Here below, you will see my amateur bad attempt to try to make this topic a little more fun to digest.
Main point #1: clostridium difficile is a serious, bacterial problem in the U.S., that can cause death.
Just today (4/30/07) our professor was telling us how four people died in the hospital of this infection last year. Usually it’s treated with antibiotics, but sometimes they fail — at which point, the outlook is grim for the patient. There is good news though! Patients could be potentially treated with probiotics (although a funkier version of probiotics). With Dr. Aas, he’s reported much success with this form of treatment when patients can’t fight off C. difficile with metronidazole or vancomycin (these are the common antibiotic treatments).
Main Point #2: Von Niel argues that probiotics should be considered a mainstream therapy (see the Von Niel reference).
There are enough randomized controlled trials out there to support such a statement. But it is slow to catch on in the U.S., possibly because it usually takes 17 years for new scientific discoveries to get widely disseminated (Balas & Boren, 2000). For safety information on which strains are safe and who can take probiotics:http://www.ajcn.org/cgi/content/abstr… The authors noted: “We found that probiotics are safe for use in otherwise healthy persons, but should be used with caution in some persons because of the risk of sepsis.”
Probiotics (from Von Neil, 2005)
We definitely know it works for:
Acute infectious diarrhea
Prevention of antibiotic-associated diarrhea Conditions that are potentially treatable by probiotics:Chronic diarrhea
Inflammatory bowel disease
Irritable bowel syndrome
Food allergyConditions that are potentially preventable:Traveler’s diarrhea
Dental cariesFuture applications proposed for:
What is clostridium difficile? (from JG Bartlett, 2006)
It’s a nasty bacteria.
Who gets it?
If you’ve taken antibiotics, are of advanced age, or in the hospital or recently came from the hospital.
What’s the significance of this problem?
A new epidemic strain of C. difficile has emerged that causes more frequent and more serious disease.
What are some symptoms?
“Clinical disease and C. difficile toxin are present almost exclusively in patients with recent antibiotic exposure, with rare exceptions.” So if you’ve taken antibiotics, that increases your risk. Clinical expression of infection almost always includes diarrhea, but symptoms vary widely.
Common findings in patients with infection: 1) colitis (inflammation of the colon) with cramps, 2) fever 3) abdominal pain 4) fecal leukocytes (white blood cells in the stool) 5) and inflammation on colonic biopsy (if you do a biopsy of the colon).
Pseudomembranous colitis (a type of infection of the colon) represents an advanced stage of disease, and although considered “nonspecific,” it is nearly diagnostic of C. difficile infection. The disease is almost always restricted to the colon.
A recent report implicates gastric acid–suppressive agents as a risk for disease, but this has not been consistently observed.
How come my microbiology professor doesn’t think probiotics work?
“Frequently, years or even decades are required for laboratory discoveries to reach clinical practice. It takes an estimated average of 17 years for only 14% of new scientific discoveries to enter day-to-day clinical practice” (Balas & Boren).
Why the Healthcare System Should Care
Based upon their hospital’s rate of CDAD (clostridium difficile associated diarrhea) in 0.7% of discharges,they estimated that the total excess in US healthcare costs attributable to CDAD was likely >$1.1 billion.– from the Center for Disease Control. Emerging Infectious Diseases • http://www.cdc.gov/eid • Vol. 12, No. 3, March 2006
Aas et al., 2003. Recurrent Clostridium difficile Colitis: Case series involving 18 patients treated with donor stool administered via a nasogastric tube. Clinical Infectious Diseases 2003; 36: 580-5
Balas EA, Boren SA. Yearbook of Medical Informatics: Managing Clinical Knowledge for Health Care Improvement. Stuttgart, Germany: Schattauer Verlagsgesellschaft mbH; 2000
Bartlett, JG. Narrative review: the new epidemic of Clostridium difficile-associated enteric disease. Ann Intern Med. 2006 Nov 21;145(10):758-64. Review.
Savino et al., (Randomized controlled trial talking about probiotics and cholic) Pediatrics 2007;119;e124-e130
Van Niel Pediatrics 2005; 115; 174-177
Weisman et al., (talking about randomized controlled trial looking at probiotics and infections in day care centers) Pediatrics 2005;115;5-9
I saw Urgelt’s video (http://www.youtube.com/watch?v=ld1azzZrfGQon) on probiotics which I thought was very interesting and it made me think of a story I wanted to share but didn’t quite know the context of how to do so — until I saw his video. Alright, so here goes:
Last month, I went to a grand physiology rounds led by the Chief of Gastroenterology, Dr. Thomas Lamont, at Beth Israel Deaconess Medical Center. We talked about a patient who had clostridium difficile colitis — an inflammed colon — and I remember distinctly that the patient sadly passed away.
For the patient’s treatments, we only discussed antibiotic therapies — hard-hitting antibiotics like vancomycin and metronidazole that kill nasty bacteria like clostridium difficile. Unfortunately, though, for some patients who relapse, the drugs don’t do the job. In these cases, long-term suffering or death is not uncommon. Such instances make you wonder about the patients’ treatment: could there have been a better way?
