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Old 09-18-2015, 12:59   #16
Trapper John
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PedOncDoc -

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In my field of expertise we treat profoundly immunocompromised patients who have no immunologic reserve and can go from well-appearing to dead in a matter of hours, so our treatment algorithms typically start broad and go to narrow - the opposite of what should be done for otherwise immunocompetent patients.
I haven't forgotten our earlier discussions. Capital raise has take all of my time but we are almost done.

In addition to the oncology application, I think our indirect (UW) approach to infection prevention will be useful in the immunocompromised kids. Mechanism of action data suggests that is the case. We plan to test this in mildly immunosuppressed mice (morphine) to mimic combat casualty cases.

More later and via email.

Hope you are enjoying your new digs.
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Old 09-18-2015, 13:05   #17
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The basic problem is the strategic approach we have been taking over the past 75 years. Antibiotic resistance began being noticed within a year or two of the widespread use of penicillin and sulfa drugs.

Think in terms of a UW strategy vs a DA strategy. We have been conducting DA centric actions against insurgent pathogens for 75 years and the insurgents are adapting defenses faster than we can develop weapons (antibiotics).

On the other hand nature has mechanisms to clear the insurgents that just gets overwhelmed at times and the infection leads to disease (note that most infections do not lead to disease otherwise we humans would not survive).

Think UW, i.e. working by, through, and with the indigenous population of cells and force multiplication via an auxillary to enhance the natural defense mechanisms.

We have shown that the UW strategy works very well and it doesn't matter what the insurgent population is.

The hurdle has been educatiing the DA centric folks. I would expect this different strategy to begin appearing in clinical usage in the next 3-4 years.
Great analogy.

I get the sense(at least down here) of a change in doctrine more towards what you are suggesting, but still with room for improvement.
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Old 09-18-2015, 14:35   #18
Patriot007
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Absolutely, spread the word! Tell them it's the worst diarrhea they ever had x 10 for days to weeks. Even then you can't appreciate its impact until you've seen it.

As PedOncoDoc stated, the ill neutropenic patient gets broad spectrum antibiotics every time because like he said they would be dead in hours.

It is interesting to think how advances in cancer treatment in addition to our aging population and even longer life expectancy are affecting this. Like neutropenic patients older people are more susceptible to becoming septic and needing broad spectrum antibiotics. Just another facet to the complexity of the issue.
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Old 09-18-2015, 15:59   #19
Badger52
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Question from a lay perspective

I find this back & forth extremely interesting and thank you all for it. Especially appreciate Trapper's UW analogy vs. the "DA" approach. Sounds like a case of "lots of big hammers here, so everything looks like a nail."

Coming from a non-med perspective; relates both to my partial (but likely increasing) role as a caregiver, as well as my own simpleton curiosity as someone who hardly ever gets sick. Am fortunate to have a family practitioner who, on those rare times when an antibiotic is called for, seems to be of the consensus here. To wit, broad spectrum and go home & do the other things that need to be done to let the body help itself.

The question I ponder is, just how involved are patients generally in their care to the extent that a doc prescribing the latest whizbang "DA SEAL team or UAV" would raise a red flag? Do you ever get a sense that some are not sufficiently involved to even query a particular treatment regime? (or has it always been so?)

Just has me wondering because the caregivee in my life has quite a few things that have to be juggled by the Doc (thus far doing a superb job).

Thank you.
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Old 09-18-2015, 16:54   #20
PedOncoDoc
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I find this back & forth extremely interesting and thank you all for it. Especially appreciate Trapper's UW analogy vs. the "DA" approach. Sounds like a case of "lots of big hammers here, so everything looks like a nail."

Coming from a non-med perspective; relates both to my partial (but likely increasing) role as a caregiver, as well as my own simpleton curiosity as someone who hardly ever gets sick. Am fortunate to have a family practitioner who, on those rare times when an antibiotic is called for, seems to be of the consensus here. To wit, broad spectrum and go home & do the other things that need to be done to let the body help itself.

The question I ponder is, just how involved are patients generally in their care to the extent that a doc prescribing the latest whizbang "DA SEAL team or UAV" would raise a red flag? Do you ever get a sense that some are not sufficiently involved to even query a particular treatment regime? (or has it always been so?)

Just has me wondering because the caregivee in my life has quite a few things that have to be juggled by the Doc (thus far doing a superb job).

Thank you.
It was my experience in primary care that patients are demanding antibiotics, not questioning their necessity. If they didn't get an antibiotic for their runny nose they would take their business to someone who would prescribe it...
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Old 09-18-2015, 18:00   #21
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It was my experience in primary care that patients are demanding antibiotics, not questioning their necessity. If they didn't get an antibiotic for their runny nose they would take their business to someone who would prescribe it...
I had a girl working for me that told me in 2014 that she took antibiotics seven times that year and her daughter six...not to mention that she had four steroid shots at different times throughout the year.

She literally went to the doctor's office every time she or her daughter sneezed or had a sniffle.

I think those antibiotics simply act as placebos for her now since she eats them like candy.
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Old 09-19-2015, 05:39   #22
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Kids and parents. As a parent of two boys under the age of 10, we are finally getting out of the ear infection every other month stage. The ear infections were the major cause for my children being on antibiotics. My youngest received tubes at age 2.5. That helped. Everytime the kids got an infection the Dr. would give antibiotics. How do we, parents and Dr., get away from that model?

