Collection of online pharmacology lectures, videos, animations, questions, and pharmacology news

Pharmamotion offers a collection of online lectures, videos, animations, questions, and pharmacology news intended to serve as a resource for the current and future physician.

This amazingly detailed resource is put together by Flavio Guzman, MD, working as teaching assistant at the Department of Pharmacology, University of Mendoza, Argentina. He also calls for others to contribute to online medical education resources.

The aim of this website is to gather educational resources targeted to health professionals that are freely available on the web, for a better understanding of pharmacology. These resources include:

• Animations and videos that illustrate mechanism of action of drugs (some of them developed by me).
• Definitions and concepts from reliable sources about the general principles of pharmacology.
• Press releases and drug reviews from official agencies (FDA, EMEA, NHS, and many others).

Treatment of Swine flu Influenza

Antiviral Treatment:

• Should be considered for confirmed, probable, or suspected cases of swine flu virus infection.
• Oseltamivir and zanamivir should be initiated as soon as possible after the onset of symptoms.
• Recommended duration of treatment is five days.
• Doses recommended for treatment are the same as those recommended for seasonal influenza.
• Oseltamivir use in children <1 year old was recently approved by the FDA under an Emergency Use Authorization (EUA).
  

Antiviral Chemoprophylaxis:

• Chemoprophylaxis is recommended for:
  • Household close contacts who are at high-risk for complications of influenza (eg, certain medical conditions, persons ≥65 years old, children <5>
  • School children who are at high-risk for complications of influenza and who had close contact with a confirmed, probable, or suspected case.
  • Travelers to Mexico who are at high-risk for complications of influenza.
  • Healthcare workers and public health workers who were not using appropriate protective equipment during close contact with an ill confirmed, probable, or suspected case during the infectious period.
• Chemoprophylaxis (pre-exposure) may be considered for:
  • Healthcare workers at high-risk for complications of influenza and who are working in areas that contain patients with confirmed illness or who are caring for patients with acute febrile respiratory illness.
  • Non-high risk persons who are travelers to Mexico, first responders, or border workers who are in areas with confirmed cases.
• Oseltamivir or zanamivir may be used.
• Post-exposure: duration of chemoprophylaxis is 10 days after last known exposure to ill confirmed case.
• Pre-exposure: chemoprophylaxis should be given during potential exposure period and for 10 days after last known exposure.
• Oseltamivir may be used for chemoprophylaxis in children <1>

level of swine influenza pandemic alert raised from phase 3 to phase 4

Human cases of swine influenza A/H1N1 virus infection also have been confirmed internationally: US has reported 40, Canada has reported 6 confirmed human cases of infection; Spain has reported 1 case; Scotland has reported 2 cases. Mexico has reported 26 cases of infection, including 7 deaths.

On the advice of the Emergency Committee of the World Health Organization, the Director-General has raised the level of influenza pandemic alert from phase 3 to phase 4. The change to a higher phase of pandemic alert indicates that the likelihood of a pandemic has increased, but not that a pandemic is inevitable.

The Emergency Committee's recommendation is based on the available data on confirmed outbreaks of A/H1N1 swine influenza in the United States, Mexico, and Canada. The Committee also considered reports of possible spread to additional countries.

The decision was based primarily on epidemiological data demonstrating human-to-human transmission and the ability of the virus to cause community-level outbreaks.

Given the widespread presence of the virus, the Director-General considered that containment of the outbreak is not feasible. The current focus should be on mitigation measures.

In Mexico, the suspected number of cases is reportedly as high as 1,600, and the suspected number of deaths in Mexico is up to 80. Potential new cases also have been reported in France, Hong Kong, and New Zealand. These numbers and reports are not yet confirmed.

Laboratory testing has found the swine influenza A/H1N1 virus is susceptible to the prescription antiviral drugs oseltamivir and zanamivir.

New subtype of influenza virus - Swine influenza

The Centers for Disease Control and Prevention (CDC) report laboratory-confirmed human cases of swine influenza A/H1N1. Human cases of swine influenza A/H1N1 virus infection also have been identified internationally.

Based on preliminary testing, the virus is being described as a new subtype of A/H1N1 not previously detected in swine or humans.

Laboratory testing has found the swine influenza A/H1N1 virus is susceptible to the prescription antiviral drugs oseltamivir and zanamivir. According to Anne Schuchat, MD, the CDC's Interim Deputy Director for Science and Public Health Program, treatment should begin within 48 hours of onset. Vaccine development is in process, but it will take several months to prepare a vaccine.

CDC has issued interim recommendations for diagnostic testing and antiviral use, but local and state circumstances may vary and individual protocols may be put in place.

The CDC also has prepared interim guidance on how to care for people who are sick and interim guidance on the use of face masks in a community setting where spread of this swine flu virus has been detected. This is a rapidly evolving situation and CDC will provide new information as it becomes available.

The World Health Organization (WHO) reports that the government of Mexico also has reported several laboratory-confirmed cases of swine influenza A/H1N1. In a media briefing today, the CDC confirmed several swine influenza-related deaths as well. Investigation is continuing to clarify the spread and severity of the disease in Mexico. Suspect clinical cases have been reported in 19 of the country's 32 states.

Investigations are ongoing to determine the source of the infection and whether additional people have been infected with swine influenza viruses.

CDC is working very closely with officials in states where human cases of swine influenza A/H1N1 have been identified, as well as with health officials in Mexico, Canada, and WHO. This includes deploying staff domestically and internationally to provide guidance and technical support. CDC has activated its Emergency Operations Center to coordinate this investigation.

WHO and the Global Alert and Response Network (GOARN) are sending experts to Mexico to work with health authorities. WHO and its partners are actively investigating reports of suspect cases in other Member States as they occur and are supporting field epidemiology activities, laboratory diagnosis and clinical management.

