US researchers have developed a new powerful microscopy technique and used it to show proteins killing bacteria in real time, thus revealing the
deadly workings of antimicrobial peptides (AMPs), naturally occurring proteins that scientists are pursuing as a new approach to treating bacterial
infections.

Led by Massachusetts Institute of Technology (MIT) Professor Angela Belcher, the researchers modified an existing technology called high-speed
atomic force microscopy (AFM) to allow them to see the onset of bacterial cell death induced by AMPs in real time, on a cell by cell basis. They have
written about their work in a paper published in the 14 March online edition of Nature Nanotechnology.

For the last twenty years, scientists have been looking for a way of treating bacterial infections by getting naturally occuring AMPs to kill them. Most
AMPs kill bacteria by punching holes in their cell membranes, thus destroying the delicate equilibrium they maintain between themselves and their
environment. Other AMPs destroy bacteria by getting inside them and interfering with their internal cellular machinery.

There has been a lot of interest in developing AMP-based drugs to replace antibiotics, but as yet none have been approved for market.

Belcher, who is MIT’s Germeshausen Professor of Materials Science and Engineering and Biological Engineering and a member of the MIT Koch
Institute for Integrative Cancer Research, told the press that the new type of high-speed atomic force microscopy (AFM) could help perfect the
technique of using AMP to kill bacteria, and also aid better understanding of how cells respond to viral infections and other drugs.

One area that could be vital is to understand how bacteria become resistant to AMPs (until a few years ago scientists thought they couldn’t, but recent
research has revealed they can).

Paul Hansma, a physics professor at the University of California at Santa Barbara (UCSB), has been working on AFM for 20 years. He was not
involved in the study and suggested the new technique could be used to study cell death in mammals, for instance to see what happens when nerve cells
die in Alzheimer’s patients.

“This paper is a highly significant advance in the state-of-the-art imaging of cellular processes,” said Hansma.

Lead author Dr Georg Fantner, a postdoctoral associate in Belcher’s lab who had been working on high-speed AFM at UCSB, brought his experience
to MIT. While he and other scientists had developed new high-speed AFM techniques, they hadn’t optimized them to study living cells: this then
became the new focus of the MIT team.

Invented in 1986, AFM is a type of scanning probe microscopy (SPM), a set of related technologies for imaging and measuring surfaces down to the
level of molecules and groups of atoms. Electron microscopy also works at this scale, but it requires a vacuum so you can’t use it with living
samples.

At the centre of AFM is a mechanical technology that “feels” the surface to be examined with an extremely sharp tip (3 to 50 nanometers radius of
curvature) that is mounted on a flexible cantilever so the tip can follow the contours of the surface.

As the tip moves across the surface of the object being investigated, it undergoes different forces of interaction with the surface which affect the
movement of the cantilever. These tiny movements are fed to selective sensors and can be used as the basis for seeing the shape and investigating other
properties of the surface.

However, conventional AFM technology takes several minutes to produce one image, making it unsuitable for looking at a series of events in
succession.

For this study, the MIT researchers used a cantilever that was about 1,000 times smaller than the one used in coventional AFM. This enabled them to
increase the imaging speed without harming the bacteria. Another factor that helped keep the bacteria alive was that they performed the measurements
in a liquid.

By using the new AFM set up the MIT team was able to take images every 13 seconds for several minutes while they looked at bacteria treated with an
AMP called CM15.

They wrote that:

“The increased time resolution (13 s per image) allows the characterization of the initial stages of the action of the antimicrobial peptide CM15 on
individual Escherichia coli cells with nanometre resolution.”

They found that AMP-induced cell death appeared to occur in two stages: a short incubation period followed by “a more rapid execution phase”.

What surprised them was that the the incubation phase took anything from 13 to 80 seconds to complete.

Co-author Roberto Barbero, a graduate student in the MIT team, told the press that:

“Not all of the cells started dying at the exact same time, even though they were genetically identical and were exposed to the peptide at the same
time.”

An Erwin-Schrodinger Fellowship, the National Institutes of Health, Army Research Office and Austrian Research Promotion Agency provided funds
for the study.

“Kinetics of antimicrobial peptide activity measured on individual bacterial cells using high-speed atomic force microscopy.”
Georg E. Fantner, Roberto J. Barbero, David S. Gray & Angela M. Belcher.
Nature
Nanotechnology, Published online: 14 March 2010.
DOI:10.1038/nnano.2010.29

Source: MIT, SPM website.