I often wonder how we survived the little things before there were antibiotics. Simple things like ear infections, acne, strep throat, etc... I have asked my parents about how it was done when they were kids in the 1940s and they said you basically suffered through it. As a kid in the 1970s, i dont remember having to suffer through it. As a parent and an adult today I dont know of any other way of curing an infection besides using antibiotics. Every person that i know uses antibiotics at least once a year. How am I supposed to know when they are needed? I have to trust the medical community to tell me. I believe that an aggressive education campaign for both the med community and patients would benefit the fight against the drug resistant strains.

As for my wife, it will take an act of God to stop her from taking the kids to the Dr. when they sniffle.
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Old 09-19-2015, 06:32   #23
Trapper John
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I had a girl working for me that told me in 2014 that she took antibiotics seven times that year and her daughter six...not to mention that she had four steroid shots at different times throughout the year.

She literally went to the doctor's office every time she or her daughter sneezed or had a sniffle.

I think those antibiotics simply act as placebos for her now since she eats them like candy.
Just out of curiosity, is she and her daughter obese? You may think that is an odd question to ask, but it is possibly relevant.
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Old 09-19-2015, 07:55   #24
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Kids and parents. As a parent of two boys under the age of 10, we are finally getting out of the ear infection every other month stage. The ear infections were the major cause for my children being on antibiotics. My youngest received tubes at age 2.5. That helped. Everytime the kids got an infection the Dr. would give antibiotics. How do we, parents and Dr., get away from that model?

I often wonder how we survived the little things before there were antibiotics. Simple things like ear infections, acne, strep throat, etc... I have asked my parents about how it was done when they were kids in the 1940s and they said you basically suffered through it. As a kid in the 1970s, i dont remember having to suffer through it. As a parent and an adult today I dont know of any other way of curing an infection besides using antibiotics. Every person that i know uses antibiotics at least once a year. How am I supposed to know when they are needed? I have to trust the medical community to tell me. I believe that an aggressive education campaign for both the med community and patients would benefit the fight against the drug resistant strains.

As for my wife, it will take an act of God to stop her from taking the kids to the Dr. when they sniffle.
Regarding ear infections - there is a lot of evidence from Europe that many ear infections will resolve on their own if you wait 48-72 hours after the diagnosis of an ear infection. It is common practice in many areas to give a "provisional" prescription with orders only to fill the prescription if the fever and/or ear pain persists beyond the 2-3 day window after the appointment.

The reason we treat ear infections is twofold: 1) on occasion they can erode into the skull and cause more severe/life threatening infections, and 2) Recurrent/chronic ear infections can lead to permanent hearing loss.

Regarding the notion of taking kids to the doc every time they sniffle - that would take a culture change. At least your wife is seeing their primary care provided and not misusing the emergency department.

General rule of thumb: If fevers last less than 5 days, the kid is alert/arousable and eating/drinking, doesn't have a severe headache/stiff neck, and doesn't have difficuly breathing, it can probably wait until one of these criteria isn't met.
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Old 09-19-2015, 10:07   #25
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Just out of curiosity, is she and her daughter obese? You may think that is an odd question to ask, but it is possibly relevant.
No sir! In fact, she is triathlete and marathon runner who monitors everything they eat like a hawk. Her husband is in the medical field who owns a martial arts school and is their chief instructor.

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Old 09-19-2015, 10:39   #26
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Agoge 2 - the reason I asked that question is that there is some interesting work showing that the obesity epidemic in the U.S. may be the result of indiscriminate use of antibiotics and/or low level exposure to antibiotics in the food supply. This work is referenced in the opinion paper I published and is attached in the Drug Resistant Infections thread (post #1) in this forum.
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Old 09-19-2015, 10:41   #27
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Agoge 2 - the reason I asked that question is that there is some interesting work showing that the obesity epidemic in the U.S. may be the result of indiscriminate use of antibiotics and/or low level exposure to antibiotics in the food supply. This work is referenced in the opinion paper I published and is attached in the Drug Resistant Infections thread (post #1) in this forum.
I will certainly give it a read. If for nothing else, my personal interest with the subject.

Thanks!
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Old 09-19-2015, 14:25   #28
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Thanks all for their additional contributions; both from specific clinical interests as well as the apparent sea-change that would be required in some cases culturally.
(The opportunity that exists of a provisional prescription is interesting.)
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Old 09-19-2015, 15:27   #29
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Agoge 2 - the reason I asked that question is that there is some interesting work showing that the obesity epidemic in the U.S. may be the result of indiscriminate use of antibiotics and/or low level exposure to antibiotics in the food supply. This work is referenced in the opinion paper I published and is attached in the Drug Resistant Infections thread (post #1) in this forum.
Not to hijack this thread, but how do you separate the effects of antibiotic exposure from those of hormone exposure from the food supply?
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Old 09-20-2015, 07:10   #30
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Not to hijack this thread, but how do you separate the effects of antibiotic exposure from those of hormone exposure from the food supply?
Experimental animal models (see Richard Flavell's work). However, both would be predicted to have damaging long-term 2nd and 3rd order effects.

I have not read the body of research on low-level hormone exposure. So I really can't comment on the hormone exposure.
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