This installment of the Puscast reviews infectious disease literature from the end of August 2011. Key topics include persistent infectious disease outbreaks in geopolitically "fragile states" and updates on HIV and influenza management. The host dedicates significant airtime to frankly dismissing a highly flawed, unblinded study suggesting gabapentin benefits postherpetic neuralgia, branding it "archetypal garbage" purely designed to sell medication. Other findings covered include the risk of resistance mutations in HIV patients with low-level viremia, the predictable serotype shift leading to increased empyema post-vaccination, and the connection between acute infection (e.g., Mycoplasma) and stroke risk, fueling the hypothesis that infection-induced inflammation necessitates universal prophylactic anticoagulation.
Puscast Review (August 2011 Literature)
0:03 Introduction & Disclaimers: The podcast is no longer CME accredited because the requirements were "too much of a pain in the neck." The host is recording outside, warning listeners to "live with" extraneous sounds like dogs and cars.
2:03 Outbreaks in Fragile States: Review of outbreaks in 22 fragile states (defined by WHO as having weak institutions, poor governance, instability). Found 38 outbreaks with reporting delays often exceeding a month. Early detection relies significantly on "hunting down rumors," which is concerning.
3:45 Gabapentin for Postherpetic Neuralgia (PHN): A study combining gabapentin and valacyclovir concluded reduced PHN incidence (9.8% vs. typical 12%). This conclusion is rejected outright. Key takeaway: "Archetypal garbage." The study was an uncontrolled, open-label trial with no placebo, serving only to "sell gabapentin."
5:26 HIV Resistance in Low-Level Viremia: In patients with low viral loads (50–1,000 copies), 37% developed new resistance mutations. Conclusion: Viral replication, even at low levels, drives resistance development, confirming the risk of "fairly active anti-retroviral therapy."
7:09 HAART and Pre-term Delivery: A trial found that protease inhibitor-based HAART regimens in pregnant women (weeks 26–36) resulted in a two-times higher risk of pre-term delivery compared to NNRTI-based regimens.
8:03 Healthcare Worker (HCW) Flu Vaccination: Only 63% overall HCW vaccination rate. Unvaccinated staff hold beliefs that the vaccine is ineffective or unsafe, reinforcing the host's opinion that refusal stems from being a "dumbass."
9:13 Steroids in H1N1: Early use of glucocorticoids increased disease severity and death in H1N1 patients. This is the third trial showing this result. Key takeaway: H1N1 + steroids equals bad idea.
10:42 Oseltamivir (Tamiflu) Meta-analysis: A meta-analysis suggested modest benefit, showing a 28% overall decrease in antibiotic requirements (37% for confirmed flu), suggesting reduced secondary bacterial complications. As far as I can tell, this is plausible, but meta-analyses (piling "cowpoo" to make "gold") must be approached skeptically.
12:40C. difficile Diagnosis: EIA toxin tests are inadequate; 32% of PCR-positive C. diff cases were missed by EIA, and these patients had the same clinical risks. Recommendation: Use PCR over EIA.
13:51 Food Safety Anxiety: A multi-state outbreak of Salmonella typhimurium was traced to peanut butter. The host finds this depressing, noting the risk of dying from one's specialty (infection).
15:01 Probiotics & Toxic Shock Syndrome (TSS):Lactobacillus ruteri cyclic peptides suppress toxic shock toxin-1 production by S. aureus. Prediction: A TSS-reducing probiotic product will be marketed soon.
17:15 Macrolides for COPD Exacerbations: Azithromycin led to a statistically significant but marginal decrease in COPD exacerbations (1.48 vs 1.83 per patient-year) but increased hearing loss (25% vs 20%). The slight benefit barely justifies the cost and potential for resistance.
19:10 Pneumococcal Vaccine Serotype Shift: Following the introduction of the conjugate vaccine, empyema rates increased due to a serotype shift to non-covered Serotypes 1 and 3 (which are more likely to cause empyema). However, penicillin susceptibility rates have improved (72% to 91%). Key takeaway: "No good deed ever goes unpunished."
21:17 Infection and Pro-thrombosis: Acute Mycoplasma pneumoniae infection increased stroke risk (1.1% rate). The host predicts that soon, all patients admitted with acute infection will receive anti-thrombotic agents due to the link between inflammation and clotting.
24:22 Contaminated Drug Paraphernalia: IV drug users using non-sterile cotton balls for filtering risk infections from organisms like Enterobacter. France's forward-thinking needle exchange programs offer sterile filters.
31:36 Healthcare Uniform Contamination: 63% of healthcare worker uniforms in Israel were contaminated; 14% of nurses' gowns and 6% of physicians' gowns carried antibiotic-resistant bacteria. The proposed, satirical solution: practice medicine nude ("Original Greek Olympics").
33:21 Conclusion: Final self-promotion for the host's "growing multimedia empire" and demand for "glowing reviews" for his "fragile ego." I don't care about his ego.