: Catharine Paddock, PhD

Continue reading →

NPR’s “News & Notes” on Thursday included two discussions about the spread of HIV in prisons and efforts to promote condom distribution to inmates.

In the first segment, Keith DeBlasio, a former inmate who contracted HIV in prison, and Lovisa Stannow, executive director of Stop Prisoner Rape, discussed the spread of HIV through rape and consensual sex in prisons. Stannow, whose group supports the distribution of condoms in prisons, said, “It’s a public health issue, and it’s also a human right issue,” adding that “incarceration simply should not lead to serious illness and premature death.”

Stannow also discussed the federal Prison Rape Elimination Act, which was passed in 2003, “News & Notes” reports. She said, “It may not have trickled down yet to the actual facility level, but we certainly see a much more serious discussion among corrections administrators and lawmakers and policymakers, that even five years ago you would still hear wardens and prison managers claim that sexual abuse was not really a problem. And we don’t hear that any more.” She added, “The question is now, how do we address the problem?” (Chideya [1], “News & Notes,” NPR, 5/15).

In the second segment, the Rev. Dorris Green, director of community affairs for the AIDS Foundation of Chicago, discussed the group’s support of HIV screening and condom distribution in Illinois prisons. According to “News & Notes,” the “state of Illinois has been resistant” to the proposals.

Green said the group is working on “educating our legislators about HIV” and sex in prisons, adding, “We have a hard time here in this state convincing our legislators that people are actually having sex in prison.” The group also is developing a demonstration project that could include condom distribution in a state prison, she said (Chideya [2], “News & Notes,” NPR, 5/15).

Reprinted with kind permission from kaisernetwork. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at kaisernetwork/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork, a free service of The Henry J. Kaiser Family Foundation.

© 2008 Advisory Board Company and Kaiser Family Foundation. All rights reserved. Continue reading →

Winter may not officially arrive this year until Dec. 22, but cold and flu season is already in full swing.

There’s good news, though: A few simple actions can greatly reduce your chances of getting a cold or the flu and help prevent your family, friends and coworkers from becoming sick as well, says Joanne C. Langan, Ph.D., R.N., coordinator of clinical resources at the Saint Louis University School of Nursing and a member of the university’s Pandemic Response Planning Committee.

“These are common-sense steps everyone should take throughout the year,” Langan says, “but it’s especially important now that winter’s here and cold and flu season is under way.”

“It’s all about respecting yourself in order to stay healthy and respecting others so they can be healthy as well,” Langan adds. “No one wants to get sick or to pass along a cold or the flu to someone else.”

Below are seven steps that Langan says are crucial to staying well this winter and prevent spreading cold or flu germs to others.

No. 1: Get a flu shot. Unquestionably, this is the most important way to avoid getting the flu and to prevent or contain an outbreak of the illness, which kills hundreds of thousands of people around the world each year. Flu shots are particularly important for people at high risk for serious complications from influenza including young children, the elderly and those with weakened immune systems.

The best time to get vaccinated is October and November but you get a flu shot in December and January and still be protected. Flu season can last as late as May.

And contrary to popular belief, there’s no chance of getting the flu from a flu shot, says Langan. That’s because the viruses in the shot’s vaccine are dead, not live.

No. 2: Wash your hands often. A study published in a British medical journal earlier this year found that regular hand washing, with soap and water, was more effective than drugs in preventing the spread of respiratory viruses such as the flu. If you can’t wash with soap and water, Langan says, alcohol-based gels and wipes can be used. The gel should be rubbed until it’s dry.

No. 3: Avoid touching your eyes, nose and mouth. Those are “major points of entry” for all kinds of germs, particularly those that cause colds and the flu, Langan says.

No. 4: Avoid close contact with people who are sick.

No. 5: Practice other good health habits. To keep your immune system as strong as possible, get plenty of sleep, eat nutritious food, drink plenty of water and other fluids and learn how to manage your stress.

No. 6: Cover your nose and mouth. If you’re about to sneeze or cough, put your hand or a handkerchief over your nose and mouth or sneeze or cough into your sleeve. It may prevent those around you from getting sick, Langan says.

