Friday, 26 October 2012

Systematic Failings Ruling Over Aspergillosis Case

A recent coroners court case found that a 68 year old man died following a lack of precautions taken to protect him from infections including aspergillosis. Extra precautions are not usually necessary following a bowel operation such as that undertaken on Mr Michael Meek in January 2009, but in this case there were several extenuating circumstances:

  1. the  patient had had a transplant operation prior to the bowel operation and as such was presumably in an immunosuppressed state as is normal to prevent rejection of the transplanted organ (in this case a kidney).
  2. At the time of the operation there had been, or there were ongoing building works in the hospital, generating dust and dirt known to increase the risk from aspergillosis
  3. Mr Meek was moved into wards where no protection was in place to prevent infection without consultation with the hospital infection prevention team
  4. Mr Meek was housed in a ward where other patients were suffering from C. difficile infection, known to be infectious and especially so in this case due to Mr Meek's reduced immune status
The coronor ruled that these amounted to systematic failures that led to the death of Mr Meek while suffering  from invasive aspergillosis (which caused severely debilitating injury) and C. difficile infection.

If any one of these circumstances had been different Mr Meek may have been less likely to have become infected. This case illustrates how carefully hospitals must manage buildings work and the identification of individuals vulnerable to infection, particularly where aspergillosis is a risk for the patient.



Thursday, 25 October 2012

GSK Increase Transparency of Drug Testing

There is an accusation regularly levelled at companies that design and manufacture medicinal drugs that they lack transparency when it comes to releasing their own experimental results after they have tested their own drugs. Drug companies are under no obligation to release all of their results and some assume that results that cast their new products in a bad light are ignored and remain unpublished.

In particular clinical trials are crucial to demonstrate the effectiveness of a new drug and billions of dollars of investment can rest on each trial result - there is certainly a lot of financial pressure for each new drug to succeed though many do not and some fall at this last, most expensive hurdle.

In the US the distrust between pharmaceutical company and consumer has reached a peak for one company as it has been fined $3 billion after being found guilty of misleading the US government over the usefulness of  its drugs and in a watershed decision the company (GlaxoSmtihKline) has agreed to release details of all of its trials for peer assessment in publically available journals - both positive and negative results. This is a first for a pharmaceutical company but the likelihood is that others will follow.

It is hoped this move will allow greater scrutiny of all new drugs (or all new purposes for older drugs), increasing transparency and rebuilding trust in the proof of efficacy of the next generation of medications.

Wednesday, 24 October 2012

Newsbite: Fungal Meningitis Outbreak: Protective Antifungals?

There are up to 14 000 people in the US suspected of having been exposed to the contaminated steroid injection solution that has so far been detected in 300 people. Questions are being asked about whether or not those suspected of being exposed should be given protective antifungal medication even if they are showing no signs of illness. Unfortunately giving antifungal medication is not to be taken lightly as it has many side effects, even risks to health for some people so indiscriminate dosing is not recommended at this stage. more...

Tuesday, 23 October 2012

Newsbite: Open Access to Medical Mycology Case Reports

This week is Open Access week (22nd-28th October) and the publishers would like to take this opportunity to thank all the authors who have published their research in the recently launched journal Medical Mycology Case Reports. We now have over 25 papers available online which are helping to shape the journal into a valuable collection of fungal cases with clinically important information for healthcare professionals, researchers and the wider public. more...

Monday, 22 October 2012

Flax Contains Natural Antifungals

New Zealand flax
A team of researchers in New Zealand is working on the fibres of the flax plant, traditionally used throughout the world to provide thread and fibres capable of being woven into cloth (linen). Linen and flax fell out of favour when synthetic fibres became popular but now may well come back into favour as synthetic fibres made out of unsustainable oil reserves inevitably become more expensive and less available over time.