Back in high school, I had read in a health magazine how probiotics, like the harmless bacteria found in yogurt, were good for serious problems of the gut. Six years later, I was now in med school — at a grand physiology rounds no less — and I had the chance to ask an expert, “why?”
But I was hesitant. Dr. Lamont’s a distinguished-looking man in his 60’s with a crisp tie and few tufts of white hair. In medical school, professors with his kind of gravitas tend to think about treatment in strictly four modalities: drugs, chemotherapy, surgery and angiogenesis inhibitors. Probiotics didn’t belong in these categories. In fact, they fell way outside — somewhere in the territory of Hawaiian yoga and herbal healing centers. The chance he’d know about them? Tiny.
Or so I thought. I approached him gingerly and braced myself for a curt response. “Uh, Dr. Lamont, what’s your, uh, take on probiotics?” He paused for a moment, contemplating. Meanwhile, my face felt hot. He’s just going to think you’re a silly student, I thought to myself.
Suddenly, he nodded. “I think probiotics will be one of the frontiers of future research. The gut microbes are a poorly understood area with vast clinical significance if we can understand the mechanisms behind it.”
I was startled. I didn’t just hear what I heard — did I?
Lamont continued, “You know, there’s this guy in Minnesota who transplants gut flora from one person to another.”
“Yes, through stool transplantation. What you need is to freeze dry the stool from a family member, administer using an enema.”
My mind raced wildly. What? I didn’t quite comprehend what he just told me, but I sensed it was profound. Or profoundly weird. Or both. I wondered for a second whether I was actually in medical school, actually talking to the Chief of Gastroenterology of a famous hospital.
Lamont went on. “You have to understand, it sounds nuts, but there may be a case for that. Healthy people who have never taken a single antibiotic in their lives, can occasionally develop spontaneous ulcerative colitis, which suggests a disruption in the gut flora.”
I studied the creases on Lamont’s face carefully — he was all seriousness. No joke, only complete earnestness. What he was referring to, after I had time to process it, is that there are trillions of healthy bacteria in our intestines that keep us going. They help us digest, absorb food, protect us from the bad germs. But sometimes, there’s an imbalance between the good versus bad bacteria. When “bad” wins, we get problems like diarrhea, or colitis (inflammatory colon).
When is there an imbalance? Most often it’s when people take antibiotics, which kill the good, the bad and the ugly — altogether and all at the same time. During this vulnerable state, certain bad bacteria like Clostridium difficile can overwhelm the good germs, causing the human host all kinds of complications and even death.
Dr. Lamont explained that most of the time, people only get clostridium difficile complications when they take antibiotics. Yet, there can be rare instances of colitis without antibiotics, which suggest that there’s more to the gut flora story than we originally thought there was. For some reason or another, with or without antibiotics, the fine balance between good and bad bacteria can be broken, and stool transplantation might be the last option. It could also be one of the most promising.
That “Minnesota guy” who does the transplant turns out to be Dr. Johannes Aas. Journalists love him. Gene Weingarten from the Washington Post wrote a dialogue about him (which I adapted for my video below) and Aas was featured in blogs like “News of the Weird.” Everybody else though — besides his patients — probably thinks he’s nuts.
But the craziest thing of all, might just be that he’s not nuts. For example, his published case reports on stool transplantation were featured in a prestigious speciality journal called Clinical Infectious Disease. This is a journal that’s peer-reviewed, with a high impact factor, meaning that it goes through a rigorous editorial review process and gets read and cited by lots of specialists.
I looked up this paper and read it. The langauge certainly seemed “scientific,” capped off with a stern enough title: “Recurrent Clostridium difficile Colitis: Case series involving 18 patients treated with donor stool administered via a nasogastric tube.” But the real litmus test, as far as I know, involve the letters to the editor. Getting published in a prestigious journal is great — but bad studies do occasionally get published in great journals. When that happens, the letters to the editor can be swift and furious. Experts weigh in, critique this, critique that — in these letters, you can find some most insightful viewpoints.
After perusing through the entire National Library of Medicine database, I found one published letter to the editor. It was in electronic form, so I had to click a few links to get to the page. Oh boy, moment of truth, I thought. This was it.
I felt a faint dread — as I approached the link to the response on stool transplants, I readied myself for disappointment. Was this the letter that was going to expose the flaws of Aas? A cynical sneer of a report, tearing us apart the way Vioxx did to people’s hearts last year?
I held my breath. Suddenly, the paper title popped open:
” ‘It lacked aesthetic appeal.’
Dear All, 4/3/07
I went to a talk by Dr. Atul Gawande, a surgeon, author and professor at Harvard. For those of you who have never heard of him, he’s a young, up-and-coming rock star in the medical world. (He’s in his early 40’s, which by surgeon standards, is young).