No. 7: If you’re sick stay home, particularly if you’re running a fever or sneezing or coughing a lot. You’ll help prevent others from catching whatever you have.

For more information on preventing the flu, go to cdc/flu/toolkit. To learn more about healthy habits and stopping the spread of germs, go to cdc/germstopper.

Saint Louis University Medical Center
St. Louis, MO 63103
United States

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The Commonwealth Government’s $36 million Australia Fellowships, through the National Health and Medical Research Council, have been awarded to researchers in cancer, infectious diseases and mental health.

Each recipient is highly regarded in their field. Each Fellowship is valued at $4 million ($800,000 per year for 5 years). The recipients are:

The fight against cancer:

– Professor Doug Hilton from the Walter and Eliza Hall Institute of Medical Research. Professor Hilton is a pioneering work covers how the body’s cells communicate with each other. His fellowship will assist him in research into the molecular basis for the onset and progression of cancer and other diseases.

– Professor David Vaux from La Trobe University. Professor Vaux is a leading researcher in the field of apoptosis, or cell death. Professor Vaux’s fellowship will assist him to expand his groundbreaking research which will lead to the development of new cancer therapies

– Professor John Hopper from the University of Melbourne. Professor Hopper is a world leader in genetic epidemiology, investigating links between genes, the environment, and breast cancer, colorectal cancer, and prostate cancer. His Fellowship will assist him in his research aimed at preventing these leading causes of death.

– Professor Andreas Strasser from the Walter and Eliza Hall Institute of Medical Research. Professor Strasser’s Fellowship will assist him to further develop his groundbreaking research identifying the processes by which anti-cancer therapy triggers apoptosis.

Easing the global burden of infectious diseases:

– Professor James C Paton from the University of Adelaide. Professor Paton’s fellowship will allow him to accelerate his research into new generation vaccines and therapeutic approaches for bacterial infections such as Pneumococcal, Streptococcus pneumoniae and Escherichia coli.

– Professor Alan Cowman from the Walter and Eliza Hall Institute of Medical Research. Professor Cowman is a world renowned malaria researcher. The fellowship will advance his work in designing new treatments and vaccines.

– Professor Tony McMichael, a world leader in environmental epidemiology from the Australian National University, who will use his fellowship to further his pioneering research on the health risks of global climate change and environmental influences on infectious and parasitic diseases and autoimmune disease.

Mind and body – moving forward on mental health:

– Professor Sam Berkovic from the University of Melbourne. Professor Berkovic will use his fellowship to work on the integration of high level clinical medicine, molecular genetics and cutting-edge neuro-imaging in the causes and treatment of epilepsy.

– Professor Ian Hickie from the Brain & Mind Research Institute at the University of Sydney. His Fellowship will allow him to expand his population-based research and development of mental health strategies on the importance of environmental factors such as infection, inflammation and alcohol and substance abuse exposure on the risk of developing non-psychotic mental disorders.

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The African Union and the United Nations on Tuesday launched an initiative to reduce the number of new HIV cases on the continent, Reuters/Yahoo! News reports (Quinn, Reuters/Yahoo! News, 4/11). In 2005, Africans accounted for 3.2 million of the five million new HIV cases globally, according to UNAIDS Regional Director Mark Stirling (Dlamini, BuaNews, 4/11). The A.U. is seeking to prevent 29 million of the 45 million new HIV cases projected to occur by 2010 in Africa (Reuters/Yahoo! News, 4/11). The initiative will rely on broad HIV education, peer education, communication campaigns, promoting consistent and proper use of condoms, and improving programs to prevent mother-to-child transmission of HIV (BuaNews, 4/11). It also will emphasize the need to provide more HIV testing (Reuters/Yahoo! News, 4/11). The initiative officially was launched in four cities across the continent: Addis Ababa, Ethiopia; Johannesburg, South Africa; Ouagadougou, Burkina Faso; and Khartoum, Sudan (ENA/Ethiopian Herald, 4/11). Speaking at the launch in Addis Ababa, A.U. Commission Chair Alpha Oumar Konare said Africa must take advantage of the “unprecedented political commitment and increased funding to translate plans and programs into services” that stem the spread of HIV (Xinhua/People’s Daily [1], 4/11). South African Health Minister Manto Tshabalala-Msimang at a news conference in Johannesburg said that the initiative would give prevention “its rightful position as the mainstay of the global response to HIV and AIDS” (Reuters/Yahoo! News, 4/11). The program is a follow-up to a decision made in 2005 by African leaders to proclaim 2006 as a “Year for Acceleration of HIV Prevention” on the continent, according to the World Health Organization Regional Office for Africa (Xinhua/People’s Daily[1], 4/11). African leaders will discuss ways to implement the initiative when they meet in May in Abuja, Nigeria, to review progress made in fighting HIV/AIDS, tuberculosis and other infectious diseases over the last five years (Xinhua/People’s Daily [2], 4/11).

