to be described here. For me, a highlight was clearly the 3rd annual ID Bug Bowl. This is the annual infectious diseases quiz competition that caps off the meeting, usually on the evening prior to the closing plenary. Even though we here at IDPodcasts still lay first claim to the term “Bug Bowl,” (Our “Bug Bowl: Bacteriology edition” podcast appeared online in 2015 the year before the first IDWeek session was inaugurated in 2016), we still try to attend every year to take in some of the excitement and “infectious” enthusiasm (pun intended) conveyed by the medical students, residents, and infectious diseases fellows from 3 or 4 different institutions who are its participants. This year, Wake Forest University and University of Kansas Medical Center battled local San Francisco institutions UCSF and Stanford University for more than an hour in a Jeopardy-style format. After “FINAL IDBugBowl,” which all participants wagered on their answer to the question, “Oculomasticatory mylorythmia is pathognomonic for this infectious disease,” Stanford University was declared the winner. Congratulations to them and all the participants!

If you know which infectious disease is associated with “Oculomasticatory mylorythmia,” please answer in the comment section of this blog. Next year’s IDWeek will be held in Washington DC on October 2-6, 2019.

Can Technology Reduce Infection in the Food Industry?

July 13th, 2018

As I often do, I recently spent a few moments on a Friday morning reviewing the CDCs “Current Outbreak List” page. This resource is a single page clearinghouse for recent United States and international outbreaks reported on by the Centers for Disease Control and Prevention. On the day I reviewed the page, recent Salmonella-based outbreaks in breakfast cereal, pre-cut melon, live poultry and backyard flocks and pet guinea pigs were mentioned. Other Salmonella-related outbreaks occurring in 2018 included dried coconut, chicken salad, Kratom, raw sprouts, cucumbers, and papayas.

The predominance of Salmonella among food-borne pathogens is not surprising, as non-typhoidal Salmonellae in the US is one of the leading causes of foodborne disease. It is also a major cause of worldwide diarrhea. The high prevalence of non-typhoidal salmonellosis in the food supply has been primarily associated with agricultural reservoirs, most commonly with poultry and chicken eggs. In recent years, outbreaks associated with raw produce have increased in prevalence, perhaps related to contamination of the food chain resulting from run off from animal agricultural lots, or the secondary cross-contamination of produce during harvesting, processing, or food preparation. Yet this is not a new phenomenon. Foodborne outbreaks have been an issue in the U.S. food industry for decades.

In the course of researching this topic, I came across a media report entitled, “Expert: Technology could help make food safer.” The article was an interview of Dr. Dennis Maki, a well-known professor in epidemiology at the University of Wisconsin School of Medicine and Public Health. Dr. Maki noted that the era of feeding 300 million plus people through the use of small farms and simple agricultural techniques has long since passed.

Dr. Maki said,

“it’s important to realize there are 300 million people in the US. The only way you are going to feed 300 million people is by industrial techniques. The common complaint or the plea is, ‘lets return back to 1945, let’s have small farms, let’s not have industrial farming and industrialized production of food on a huge scale. Then we wouldn’t have the problems that we have now.” But such an approach would not result in the ability of our agricultural industry to feed a 21st Century population, he asserted.

Dr. Maki emphasized several approaches for the consumer to reduce their likelihood of acquiring foodborne illness. (1) Buy food from reputable sellers. Most large grocery chains are highly reputable, or they would not be in business. (2) Wash fruits and vegetables thoroughly as this will greatly reduce, though not completely eliminate contamination. (3) Cook meats properly and to the recommended temperature.

The article featuring Dr. Maki, though very relevant today, was not from 2018, but 2007. And over the last decade, seemingly very few manufacturing components of the agricultural industry appear to have changed. However, the grocery marketplace continues to emphasize foods that are more “natural,’ ‘organic,’ or preservative-free. Similarly, upscale grocery chains promote food products that are marketed as being less associated with the food-industrial complex (grain fed beef, cage-free eggs, organic sprouts, etc.). At the same time, the public’s insatiable demand for all-season produce results a food distribution system that needs to be worldwide. (i.e., grapes from Chile, avocados from Mexico, pineapples from Thailand, oranges from Brazil, figs from Turkey, etc.)