In the meantime the New Zealand research group are looking for new applications for New Zealand flax (or harakeke as it is know in New Zealand) and the realisation that it has antifungal properties mean that it could be used in situations where spoilage by fungi is a problem e.g. storage of spoilable foods. It is also of course a natural, sustainable, biodegradable material so is ecologically beneficial where used especially when used to replace synthetic materials.

Friday, 19 October 2012

Bioplastic Aspergillus 'Bullets' Fight Aflatoxins

Aspergillus growing out of a bioplastic pellet
The USDA has developed an efficient method of 'packaging' biocompetative strains of Aspergillus for use to introduce strains of Aspergillus that do not produce dangerous aflatoxins onto crops that are at risk from growth of strains of Aspergillus that do produce mycotoxins - it is established that the non-producers can outgrow the aflatoxin producing strains in the field while crops are growing and thus reduce the amount of aflatoxin contaminating the crop.

'Bioplastic bullets' made out of cornstarch and vegetable oil are effective at containing the 'non-producer' fungus for dispersal and subsequently allow good growth of the fungus. This method of packaging has improved properties for stable storage of the mold compared with the earlier methods involving the used of grain coated in fungal material, and the bioplastic is a lot less attractive to animals that eat seeds & grain so losses are reduced (as well as reducing the health risk to the animals presumably). Bioplastic degrades naturally once scattered onto the field.

For full story click here.

Monday, 15 October 2012

Another Mechanism Suggested for Mould Toxicity in the Home

Trichoderma longibranchiatum
The debate on whether or not the toxins produced by moulds is a contributory factor to the illnesses claimed by many when living in a home with increased levels of moulds caused by dampness continue. Proponents of the theory in the US (where most of this information seems to come from) highlight many perfectly reasonable research studies showing the well characterised toxicity of mycotoxins, volatile chemicals, ozone and many others (see Sick Building Syndrome). Much time has been spent trying to prove that enough of any one of those irritants may come into contact with the occupants of a building to cause health problems.

Those who oppose (and those who consider the principle unproven as yet)  point out that although there are many potential toxins in the indoor environment we are yet to be able to demonstrate convincingly how enough toxin could enter our bodies to cause health problems. Perhaps low doses of several toxins have health effects we do not yet understand?

A recent paper from a research group in Finland outlined a 'new' type of toxic peptide that might be prevalent in the damp indoor environment - trilongins. Up to 2.6% of the mycelial mass of the common fungus that produces them is made up of various types of trilongin, and different types of trilongin are shown to act synergistically to inhibit mitochondrial activity in mammalian cells. The suggestion is that this is a source of toxin that is plentiful and is a candidate for one cause of health problems in damp homes. We are still lacking quantitative estimate of the amount of trilongin produced in a 'sick' home and the suggested mode of  ingestion so doubts remain about the effect on human health as it is difficult to estimate dose but the case for the presence of multiple sources of toxin which can interact to increase toxicity in a damp home is strengthened by this paper.

Friday, 12 October 2012

US Genomic Sequencing Laws to Strengthen Privacy



The US Presidential Commission for the Study of Bioethical Issues has this week published a report entitled 'Privacy and Progress in Whole Genome Sequencing'






Quoting from the introduction of the report:

Over the course of less than a decade, whole genome sequencing has progressed from being one of our nation’s boldest scientific aspirations to becoming a readily available technique for determining the complete sequence of an individual’s deoxyribonucleic acid (DNA)—that person’s unique genetic blueprint. With this tremendous advance comes the accumulation of vast quantities of whole genome sequence data and complex questions of how—across a multitude of clinical, research, and social environments—to protect the privacy of those whose genomes have been sequenced. Collections of whole genome sequence data have already been key to important medical breakthroughs, and they hold enormous promise to advance clinical care and general health moving forward. To realize this promise of great public good ethically, individual interests in privacy must be respected and secured.  The report identifies several instances where processes to ensure confidentiality or privacy needed to be clarified and strengthened. Some of them have been discussed before in this blog - for example there are legal differences depending on whether the tissue sample taken for sequencing was taken by your doctor or a researcher - but others are more obscure;