“Reprinted with permission from kaisernetwork. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at kaisernetwork/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork, a free service of The Henry J. Kaiser Family Foundation . © 2005 Advisory Board Company and Kaiser Family Foundation. All rights reserved. Continue reading →

This life threatening disease is caused by parasites that are transmitted to people through the bites of infected mosquitoes. Prevention is certainly better than cure, as any bout of malaria is likely to reoccur throughout life.

Malaria is still common in many parts of the world, although it is usually more prevalent in rural areas than major cities. Approximately 40% of the world’s population – mostly those living in the poorest countries – are at risk of malaria. Of these, more than 500 million become severely ill with malaria every year and more than one million die from the effects of the disease.

Expatriates and international businessmen travelling from malaria-free areas to disease ‘hot spots’ are especially vulnerable to the disease, as they have a low natural immunity and little resistance to the disease. An even higher category of risk is pregnant women, as the illness can result in high rates of miscarriage and maternal death. Most malaria cases and deaths are in sub-Saharan Africa. However 109 countries in total can be affected, including: Asia, Latin America, the Middle East and parts of Europe, so it is crucial that travellers check whether malaria precautions are needed.

Malaria transmission rates can differ depending on local factors such as rainfall patterns, the proximity of mosquito breeding sites and the types of mosquito species in the area, so some areas are more dangerous at certain times of the year. A local Doctor or travel clinic will be able to let you know whether your forthcoming trip or relocation should involve malaria preventative medicine.

You cannot be vaccinated against malaria, but you can protect yourself in a number of ways:

Basic precautions include:

- Mosquitoes bite at any time of day but most bites occur in the evening, so use mosquito nets for night time, and insect repellant for the body and the room.
- If you are out at night wear long sleeved clothing and long trousers.
- Mosquitoes may bite through thin clothing, so spray an insecticide or repellent on them. Insect repellents should also be used on exposed skin.
- If sleeping in an unscreened room or out of doors, a mosquito net (which should be impregnated with insecticide) is a sensible precaution. Portable, lightweight nets are available.
- Garlic, Vitamin B and ultrasound devices do not prevent bites.

Taking Anti-Malaria Tablets

- Start before travel as guided by your travel health advisor -with some tablets you should start three weeks before, so make sure you check well before any trip.
- Take the tablets regularly, preferably with or after a meal.
- It is extremely important to continue to take them for four weeks or as directed after you have returned, to cover the incubation period of the disease. Atovaquone/proguanil (Malarone) requires only 7 days post-travel)

Drugs Most Commonly Used for Malaria Prevention

Travellers must always ensure they use a drug which they can tolerate and one which is appropriate for their destination(s). Your doctor or pharmacist will give advice in this respect, but remember, no drug is 100% effective.

In Britain, chloroquine and proguanil can be purchased from local pharmacies or chemists. All other drugs require a doctor’s prescription.

Symptoms

The common first symptoms of malaria are fever, headache, chills and vomiting, which usually appear 10 – 15 days after a person is infected. If not treated promptly with effective medicines, malaria can cause severe illness and is often fatal.

Prompt Treatment

If you do get a fever between one week after first exposure and up to one year after your return, you should seek medical attention immediately and tell the doctor that you have been in a malaria infected area, so they know to check for the disease. Otherwise, it could go unnoticed for several days.

David Pryor, Senior Executive Director of Medicare International, specialist provider of international healthcare to both individuals and company employees, commented: “Malaria is still virulent in many parts of the world, although many governments and charitable organisations such as The Bill and Melinda Gates Foundation are working hard to reduce the number of deaths from malaria in Africa. In the meantime, travellers should be cautious and be aware of the dangers of this sometimes fatal disease. There is no vaccine against this disease and so despite precautions, visitors can sometimes be prone to infection. Finding the right international health insurance policy which allows for flexibility, provides 24 hour access to trained medical staff on the phone and of course includes repatriation is also key, as depending on which part of the world you are visiting, the right treatment may not be available locally.”