So the original question in the 2007 article still applies today: “Can technology reduce infection in our food?” One of the most fascinating and progressive areas where technology is pushing the envelope is in the meat industry. American consumers eat 26 billion pounds of beef a year. A single cow is said to consume up to 11,000 gallons of water annually. The fast food chain McDonald’s cells 75 hamburgers every second. As a result, the cultivation of meat products requires a huge worldwide industry that is estimated to be responsible for 15-20% of all greenhouse gas emissions. Furthermore, the production of the millions of poultry, pork and beef livestock animals places considerable demands on agricultural areas to contain and manage the tremendous quantities of animal waste and other industrial byproducts of meat processing, much of which is at risk for contamination of the environment and at various points in the food chain.

As a result, several Silicon Valley technology start ups have for several years now been working on different lab-based techniques for the production of meat. The concept in itself is deceptively elementary: What if the production of meat could be made as simple as growing yeast in a vat? If we could turn the philosophy of, “kill it and grill it” to “fill it and then distill it.” If we could culture meat in a lab and then grow it utilizing industrial techniques similar to beer production, this would eliminate a large proportion of the land use, water consumption, greenhouse gas admissions, and production of animal byproducts that result in the runoff of enteric pathogens such as Salmonella and the contamination of the environment and of our food.

Just, a Silicon Valley company, is perhaps the leader in attempts to bring the first “clean meat” products to market. Their process involves the development of a large-scale cell culture process for cultivating sustainable meat cells into high-grade meat and seafood with a production process that promises to be over 10 times more efficient then the world’s largest slaughter houses. They claim their process uses unmodified cells which naturally occur in livestock animals and can be grown antibiotic free. Because the process does not involve slaughtering live animals, they claim their manufacturing chain will have a significantly lower risk of foodborne illness (and be much less negatively impactful on the animals in general). Other lab-based meat companies looking to develop similar technologies include Memphis Meats and Future Meat Technologies.

Such food technology elicits a wide variety of reactions from the public, ranging from those who say, “I would never eat that,” to individuals who claim that “cultured meat is not natural,” to the more adventurous who boast, “I’ll eat it if it tastes good and is safe.” But the history of food in the U.S. suggests that similar battles have been waged in the past, from the adoption of margarine as a butter substitute in the late 19th Century to the rise of nut-based milk products (e.g., soy milk, almond milk, etc) in the last 15 years, with the new products ultimately finding acceptance if they are felt to be economical, healthier, and no less palatable than their traditional counterparts. But with the production of meat and seafood estimated to double to 1.2 trillion pounds by 2050, given a finite land supply and limited environimental resources, current industrialized processes for meat and food production are unsustainable, and new techniques are clearly needed.

The development of cultured meat products has led to an industry debate, led mainly by traditional agricultural industry firms and trade associations, on what constitutes the terms “meat” and “beef” at all. The FDA will hold public hearings on this topic this summer.

As consumers, all of us can play a role in ensuring the safety of the U.S. food system in the products we consume, the choices we make, the food preparation techniques we use, and in the ways we maintain awareness of what is going on with our food supply.

Please note that the opinions expressed in this blog post are my own and do not necessarily reflect the views of IDPodcasts, the Division of Infectious Diseases, USF Health, or the University of South Florida.

Ten Years of IDPodcasts

May 23rd, 2018

Ten Years of IDPodcasts

By Richard L Oehler, MD

There’s an expression I’ve often seen online — “what a difference a decade makes.” And it resonates across many epochs of our recent history. Historians can look at the transition our country made in the 1960’s, for instance, and see the United States emerging from the consumer-based post-war era of the late 1950s to the turbulent and transformative year of 1969 as indicative of how much things can change over 10 years.