Another quote from the report:

Another privacy concern associated with whole genome sequencing is the potential for unauthorized access to and misuse of information. For example, in many states someone could legally pick up a discarded coffee cup and send a saliva sample to a commercial sequencing entity in an attempt to discover an individual’s predisposition to neurodegenerative disease. The information might then be misused, for example, by a contentious spouse as evidence of unfitness to parent in a custody case. Or, the information might be publicized by a malicious stranger or acquaintance without the individual’s knowledge or consent in a social networking space, which could adversely affect that individual’s chance of finding a spouse, achieving standing in a community, or pursuing a desired career path.  

The report recommends procedures & laws for the protection of privacy are consistent across all possible sampling entities, all sequence data must be stored anonymously and protected to a high  degree of security. Those who's DNA is being sequenced should remain in control of its use and steps are to be taken to promote all that is learned from the data to the widest possible audience, in the public interest.

Thursday, 11 October 2012

Aspergillus Meningitis Outbreaks Spreads - Officials Fight Back

Map of Healthcare Facilities which Received Three Lots* of Methylprednisolone Acetate (PF) Recalled from New England Compounding Center on September 26, 2012
The past week has seen a developing disaster in the US involving Aspergillus. As we know infection of people who have normal, fully functional immune systems is rare and is mainly confined to the lungs and sinus' when conditions exist that provide a 'toehold' for the fungus to evade our normal immune response to their presence. Favourable conditions include damage caused by other infections and overproduction and lack of drainage of mucus (e.g. in the airways of cystic fibrosis sufferers and in the inflamed sinus).

However, if Aspergillus can find a way past our skin - occasionally via a wound or after surgery - it can sometimes infect parts of the body that seem less well defended and it can be difficult to diagnose as it resembles other much more common infections so precious time when the patients could be receiving antifungal medication is lost. Once established it can be difficult to treat.

The first news reports emerging last week (reported in this blog here) focussed around 12 cases reported in a small area which is a highly unusual event. At that time we speculated that this outbreak would be due to a failure in the medical care systems - in particular the use of non-sterile equipment or solutions.

Tragically there has now been 137 people effected and 12 deaths so far due to a contaminated solution of steroid being distributed and used widely in the US (see map above). As this is a preparation designed for injection it has no preservative added to it which might have prevented contamination. Those who have been injected directly into the spine would be most vulnerable to a rapid onset as the fungus can grow more quickly in that location, especially as steroids can act locally to reduce the bodies immune response which would normally fight the infection. Injections into other sites of the body may also be infected - anyone who is concerned is being advised to contact their doctor immediately.

Chances are there will be more infected people found in the weeks to come as Aspergillus does not always cause symptoms immediately but the rapid detection of the source of the infection and efficient recall of infected medication  should minimise the number of further cases as far as is possible.

News report
CDC statement 

Wednesday, 10 October 2012

Identify Common Pills Using Mobile Phone

For people who have to take several different medications and for those who have to hand out many different pills (e.g. hospital staff, nursng home staff, relatives) identification of each pill is important and can be quite difficult as many pills look very similar despite having completely different contents. There are only a small number of shapes and colours available to pill manufacturers!

Mistakes can have serious consequences and are not uncommon. Referred to as medicine-related problems (MRP's) symptoms often include

  • excessive drowsiness
  • confusion
  • depression
  • delirium
  • insomnia
  • Parkinson’s-like symptoms
  • incontinence
  • muscle weakness
  • loss of appetite
  • falls and fractures
  • changes in speech and memory.


This article in the New Scientist Journal describes a new 'App' (a computer program that runs on a smartphone or tablet computer) that allows the user to identify most common pills (568 currently tested)  from their shape and colour just by taking a photo of the pill using a phone camera. The App should be available soon.