Notes

MediCare International have over 25 years experience of offering international health insurance policies to expatriates and local nationals. Their policies are suitable for all nationalities, all ages and all occupations.

MediCare International were one of the first insurers to offer chronic care costs cover and their flexible group underwriting approach allows for discounted group schemes of employees to be underwritten with just 3 lives covered.

MediCare International

View drug information on Malarone. Continue reading →

Cooperation is seen in every corner of life from microbes to humans, many times with no obvious advantages to those that provide it at high costs. Given the existence of “freeloading cheaters” ready to exploit the resources of those cooperating, why is it that cooperation persist? In an article now published in the journal Current Biology Nogueira and colleagues suggest that in bacteria this can result from highly mobile genes that “jump” from one cell to the next carrying the cooperative traits, effectively turning everyone into a cooperator. They also show that, at least in Escherichia coli (E. coli), this new population remains stable through “punisher” genes that impose a mafia-like strategy of “cooperation or death”, ensuring that the new cooperators do not revert to freeloading. The work by shedding some light on the complex interactions of microbes that ultimately determine which bacteria thrive or disappear can have important implications for both human health and economy.

Scientists now agree that cooperation thrives if it benefits the cooperator or/and its relatives. The logic behind this last behaviour resides in the fact that to benefit relatives – which are genetically very similar to the cooperator is to increase the probability that shared genes, including the cooperative traits, will pass to the next generation. Natural selection that preserves cooperative behaviours benefiting relatives sometimes even at a cost to the cooperator’s survival and/or reproduction is called kin selection. Classic examples of kin selection in action are “watchers” individuals that, at the expense of their own security, guard and raise the alarm in the community or the sterile workers found in ants and honey bees colonies. So cooperation is affected not only by its costs and benefits, but also by the genetic similarity between cooperator and those benefiting from the behaviour, with higher relatedness increasing the probability of cooperation occur.

Following this idea Teresa Nogueira (Centre for Environmental Biology, Univ. Lisbon, and Superior School of Health Technology of Oporto, Portugal), Eduardo P.C. Rocha and colleagues, at the Institute Pasteur and the UPMC Univ. Paris 06 (Paris, France) while trying to understand cooperation among bacteria wondered if horizontal gene transfer a non-sexual process, very common in bacteria, where genes “jump” from one individual to another by increasing the genetic similarity between “infected” individuals, could lead to cooperation via kin selection. Using mathematical tools and adding the effect of horizontal gene transfer to costs, benefits and genetic similarity the researchers confirmed that theoretically at least highly mobile genes carrying cooperative traits should promote cooperation, which is then be maintained by kin selection.

To confirm this hypothesis Nogueira and colleagues looked at Eli, which is an abundant microorganism in the human gut flora, where the bacteria typically live in a mutually beneficial relationship with humans. However, changes in its social interactions with other microbes and/or the human host can turn E. coli into an extremely virulent organism, making it a particular interesting subject for this study. Not only that, but many of E. coli vital functions depend on secreted proteins (the so called secretome) that are easily exploited by other microbes, turning E. coli into a potential “collaborator”, even if an unintentional one.

The work now published analyses 21 E. coli genomes and their secretome genes and starts by finding that only a very small percentage of them are part of the “core genome” those genes shared by all the strains of the species so, supposedly, those linked to functions crucial for survival what agrees with the idea that the secretome contains cooperative traits, since, by definition, cooperative genes can be easily lost by natural selection.

Next Nogueira and colleagues try to identify the proteins of the secretome by comparing them to a large known sample from the human gut. And in fact, several of them were potential cooperative traits but, and even more interesting, they also found many E. coli secretome genes in other bacteria. This agrees with Nogueira’s prediction that cooperative traits accumulate in highly mobile genes that, by “moving around”, increase the genetic similarity of previously unrelated bacteria (in this case, even across species). This conclusion was further supported by the fact that large part of the secretome was found to be coded by a piece of extra-chromosomal DNA called plasmid, which is, simply, the most mobile part of the whole bacterial genome

Finally, secreted proteins are costly as they are not recycled and if Nogueira’s hypothesis was correct – as cooperative traits liable to be exploited by cheaters, they should be under intense selection pressure. And indeed the secretome was found to comprise the proteins least expensive to produce in the entire organism, consistent with cooperation costs.