As I reflect upon IDPodcast’s ten-year milestone, recently celebrated in 2017, I think about the many ways medicine, education and society have changed since 2007, when I first sat down with our Chief of Infectious Diseases and IDPodcasts’ co-founder, Dr. John T Sinnott, to look at ways that USF’s Division of Infectious Diseases could broaden its outreach and share its teaching excellence beyond the small community of medical students, residents, and clinical faculty that had been attending our conferences for many years. I credit Dr. Sinnott with the original idea of broadening our educational footprint, when I recall him saying, “why don’t you take these lectures, record them, and place them online on a website.”

A light went on in my head. A website for infectious diseases podcasts, “IDPodcasts,” I thought.  “Wait a minute. If we recorded these lectures, then maybe I and others can listen to them on an iPod.”  I immediately started thinking of how I could set up and design a website and get us online.

It’s easy to forget: In early 2007, most online content was limited to desktop computers or laptops.  Portable content was available only through mobile MP3 players such as the iPod. (Thus, the name, “POD-casts.”) Although the iPhone was first announced in January, 2007, it was not released to consumers until July of that year. The first iPhone had no installable apps, sluggish 2G (EDGE) connectivity, and a relatively tiny low resolution screen. Tablets did not exist at that time.

Online streaming was in its infancy in 2007. YouTube had just been acquired by Google the year before, and was relatively not well known by online users.

 

YouTube in 2006. (Source, Wayback Machine)

Other educational online streaming sites were also in figurative diapers. Khan academy was founded in October, 2006, but did not offer regular online content until 2008. Most educational medical content was distributed via VHS Cassette, CD-Rom or DVD.

Utilizing website creation tools available through Apple’s now obsolete iWeb program, IDPodcasts.net first went live on June 27, 2007. The inaugural podcast was, “A tour of the Medical Wing of the London Museum of Science.”  A great many podcasts in a variety of different infectious diseases subcategories soon followed, and the website celebrated its 50th podcast in 2008, entitled, “A Global Swarming: Infectious Diseases and Climate Change.”

After IDPodcasts established itself as the very first infectious diseases online podcast site, we started looking at other ways we could share content online. Given the popularity of iPods during that time, we inaugurated IDPodcasts’ iTunes Podcast Channel in 2008.

While our website was attending to establish a foothold online, another revolution was rapidly advancing in the mobile universe—smartphones.  The first mobile online applications were being introduced with the next generation iPhone, and our quest to capture medical users of smart phone devices became our next initiative. In 2009, we partnered with Absolute Mobile Solutions in Tampa, Florida to create our first IDPodcasts app.  The IDPodcasts mobile viewer was the first streaming iPhone app at the University of South Florida and the entire state of Florida University system.

As mobile online devices became more popular, device manufacturers soon began to innovate and look for more ways that mobile devices could replace traditional desktop or laptop computers. In 2010, the iPad was born, and IDPodcasts introduced the first iPad app created at the University of South Florida, and then introduced a sister app for android mobile devices.

In 2011, the website introduced social media integration into its main page, permitting users to be notified through their Facebook or Twitter pages of new online content. To capture users of the increasingly popular streaming site, YouTube, in 2012, we inaugurated the IDPodcasts YouTube channel, which has gone on to become one of our most successful online sites with thousands of views.

Our latest generation smartphone and tablet apps premiered in 2016, incorporating many new features such as favorite and playlists, Apple watch controls, enhanced search features, and social media integration.

We commemorated our tenth anniversary in 2017 with the “IDPodcaster awards,” celebrating the best of our podcast presentations over our history. And as we began our second ten years in 2018, IDPodcasts premiered its most significant upgrade yet:  A brand new website designed for maximum usability, speed, and performance across any desktop, portable, or handheld device.  And we look forward to even more refinements and enhancements moving forward. This includes our new blog feature, which recently has highlighted the artistic and literary talents of our faculty and invited contributers.