Tuesday, 9 October 2012

Newsbite: 15 ALLFUN Fellowships for Young European Scientists

On behalf of Prof. Romani, I'm glad to inform you that, within the next Gordon Research Conference that will be on January 13-18, 2013, there are 15 fellowships available on a first come basis for European postdocs and students that attend the GRC. They are available through ALLFUN grant. Information can be found at: http://www.allfun-fp7.eu/training_dissemination.html

Monday, 8 October 2012

Human Lung Regrowth - Is It Possible?

Mouse lung tissue regrowing after 'flu
There are many groups of patients with respiratory disease (including aspergillosis) who have severely damaged lungs, the worst affected of whom are dependent on a lung transplant for long term recovery. Even for those least effected by lung damage replacement of damaged lung tissue could greatly improve their quality of life.

Recent research has found stem cells capable of regrowing lung tissue - something I mentioned in a talk I gave to our Patients support group and the National Aspergillosisi Centre, UK. Boston University has a research group led by Dr Darrell Kotton which demonstrated convincingly that lung tissue could be rebuilt and regrown in a mouse experimental model system, opening the way for many more researchers to work on how to get this to happen in humans.

When reporting on this work in an earlier blog we noted that some of the results suggested that our lungs may contain 'natural' stem cells which were capable of carrying out lung tissue repair without any intervention by doctors - in other words our own lungs had some capacity to repair themselves. This sounds absurd, after all if this were possible why would we have illnesses such as tuberculosis and chronic pulmonary aspergillosis where there are large areas of lung that are completely destroyed and never seem to recover?

However - absurd as it might be there is now solid evidence that in one case at least, regeneration of lung tissue has been precisely tracked and recorded. The authors of this paper in the New England Journal of Medicine describe a patients losing a large part of their lung as part of their treatment for lung cancer. Lung capacity was not surprisingly markedly reduced, but more surprisingly over the next 15 years a steady increase in capacity was noticed.
CT scans showed an increase in the size of the lung and careful testing with an MRI scanner revealed evidence for an increase in the number of lung alveoli - the lung was literally growing back!

Although not a common event this case proves unequivically that lung tissue can grow back once damaged.  Further research is needed to detect why this happened in this patient in the hope of making it a more common event but the potential is clearly there.

Thursday, 4 October 2012

Newbite: Allergy to Fungi Can Indicate Lower Risk of Glioma in Women

Allergy to common allergens (e.g. pet dander, pollen) including some fungi has been systematically compared with risk of developing glioma in nearly 600 cases. Remarkably it has been found (confirming some earlier simpler studies) that women who tend to have high IgE levels to common allergens have a significantly lower risk of developing glioma compared with those who have low levels of IgE, even when the IgE tests were carried out at least 20 years before the patients developed glioma.
This correlation does not hold for men. more...

Wednesday, 3 October 2012

ISHAM Committee launched on Nomenclature of Clinical Fungi

Reproduced from ISHAM publication:

On 12 and 13 April, 2012 the CBS Spring Symposium was held in Amsterdam, The Netherlands and was devoted to fungal nomenclature. It was entitled “One Fungus = Which Name”, being an extension of the 2011 workshop “One Fungus = One Name”. These symposia will have a strong impact on nomenclature of medically significant fungi, and therefore it is important that we as ISHAM implement a democratic procedure to achieve a stable result which will be adopted quickly by the entire community. Your  cooperation and input is therefore explicitly requested.

In essence, changes involve the abolishment of Art. 59 of the Code of Nomenclature, which previously allowed separate names for sexual stages and different asexual stages of one and the same fungus. From 1 January 2013 onwards this will no longer be allowed. The question now is which name of polymorphic fungi has priority and should be used in the future. Nomenclature has always been a very formal process on the basis of strict rules in the Code of Nomenclature, but with the Amsterdam symposia there was a consensus for a much more practical approach, taking the needs of the user as a starting point.

This has led to some suggestions outlined below.