A last question remained – if highly mobile cooperative genes, by jumping between individuals, turn everyone into a cooperator, in the same way their mobility should lead them to be easily lost, creating, yet again, a new freeloading population. So how is this avoided? One way would be by imposing punishments and this possibility led Nogueira and colleagues to search for proteins known to stabilize gene integration by “punishing” the organism if the gene is lost.

And indeed they found two such mechanisms – the “Restriction Modification” and the “Bacterial Toxin Antitoxin” system. Both systems work as a complex of two genes where one provokes the death of the host if the other goes missing. In E. coli these systems were found next to the secretome genes suggesting that the stability of the new cooperator population is maintained by making the cost of losing the cooperative trait higher then the benefit of becoming a freeloader.

In conclusion, Nogueira and colleagues’ work showed that the secreted proteins of E. coli behave as cooperative traits – they are part of the “disposable” part of the genome, show signs of intense selective pressure and some were even identified as potential cooperative traits. In agreement with the researchers’ model most of the genes coding for the secretome are located in the highest mobile part of the bacterial genome and found to be shared by other bacteria. This last increased genetic similarity allows the cooperative traits to stay in the population through kin selection, while “punisher” genes further assure the stability of the new population via a “cooperate or die” policy.

These results strongly suggests that like Nogueira proposed cooperation among bacteria can be enforced by extremely mobile genes containing the cooperative traits that jumping between individuals turn them into cooperators. This new population is then maintained by kin selection and punishment.

Microbes are used in a variety of jobs important for humans, from cleaning petroleum oil of the oceans or wastage treatment to food growth, and, of course, they are crucial agents of disease and health. They are also extremely social organisms normally living in a mix of many different species – the flora of the human gut is a good example with different populations growing more or less in result of the social interaction between them and/or the host. Nogueira, Rocha and colleagues’ work is an important step in the understanding of these complex relationships and might contribute one day for better ways of manipulating bacterial growth, whether with the intention of stopping pathogenic populations or to stimulate beneficial ones. In the specific case of E. coli this knowledge is particularly important as many of its cooperative traits are virulence factors capable of turning a normally innocuous bacteria into a life-threatening dangerous pathogen.

Source: Ciencia Viva Continue reading →

Judge Susan Thomas in a New Zealand court last week ruled that Justin Dalley, who is HIV-positive, did not have to disclose his status to a sexual partner because he had taken “reasonable precautions” to avoid transmitting the virus. New Zealand law requires that people disclose their HIV status if it could endanger their sexual partners. Dalley, who had sex with a woman he met over the Internet in April 2004, did not disclose his HIV-positive status and was charged with two counts of criminal nuisance. Thomas ruled that Dalley had taken reasonable precautions because he used a condom during sexual intercourse and did not ejaculate during unprotected oral sex. Thomas said that although people might have a moral duty to inform their sexual partner of their HIV status, it is not required by law (Kaiser Daily HIV/AIDS Report, 10/7). The New Zealand Herald recently published an editorial and an opinion piece about the ruling, which are summarized below.

Editorial
If the New Zealand court ruling that Dalley was not required to tell his sexual partner he was HIV-positive because he used a condom during intercourse “is to stand, there is a compelling case” for the country’s Parliament “to change the law so it would become a legal, rather than just a moral, duty to tell a prospective partner” your HIV status, a Herald editorial says. The ruling was “faulty” on both “moral” and “pragmatic” terms, according to the editorial. “[T]he act of sex is a mutual one, and it is wrong for one of the partners to conceal a life-or-death secret from the other.” In addition, the Herald writes, “Given that the risk” for HIV transmission “remains” during intercourse using a condom, “it is hard to see how wearing a condom can be judged to be a ‘reasonable precaution.’” By “clarifying the law,” Thomas has “unavoidably” entered the government into “the bedroom and has made a rule that most people will find abhorrent,” the editorial says (New Zealand Herald, 10/7).