Throughout the last ten-plus years, IDPodcasts has continued to publish high-quality, well produced, and educationally innovative content at no cost to our listeners. We accept no commercial sponsorship, relying on university and small contributor support. Our biggest reward is the feedback we get from our listeners, including clinicians and lay people from more than 160 countries around the world. Our goal, as our new slogan suggests, is to simply “make infectious disease learning contagious.”

IDPodcasts owes a huge debt of gratitude to its cofounder and Chief of the Department of Internal Medicine, Dr. John T. Sinnott, as well as the Division of Infectious Diseases Director, Dr. Douglas Holt, for their unwavering support of this decade-long educational initiative.  And ID podcasts is especially indebted most of all to its more than 60 faculty contributers who have shared their teaching excellence with a worldwide audience over more than 10 years, as well as its loyal online audience.

IDPodcast’s iTunes Podcast Series is Back Online!

May 8th, 2018

Fans of downloadable podcast content can now rejoice.  IDPodcast’s iTunes Podcast Series is now back and better than ever!  The series, originally started in 2007, and one of the original infectious diseases podcast series on iTunes, got sidetracked in January after the migration of IDPodcast’s website to an all new WordPress-based platform.  For technical reasons, podcast updates had to be suspended until new software updates could be completed.  With the updates having been accomplished earlier this week, “IDPodcasts on iTunes” made its glorious return.

IDPodcasts on iTunes will feature ten of the most recently uploaded podcasts available for downloading or streaming directly via a podcast app. The re-inaugurated podcast series is another way that IDPodcasts is “making knowledge contagious.”

To access IDPodcast’s podcast series on iTunes, please enter the following link:

Click here

 

Dr. Ana Velez’s “Art In Infectious Diseases”

April 10th, 2018

 

Dr. Ana Velez is an accomplished artist and University of South Florida Associate Professor and Infectious Diseases physician who has practiced at Moffitt Cancer Center among immunocompromised patients since 2007.  Although she paints in many different styles, among her favorite subjects are the microorganisms she confronts everyday as a health care provider.  With her art, she conveys the complexity and beauty present in even some of the most challenging pathogens.  Her paintings mix bright colors and subtle shades to capture the simple yet elegant nature of fungi, bacteria, and viruses. Below is some of her artwork each with an accompanying legend. Please click each picture to link to a larger version.

 

Aspergillus

Aspergillus is a fungus found throughout the world that can cause infection in primarily immunocompromised hosts and individuals with the underlying pulmonary disease. There most important types of respiratory tract infections caused by aspergillus include: invasive aspergillosis, and allergic bronchopulmonary aspergillosis. Aspergillosis infection can also manifest as sinus disease in immunocompromised hosts and cutaneous disease after traumatic inoculation.

The treatment of choice is Voriconazole. Isavuconazole, Posaconazole and Amphotericin also have activity.

The painting below illustrate aspergillus with its septate acute angle hyphae (white arrow) a vesicle (blue arrow) with phialides (orange arrow) and sporulating conidia (red arrow).

 

 

Dengue Virus

The dengue virus is a single positive-stranded RNA virus of the family Flaviviridae. It is transmitted by the Aedes aegypti female mosquito. The clinical presentations include dengue fever, dengue hemorrhagic fever and dengue shock syndrome.

The painting below illustrates the main parts of the virus including the E protein (white arrow), the M protein (black arrow), the capsid protein (red arrow) and the genomic RNA (blue arrow)

 

 

Fusarium

Fusarium is a hyaline mold that can cause severe invasive infections in neutropenic and transplant patients. The most common type of infections in this population includes invasive nodular pneumonia, sinusitis and necrotizing cutanous infections from traumatic inoculation.

This mold is angioinvasive, but can also cause disseminated disease from metastatic conidias that travel distally from the initial site of inoculation thru the bloodstream.

The treatment is Voriconazole orAmphotericin depending on the subspecies and suceptibilities of fusarium.

The painting below illustrates septated hyphae (green arrow) and banana shape conidia (black arrow).