Concerning name changes of pleomorphic fungi:


  •  We, the community of medical mycologists, first have to decide which names we want to keep above all doubt. For example: Candida albicans and Aspergillus fumigatus should be maintained,and we wish to use Trichophyton rather than Arthroderma. Probably there are many other classical pathogens and opportunists that we wish to keep. This list of names can be proposed for conservation.
  •  An important criterion for choice of a name will be how frequently names have been used.  But“commonly used” is an unclear criterion; for each of the names the reasons for proposed conservation should be specified. For example: how to establish whether Scedosporium is more current than Pseudallescheria?
  •  If no single name is strongly favoured, the oldest name (anamorph or teleomorph) has priority. For example: names of Aspergillus are older than Neosartorya, and therefore the Neosartorya species will be Aspergillus in the future.


Concerning name changes due to reclassifications of fungi:


  •  Taxonomic methods are not regulated by the Code, so these may be classical phenotypic, or molecular phylogenetic. Phylogenetic criterion of a group (“genus”) is the monophyletic clade. The clade determines the genus name. Preferably the oldest name available for that group is used, see the example of Aspergillus.
  •  New molecular taxonomy may reveal groups where all experts agree that they are clearly monophyletic and may share essential characteristics such as pathogenicity or antifungal susceptibility. This may be the case in the yeasts.
  •  But there are also groups where so many new data – often of environmental relatives – are added, that the phylogeny is highly unstable. For example, black yeast taxonomy develops rapidly. We may propose that for the time being we just leave the names as they are, even if form-genera are polyphyletic.
  •  Ancient, poorly differentiated genera, such as Acremonium today may be highly polyphyletic, and thus have become ambiguous. There was a proposal to abandon such genera at all, but an alternative option would be to redefine them in a modern sense on the basis of accessible type material.

What’s next

The community of medical mycologists including the ISHAM membership is requested to propose lists of preferred on the basis of the above criteria. Many fungal pathogens have an ancient history and have become source of confusion over the years. We therefore urge taxonomists, if necessary, to (re)define the groups of fungi they are working with by the deposition of (new) type material; the procedures are> outlined in the Code of Nomenclature. (http://ibot.sav.sk/icbn/main.htm).

Proposals for preferred names will be submitted to the International Commission of the Taxonomy of Fungi (ICTF, http://www.iums.org/ICTF) for approval. An ad hoc commission (below) will provide a list of fungal names in current use based on the Atlas of Clinical Fungi for the ISHAM membership to send any kind of comments to de.hoog@cbs.knaw.nl.

We hope to have active involvement of many medical mycologists.

Best regards,
Sybren de Hoog, Vishnu Chaturvedi (reporters)
Teun Boekhout, Walter Buzina, Heide-Marie Daniel, Marizeth Groenewald, Wieland Meyer, Richard
Summerbell

Tuesday, 2 October 2012

Aspergillus Meningitis Cluster Reported in Tennessee, USA

Tennessee Department of Health official have revealed that there have been an unusually high number of fungal meningitis infections at two surgical centres in Tennessee and North Carolina. 12 patients have become infected and two have died as a result of this serious infection of the central nervous system.

As yet the cause of this cluster of infections is unknown but all those infected had undergone a lumbar epidural steroid injection.

Aspergillosis infections are not passed from person to person (unlike meningitis caused by viral infection (viral meningitis) or bacteria (bacterial meningitis)) so that can be ruled out as a cause. More likely routes of infection are use of a non-sterile batch of instruments/medical solutions, badly contaminated environment where the procedure was carried out or poor procedure/human error.

This type of infection is extremely rare amongst people who do not have a compromised (suppressed) immune system as there is no 'way in' for the infecting fungus to exploit in order to infect - our skin and highly effective immune systems usually prevent infection even when hundreds of fungal spores are breathed deep into our lungs.
However once past the barrier of our skin the fungus has a much better chance of surviving within our bodies (though it is still only a very slim chance) so doctors take precautions to prevent infection such as ensuring the injection site is sterile and obviously the needles, catheters and solutions used are sterile. If either becomes contaminated there is a small chance that infecting spores can be pushed deep into our bodies.