I think we are intrigued because he’s intelligent, well-spoken, friendly, handsome and has a shock full of black hair (most surgeons are either bald or graying by forty). Med student guys want to be like him, med student ladies want to marry him. Well, something like that…
And then the writers admire him too for his eloquence — he was a finalist for the National Book Award. Today, he was here to promote his new book, Better, which is on medical performance and errors. After his lecture, there was a huge line of eager students waiting to get their copy of Better signed. I felt like such a groupie as I waited in line to ask him a few questions about one of his papers called “Risk factors for retained instruments and sponges after surgery,” published in the New England Journal of Medicine (NEJM 2003 Jan 16;348(3):229-35).
In this study, his team looked at several hundred cases of surgeries and tried to figure out how in the world doctors could do something as “stupid” as leave a sponge in a patient’s body. It’s one of those things that you probably have heard about and would make you shake your head in disbelief. I wanted to post a Youtube video on this topic, but because of the potential explosiveness of the issue (i.e., I didn’t want to my surgical professors to fail me for getting it wrong) I thought it best to double-check.
Dr. Gawande was gracious, answering my questions while signing books at the same time. He pointed out, “it’s not for lack of trying.” The surgical team hand counts the instruments and double-check, triple-check all the time to avoid this error, and it doesn’t happen often. But the problem is that, when it happens, the consequences can be life-threatening. Plus, the surgeons who do so feel terrible and the media makes them look–well, stupid.
The point that progressive healthcare policy experts — such as Dr. Gawande and Dr. Don Berwick — are trying to make is that, often, the error is not caused by ‘stupidity’ and ‘clumsiness.’ Instead, it’s the problem of the structure of the healthcare delivery system. Perhaps, doctors are overworked, hospitals understaffed, budgets are cut (to name a few possible reasons). Nobody tries to be clumsy — most doctors are trying their hardest not to be. The solution ought not to be blame, but rather to find out why the errors are happening. Often, the answers are simple (and that’s why I hope to post up a lot of them in this blog, so that you can share with your family and friends easy, but powerful tips).
Dr. Gawande points out three risk factors that can explain in large part why doctors leave tools in the patient’s body. The first one is if the patient is obese — it can be tricky to perform surgery on someone who has a high body mass index. The second is when there is an emergency procedure that needs to be done — as you can imagine from the frantic scenes you’ve seen on ER, it’s tough to keep track of everything. The last factor is when there is a change in the surgical procedure; for example, if the surgeons originally thought they were going in to remove the appendix but found a surprising cancer instead.
The solution to prevent tools getting left inside the body is simple: take an X-ray before the patient wakes up from recovery — if there’s anything left in the body, you just quickly take it out before it causes any harm. It’s simple, almost common-sensical — but unfortunately, not enough surgical teams are making it common practice.
So please keep this in mind if you or your family friend needs surgery. And if your doctor has any questions, you can pull up Dr. Gawande’s article and show it to them – if you need a copy e-mail me and I can help you find one.
I’m a first year medical student in Boston. Every day, I’m learning exciting and critical topics on medicine and health. But too often, the things I’m learning about never reach the public.
I wanted to try an experiment — sharing health information on Youtube and on this blog, with the sole purpose of trying to get more important health information to you all.
Unlike some health posts or videos you may have run into, mine are not about promoting a diet, a pill, a brand or product. In fact, this whole idea came about in part because I got frustrated with how much wrong information is out there. I hope to answer your questions either through e-mail or through the video updates.
Please message me any questions and I will try my best to answer them by asking my professors and by citing credible sources.
Hopefully what will be unique about this blog is that I will cover topics in mainstream medicine — surgical errors, drugs, nutrition — as well as those considered in the complementary or alternative medicine sphere — such as herbs and acupuncture. But regardless of what type of medicine I will write about, you can always be sure I will post the references of the studies I refer to, and you can be sure I will use studies from the top medical journals, such as JAMA, New England Journal of Medicine, Annals of Internal Medicine, Americal Journal of Clinical Nutrition. I will try to point out things our medical professors have taught us to recognize — such as the fact that even studies in the best journals can be deeply flawed. In short, I’m going to try to give you news that you won’t hear elsewhere — this will not be a blog about how you should all get the flu vaccine.
I hope this experiment works — and if it fails, I hope someone sees the videos and the blog and, says, “hmmm, this is bad stuff, but I love the idea,” and decides to go for it.
- i’m back! (for a bit)
- a “new” take on eggs — they’re not bad!
- More fish, fish oil, omega 3
- What fish and what fish oil should I eat?
- Strategies to Prevent and Treat Vitamin D Deficiency
- Follow up to Omega-3’s
- Fish Oil Saves Babies
- Youtube Video on Omega-3 and Fatty Acids
- References for Blog Entry Titled, “Fish Oil Saves Babies with Short Gut”
- Hey I’m Back!
- Youtube Summary of Probiotics
- Professor Lamont, Doctor Aas, and the Bacteria