 

 

Actinomycetes

Actinomycetes are acid-fast gram positive bacilli that are sometimes branching depending of the species.

The Actinomycetes sppinclude Mycobacterium spp, Corynebacterium spp, Nocardia spp, Actinomyces spp, Rhodococcus spp, Tsukumurella spp, Gordona spp, Actinomadura spp, Streptomyces spp, and Tropheryma wippelii.

The painting below illustrates Nocardia, Actinomyces and Rhodococcus.

Nocardia spp(black arrow) are aerobic filamentous branching beaded, gram positive rod, that stain acid-fast positive given its mycolic content of the cell wall.

Actinomyces spp(white arrow) are anaerobic branching gram positive rods that can be differentiated from Nocardia because they are acid-fast negative.

Rhodococcus spp(yellow arrow) are aerobic gram positive rod non branching acid-fast positive.

 

Chikungunya

Chikungunya virus is an RNA alphavirus transmitted by Aedes mosquitoes in the tropical and subtropical areas.

It causes acute febrile illness with polyarthralgia, arthritis and occasionally headache, rash and periarticular edema.

The painting below illustrates the structure of the Chikungunya virus with the E proteins (yellow arrow) Membrane (white arrow) capsid (red arrow) and the genomic structure (black arrow).

 

 

Herpes Simplex Virus

HSV is an enveloped double stranded DNA virus that belongs to alpha herpes virus.

There are 2 types of herpes virus (HSV): herpes virus type 1 (HSV-1) and herpes virus type 2 (HSV-2). Both are closely related.  HSV1 is more commonly associated with orofacial disease whereas HSV2 is more commonly associated with genital disease.

Medications to treat HSV infections include acyclovir, valacyclovir, and famciclovir.

The painting below illustrates the HSV virus. It has the DNA gene (white arrow), nucleocapsid (black arrow) the tegument (blue arrow), the lipid envelop (orange arrow), and the envelope proteins (red arrow).

 

 

Polymicrobial abscess

The painting below illustrates the polymicrobial purulent and bloody fluid from an abscess. The gram positive cocci in chains are Streptococcus spp (orange arrow), the gram positive cocci in clusters are Staphylococcus aureus (blue arrow) and the gram negative rods are Pseudomonas spp (white arrow).

 

 

Scedosporium

Scedosporium is a filamentous mold present in soil, sewage, and polluted water. It has two main species: Scedosporium apiospermum(and its sexual form Pseudallescheria boydii) and Scedosporium prolificans. Scedosporium spp may colonize transitory previously damaged airways, but can also cause severe respiratory infections in near-drowning and immunosuppressed patients. The infection may spread locally by angioinvasion or hematogenously to distant organs (lung and brain are common organs). Scedosporium spp are often resistant to several antifungals. Voriconazole can be used to treat infections by Sedosporium angiospermum. Scedosporium prolificans is often multi-drug resistant.

The painting below illustrates Scedosporium spp with broad hyphae (blue arrow) and Pseudallescheria boydii (red arrow) with fully developed and ruptured cleistothecium, the typical form of the sexual stage of Scedosporium apiospermum.

 

 

Zygomyces

Zygomyces is hyaline fungus that causes severe invasive infections in transplant and neutropenic patients. It can also cause severe infections in poorly controlled diabetic patients.

The most common type of infections includes invasive necrotizing nodular pneumonia, severe sinusitis with peri-orbital cellulitis, and cutaneous infections  from traumatic inoculation.

The treatment of choice is Amphotericin. Isavuconazole and Posaconazole are also effective but are often used as an alternative to Amphotericin.

The painting below illustrates different Zygomyeces spp with the typical large ribbon like non septate 90 degree angle hyphae (green arrow).

 

IDPodcasts’ new state of the art website is now online!