In these cases there is an added risk factor as the steroid used can aid infection if spores have been introduced into the injection site - they tend to locally suppress immune response.

The outbreak was detected by vigilant doctors quickly and correctly diagnosing this infection which is difficult to positively identify as it mimics other types of infection. Further infections have undoubtedly been prevented by their professionalism.

Both clinics are closed until the cause has been detected.

Further Information & References

Post-operative Aspergillosis
Aspergillus Website article

Social Media and Medical Care

Not so long ago people were being warned off reading medical information on the worldwide web (WWW) as much content was untrustworthy or information was unsuitable for the untrained eye.

A lot has changed. There is still a need for high quality information resources to be clearly distinguished from less useful or even damaging content (HonCode) but overall there is considerably more good trustworthy content than there was 5 years ago - in the UK we have the NHS hosting its own content and other high quality medical services do the same e.g.(Mayo Clinic, Great Ormond Street, Drugs.com).

It is a good thing that availability of high quality information is becoming the norm as a recent Price Waterhouse Cooper survey found that:
According to HRI’s survey, 42% of consumers have used social media to access health-related consumer reviews (e.g. of treatments or physicians).

Andrew McCracken  takes a closer look in his recent article for the Royal College of Physicians. In particular the ability of Twitter to promote and support rapid 'conversations' online are mentioned. In one example someone uses Twitter to send a quick question to NHS direct (a phone based health information resource used by UK government to provide information to patients) which was relied to quickly, saving a phone call and time on both sides of the conversation.

An example in the PwC report is of a patient in a waiting room sending a message to Twitter (known as Tweeting) complaining that they had not yet been seen while others that came into ER (known as A&E in UK) had already passed through. The Twitter was read by a member of staff and they responded by coming to explain to the patients why they were waiting. This can only have been possible if the ER ran and monitored its own Twitter account and the patient had Tweeted to that account, or mentioned the hospital directly.

There are possibilities for the use of this technology that may be attractive to the patient (i.e. getting attention quickly) but any advantages would quickly lost if the care provider was unaware and failed to monitor the tweets constantly. It also has limitations as Twitter only accepts 140 characters per message and conversations are made public.
Used incorrectly or without great thought it is hard to see how this is going to save much money for those that pay for healthcare yet (paid staff may well be needed to monitor Twitter) and not many doctors are going to have time to constantly reply.

  • Is there an advantage to the public asking questions on Twitter? Yes - it is free of charge whereas phonecalls are not. 
  • Is there an advantage to the provider answering questions on Twitter? Fewer, shorter interactions are possible but then the phonecall charges presumably go towards providing the service.
  • Is there an advantage to having all conversations made public on a website with facilities to search? Yes as earlier answers can be found easily thus potentially avoiding the need for another Twitter/call. This cannot happen with phonecalls.
  • Can Twitter conversations reduce the numbers of appointments needed with GP's much like it is hoped NHS Direct phone lines do? Possibly yes - NHSDirect are already hosting & monitoring Twitter and the NHSDirect service is ever expanding in response to demand - we can only assume that translates into less need for a GP appointment.

Perhaps this is the future of healthcare advice in the UK - NHSDirect are effectively constructing a new model for providing healthcare information in just the same way as they did when setting up the original phone service.

Monday, 1 October 2012

US Doctors TV Show Mold Guidelines


“Mold can also be completely harmless, but in some situations, it can be truly deadly,” E.R. physician Dr. Travis Stork says.

“One study found a child’s risk of asthma can double from simply smelling mold,” pediatrician Dr. Jim Sears says.

“Pregnant women fall into the [compromised immune system] category,” Dr. Lisa says. “They can get really sick from respiratory infections, however no studies have shown that mold causes birth defects.


more...

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