Opinion Piece
“[T]hose of us who are HIV-positive have a moral duty to inform our partners, but legislating for morality is not a wise course,” Michael Stevens, a doctorate candidate studying the social context of HIV infection at University of Auckland, writes in a Herald opinion piece. About one-third of the world’s HIV-positive people do not know their status, so “[f]rom a public health stance, it is far more desirable that people are encouraged to take responsibility for their own sexual well-being,” according to Stevens. HIV-positive people “should be allowed to have a sex life” if “all reasonable precautions are taken,” Stevens says, adding, “The real reason this case has excited such a reaction is that our culture does not deal comfortably with the topic of sex” (Stevens, New Zealand Herald, 10/11).

“Reprinted with permission from kaisernetwork. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at kaisernetwork/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork, a free service of The Henry J. Kaiser Family Foundation . © 2005 Advisory Board Company and Kaiser Family Foundation. All rights reserved. Continue reading →

Specialty care physicians can improve the health of high-risk patients by reviewing electronic health records and proactively providing e-consultations and treatment plan recommendations with primary care physicians, according to a Kaiser Permanente paper published online in the British Medical Journal.

The quality improvement project at Kaiser Permanente demonstrated that specialists can take a more active role in managing the health of populations with chronic illness – in this case, kidney disease – by using electronic health records to coordinate care among primary and specialty care providers. In the project, nephrologists (kidney specialists) proactively consulted remotely with primary care doctors to help manage patients at risk for end-stage renal disease.

Using a new system developed by the paper’s lead author, Brian J. Lee, MD, and his colleagues at Kaiser Permanente, nephrologists in Hawaii used electronic laboratory results to rank more than 10,000 kidney patients not yet referred to a specialist by their risk for kidney failure. Then, they monitored the patients who were most at risk to make sure they were getting care in line with evidence-based treatment recommendations. After identifying the at-risk patient population, the nephrologists relied on Kaiser Permanente HealthConnect(R), an electronic health record system, to evaluate next steps.

The nephrologists used the EHR to review the patients’ electronic medical record and to provide an e-consult to the patients’ primary care physicians. In many cases, the nephrologists recommended referral for more intensive specialty care. In others, the primary care physician was given the treatment plan necessary to prevent the need for referral. Results of the five-year project showed it increased early intervention for high-risk patients and reduced by two-thirds the number of late specialist referrals – those occurring within four months of the onset of end-stage renal disease.

“The goal with kidney disease is to detect it early enough to make changes that will slow the disease down. If you’re more likely to end up with kidney failure, we want to reach you in time to help prepare you for successful dialysis treatment,” said Lee, a nephrologist with Kaiser Permanente Hawaii. “Patients who have a chance to consult with a nephrologist well before the onset of kidney failure are less likely to be hospitalized and more likely to survive longer. Our patients are more successful in starting dialysis when they are able to choose the type of dialysis or transplant with their physician, have a dialysis access implanted, start treatment outside of the hospital before becoming very ill, and be educated and psychologically prepared for it.”

While the vast majority of chronic kidney disease patients can be successfully managed by primary care doctors, some patients are better off cared for by a nephrologist, particularly those at highest risk of worsening kidney disease. Many people with chronic kidney disease don’t even know they have it, and yet it is critical to reach people before their kidney disease progresses too far. The most common risk factors are obesity, diabetes and hypertension – all controllable through healthy lifestyle changes and medication.

“We want to provide the best and most comprehensive care that we can to our patients,” said Geoffrey Sewell, MD, president and executive medical director of the Hawaii Permanente Medical Group, whose 410 physicians exclusively provide care for 222,594 Kaiser Permanente members in Hawaii. “Our integrated system of primary and specialty care physicians working together provides complete care – from the prevention of disease to the management of acute and chronic illness. This coordinated care program is made possible by KP HealthConnect, a system that supports the decisions we as physicians make with our patients every day.”

“This pilot illustrates the benefits of leveraging technology and the expertise within a multi-specialty group practice,” said Lee, the paper’s lead author. “In the past, specialists have been limited to helping only those patients who were referred to them. Now that we can use databases to identify disease trends and populations, and electronic health information to provide data on individual patients, our specialists can proactively find and recommend treatments for patients who could really use their help.”

The paper was co-authored by Ken Forbes, a care management analyst with the Kaiser Permanente Care Management Institute.