February 2nd, 2018

IDPodcast’s new website is finally online! After ten years, at long last, the IDPodcasts platforms now have a state-of-the-art website to host our 10+ years of content. The site features sections with our latest and most popular podcasts, an archives page featuring a robust search engine with the capability to search by category, author, and more, a contributors page with information on our more than fifty faculty and guest presenters, and an updated section on recommended ID web resources. Several completely new features have also been added. IDPodcasts will now feature a regular blog section. Our inaugural blog is authored by co-founder, webmaster, and regular contributor, Dr. Richard Oehler, entitled, “A Textbook Case: Making the Transition to the Online Universe.” We have also included regularly updated ID news content from our news partner (CIDRAP) and from USF Health’s ID Division on the main page. Also, we have added the capability to have users submit peer-reviewed podcasts to our site for potential addition to our online library and for sharing with our worldwide audience. And lastly, even though our web resources are completely free to our users, the web site has added the capability to accept contributions of support from our audience members.

Our thanks to USF Health, the Division of Infectious Diseases, Division Director Douglas Holt, Chief of Medicine and IDPodcast’s Co-founder Dr. John T Sinnott, our web site co-developers at Absolute Marketing Solutions, and most of all, our loyal audience, for their support.

A Textbook Case: Making the Transition to the Online Universe

January 28th, 2017

With this blog, IDPodcasts inaugurates its new online presence. At its inception in 2007, our original goal was to make our division’s infectious diseases teaching available via a simple web site to a broad online audience. Since then, IDPodcasts has followed the pace of technology, explanding its reach to smartphones, tablets, YouTube, and to social media. In 2017, we celebrated our tenth anniversary. Recently, the development of our new web site led me to reflect again on how far online medical education resources have progressed since the beginning of this decade. For instance, In 2010, one of Oxford University’s “great medical legends” received a long awaited transplant. Long the close confidant and trusted aide to generations of doctors and medical students, it had become impersonal, grossly overweight, and unwieldy. Oxford University Press’s Textbook of Medicine, 5th Edition, first published in 1983, long regarded as perhaps the most comprehensive medical reference in publication and an emissary for evidence-based medicine around the world, was launched as a complete online edition. The project, five years in the making, brought the entirety of its massive twenty-five pound, three-volume, six thousand page print edition to the web, complete with all of the text, figures and illustrations. Though available to hospitals, universities and individuals as a paid subscription, the move to an online edition offered an unexpected benefit: inexpensive and even free access for more than 3,500 institutions in less-developed countries sponsored by the U.K.’s Wellcome Trust. 1

Oxford’s initiative, following a trend established by many medical publishers in the last decade and a half, reflected not just a gesture of altruism to third world countries but also a matter of contemporary professional and economic necessity. Since at least 2600 B.C., when Imhotep is said to have written his first papyrus on ancient Egyptian medicine 2, heralding the age when medical knowledge could be shared and adopted by others, clinicians have attempted to codify the practice of medicine onto the printed page. For more than 4500 years, the tradition of the paperbound medical text thrived, surviving the destruction of the Alexandria library in Egypt, the austere anti-intellectualism of the middle ages, and even the emergence of the new broadcast media of the second half of the 20th century. But as the practice of medicine now approaches the third decade of the new millennium, the bound medical textbook, so symbolic of the scholarly traditions that form the basis of our craft, is facing extinction. The solidification of electronic media, from online peer-reviewed information resources, medical web portals and search engines, to personal smart phones and tablet computers has now supplanted the hardbound textbook for many health providers.

In an original informal January, 2011 survey of internal medicine housestaff I conducted at my institution, only 15% had consulted a hardbound textbook in the last month, preferring instead to reference online resources such as “Up to Date,” “Harrison’s Online, “ and “Emedicine.” Less than half (47%) had reviewed a printed reference of any kind, underscoring the waning popularity of the softbound handbook or pocket guide. Now, seven years later, that number is probably close to nil. The migration that medical publications have made online reflects a societal shift away from the printed page, especially in basic and secondary education. Having a son and daughter, in both college and high school, respectively, I know that it is possible for my tablet and notebook-laden kids to never open a physical text if they wished to do so. For those of us who have been in practice more than twenty years, the transition away from the printed textbook in the last decade has presented some unexpected problems. No longer is a clinical question or controversial medical decision between clinicians resolvable via an obsolescent, forlorn text in the corner of a nurse’s station. Many resourceful clinicians now consider even a newly published hardbound volume to be out of date, questioning the validity of any reference that is not updated continuously. In an era where every question seems to be answerable via an online query, use of the search engine may have even superseded Pubmed or the National Library of Medicine, with sometimes variably reliable results.