About Kaiser Permanente Hawaii

Kaiser Permanente Hawaii has provided total health to the people of Hawaii for more than 50 years. Today it has the largest medical group with over 410 physicians supported by 4,400 nurses and other staff. Care for members is focused on their total health guided by our personal physicians, specialists, and team of caregivers. Our expert care and medical teams are supported by industry-leading technology advances and tools for health promotion, disease prevention, state-of-the-art care delivery, and world-class chronic disease management. Kaiser Permanente is dedicated to care innovations, clinical research, health education and the support of community health.

About Kaiser Permanente

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Tuberculosis strains that are resistant to first- and second-line drugs — known as XDR-TB — have appeared among HIV-positive people in the South African province of KwaZulu-Natal, according to a study presented Thursday at the XVI International AIDS Conference in Toronto, the New York Times reports. Gerald Friedland of Yale University and colleagues examined the sputum samples of 536 people living with TB in the town of Tugela Ferry in the Msinga district of KwaZulu-Natal that were collected between January 2005 and March 2006. They found that 221 — or 41% — of the study participants had multi-drug resistant TB, and of these, 53 had XDR-TB. All of the people with XDR-TB were HIV-positive, the Times reports. According to study co-author Neel Gandhi of the Albert Einstein College of Medicine at Yeshiva University, most of the people with XDR-TB were carrying a genetically similar strain (Altman, New York Times, 8/18). According to the study, 52 of the 53 people with XDR-TB died, most within 30 days of having their sputum collected. The average survival period among the people with XDR-TB was 16 days, according to the researchers (Chase, Wall Street Journal, 8/17). According to Friedland, most of the participants who died had progressed to AIDS, and about half contracted the disease at hospitals or clinics. Because most of the people with XDR-TB had never been treated for TB, the researchers concluded that they did not develop resistance to treatment but had contracted the resistant strains from other people.

Implications
XDR-TB is a “potential time bomb,” Friedland said, adding, “It’s an extremely serious thing. I don’t want to convey a sense of panic — it’s not Ebola. It’s urgent, but it’s not the same.” According to Gandhi, there has been little research into the prevalence of XDR-TB in Africa or among HIV-positive people (New York Times, 8/18). He added that the emergence of XDR-TB in parts of Africa with high HIV prevalence could hinder the efficacy of antiretroviral drugs, as well as the DOTS strategy for treating TB, and undermine success in the fight against the two diseases. Peter Small, head of TB programs at the Bill & Melinda Gates Foundation, said that XDR-TB could be the “Achilles heel” of current treatment methods if increased efforts are not made to control it (Wall Street Journal, 8/17). Health officials from South Africa, the World Health Organization and other public health organizations plan to meet within the next few weeks to devise a plan for tackling XDR-TB, Friedland said (New York Times, 8/18).

Spread of TB Among HIV-Positive People Worldwide Undermines Effectiveness of Antiretrovirals, Experts Say
The spread of TB among HIV-positive people worldwide is undermining the effectiveness of antiretrovirals, experts at AIDS conference said Wednesday, CP/CBC News reports. More than one-third of HIV-positive people worldwide also have TB, which causes the deaths of 250,000 HIV-positive people annually, Helene Gayle, co-chair of the conference and president of CARE, said. She called for the acceleration of prevention efforts that address both TB and HIV, saying that HIV-positive people should be guaranteed access to TB services and that all TB patients should be tested for HIV (Ubelacker, CP/CBC News, 8/16). Kevin De Cock, director of the World Health Organization’s HIV/AIDS Department, called for TB management to be placed “at the head of AIDS management” (Berman, VOA News, 8/17). He added that unless the issue of TB/HIV coinfection is addressed aggressively, “we risk dealing with the specter of drug resistance and multi-drug resistance” (CP/CBC News, 8/16). Richard Chaisson, a professor of infectious diseases at Johns Hopkins University, said there is an urgent need for research into new TB drugs, diagnostics and vaccines for HIV-positive people, as well as studies and effective models to deliver the services to those who need them. Also at the conference, Lucy Chesire, an advocate from Kenya for HIV-positive people with TB, said HIV-positive people should urge their governments to allocate more resources to TB control and to ensure collaboration on TB and HIV activities (WHO/International AIDS Society release, 8/16).

Kaisernetwork is serving as the official webcaster of the conference. View the guide to coverage and all webcasts, interviews and a daily video round up of conference highlights at kaisernetwork/aids2006. A webcast of a session examining the relationship between HIV/AIDS and TB is available online.

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