In the past, the immutability and permanence of the printed page added certainty to hardbound textbook-based medical decisions. With the increasing reliance on online resources, it has become more difficult to distinguish credible from less credible sources of medical information, especially for patients who are sometimes forced to seek online medical advice in an era of “fake news.”. For less technologically adroit clinicians, clinging to hardbound medical resources they have used for decades, adaptation to electronic media may present formidable obstacles to reaching the information they once felt comfortable obtaining.

Yet, the online transition has had far more positive than negative consequences. Online reference sources are easier to produce and distribute, and for subscribers, often more affordable to obtain. In many medical facilities equipped with an electronic medical record, online medical references have been integrated with desktop, mobile or handheld devices at the point of care, permitting instantaneous access to evidence-based information critical to medical decision making. In fact, the growth of the evidence-based medicine (EBM) movement is likely to have been fueled since the turn of the millennium by the rapid growth of online medical resources. For many providers, the availability of medical blogs, subscription online content, YouTube videos, podcasts like our own, online access to full text medical journals and even social networking sites (e.g., Facebook and Twitter) ensure that no major medical advance, clinical trial, drug recall or outbreak can escape our awareness. In less developed countries, where medical reference resources were once limited to antiquated or donated textbooks, online resources offer resource-challenged providers with access that can level the playing field of medical information with wealthy countries, a development that is likely to be crucial to improving the quality of medical training and care in the third world. In the U.S., health information companies have also increasingly begun to acknowledge the promise of the new online frontier. Both Emedicine and Up-to-Date, among the most popular of the online peer-reviewed sites, began as struggling start-up firms in the 1990s, attracted an sizable user base, and then were ultimately acquired by large multimedia conglomerates. 3,4 For traditional publishers, almost every major hardbound text now coexists with an online edition, many enhanced for portable devices.

Like audiophiles who still extol the tonality, sonic imperfection, and nostalgia of the vinyl LP in an age of digital music streaming, there will always be those who cherish the great joy inherent in un-wrapping a new-edition hardbound text, resting its weighty spine on one’s lap, and thumbing through its unwrinkled and carefully typeset pages. Although classic medical textbooks may never completely disappear, they may be relegated to the novelty of display cases.   The ongoing transformation of medical information to the online universe will continue to affect the discipline of medicine in many ways and may even alter the foundation of what it means to be a physician. For if healthcare providers can now have access to a portal that can instantly provide them with unlimited online knowledge, updated constantly, and personalized to their patient’s individual needs, at what point could the physician, like an out of print textbook, also become obsolete, replaced by an artificially intelligent machine? It seems unlikely that this will happen anytime soon, one might think, because it is not what we know that endears us most to our patients.   “The art of medicine,” the 16th century Renaissance physician Paracelsus once wrote, “cannot be inherited, nor can it be copied from books.” 5

 

 

References:

  1. Moisse K. A medical classic gets a 21st century makeover, going online and low cost. Scientific American http://bit.ly/dpVuEk. Accessed February 2, 2010.
  2. Breasted JH, ed The Edwin Smith Surgical Papyrus: published in facsimile and hieroglyphic transliteration with translation and commentary on two volumes. Chicago: University of Chicago Press; 1991; No. 3-4.
  3. Emedicine.com. http://emedicine.medscape.com.
  4. Uptodate.com. http://www.uptodate.com. Accessed 01/15/2018.
  5. Jacobi J, ed Paracelsus, Selected Writings. New York: Pantheon books; 1951.