Effective teaching: Make your teaching more interesting and enjoyable

Students usually learn best when they're motivated. Although you can't make someone learn, you can create an environment that supports and encourages learning success. Use an effective teaching style that allows people to participate in their learning. Find ways to emphasize the benefits of learning new skills, and make learning relevant to people's jobs. Encourage them to take control of their own learning, and allow them to set their own objectives. The more you develop motivation to learn, the more successful you'll probably be. Start today to recognize the value of learning, and see the many learning opportunities around you!

As well as increasing the motivation to learn, there are many ways to make your teaching sessions more interesting and enjoyable. These ideas can be used for formal lessons, or for spontaneous learning opportunities that present themselves.

You can help the learning process by doing the following:

• Use pre-instruction questions - These can get students to think about why they should be learning this new skill, as well as to appreciate the benefits of learning.
  

• Use conceptual models - These are often a useful way for helping students to store and retrieve information. Mental models (which can be in the form of diagrams and charts) are often helpful for learning the details of a lesson.
  

• Vary the learning material - This will help you deal with the different ways in which people learn. You can vary your material for different learning styles as follows:
  
  

  • Visual Learners - Charts, graphs, or images are useful for representing the information being conveyed, as well as information in books or reports.
    

  • Auditory Learners - Lectures, presentations, and group discussions help auditory learners 'talk through' what's being presented.
    

  • Kinesthetic Learners - These learners like hands-on practice that's either real or simulated.
    

  We all have our own preferred learning styles. If you provide as many different learning experiences as sensibly possible, you'll be more likely to connect with each learner.

• Group students together - Encourage learning and understanding by having students work together while learning the same skills. By helping one another, they can all reinforce what they're learning. Everyone in the group will then benefit from the strengths of the individual members.
  

• Provide opportunities for reflection and thinking - Learning journals are a popular and effective way for people to write down their thoughts about how the learning process itself has been helpful to their overall development.
  

• Actively review the lesson at the end - What progress did the students make, and what difficulties did they encounter? By revisiting the lesson, you have an opportunity to learn from the experience yourself - and hopefully figure out how to improve the content or approach next time. Reviews also give students opportunities to analyze their performance, and increase their commitment to continuous learning.
  

• Use all of your emotional intelligence and communication skills - This means establishing a connection with students, listening actively, using empathy where appropriate, being patient, and showing genuine interest in the students and in your teaching. Your attitude toward learning has a huge impact on the learners' attitudes, so make sure you're a good role model for continuous, active learning.

Effective teaching: Motivating students to learn

A useful model for motivating students is ARCS, which stands for 'Attention, Relevance, Confidence, and Satisfaction.' This was developed by John Keller in 1983, and it's been used and validated by teachers and trainers across a wide range of learning environments - from universities to the military.

Here are the basic components of the ARCS model:

• Attention - Capture learners' attention at the start of the session, and maintain it throughout.
  
  

  • Ask learners questions to make them think about why they should learn the skill.
    

  • Use role-playing or other activities to show the importance of learning the skill.
    

  • Use specific examples, and ask learners to offer their own solutions, to stimulate their interest further.
    

• Relevance - Explain to learners how important the lesson is, and how it could benefit them.
  
  

  • Describe the benefits.
    

  • Relate the lesson to their current jobs and experiences. The learning materials, assignments, and projects should be applicable to their work, and to specific situations they face in their daily jobs.
    

  • Develop a connection between learning the skill and developing their careers. Discuss issues like increased satisfaction, better job, and increased patient satisfaction.
    

• Confidence - Tell learners what is expected of them.
  
  

  • Set clear objectives for the session, and check in regularly with learners to make sure they're not falling behind.
    

  • Design projects and lessons so that learners experience small successes along the way, before they completely master the skill.
    

  • Give learners enough time to practice skills, so that they'll be successful when they apply these skills to the job.
    

  • Make sure you're teaching at the right level. Learners can lack motivation if something is too difficult - or too easy.
    

  • Allow learners to have input into their learning by helping them create their own learning goals.
    

• Satisfaction - Reinforce successes and motivation.
  
  

  • Give lots of feedback. Make sure it's specific, timely, and relates to how learners can put the skill into practice on the job.
    

  • Recognize learners' successes. Appreciate often, and find ways to reward achievements.
    

  • Look at ways to increase motivation. Find out what learners are interested in and passionate about. And find ways to get learners to motivate one another as well.

  Source: MindTools
  

Drug Prescribing Pattern in Dental Teaching Hospital

MT Salman, FA Khan, SZ Rahman, M Makhdoom. JK Science, Vol. 11 No. 2. 107, April-June 2009

Objective: To study drug prescribing pattern in the Dental OPD.
Methods: 50 prescriptions were collected from Ziauddin Ahmad Dental College, AMU, Aligarh, and analyzed for percentage of drugs prescribed as per VEN Method. We also looked into the percentage of drugs prescribed with generic name, groups of drugs commonly prescribed, antibiotics’ prescription pattern, number of injections and cost per prescription as per WHO basic drug indicators.
Results: The percentage of drugs from Essential Medicines List (EML) was 25%, while percentage of drugs prescribed by Generic Name was only 4%. Most common groups of drugs prescribed by Dental Physicians were Antiseptics (40%), NSAIDs (34%), Antibiotics (30%) and Vitamins (4%). The most extensively prescribed drug from each group was Betadine Gargle, Tablets Voveron, Novaclox and Basiton Forte respectively. The average number of drugs prescribed, number antibiotics prescribed and cost per day per prescription were 3, 1 and Rs. 24.2 respectively.. Average number of antibiotics prescribed per prescription was 1.0. No injection was prescribed to any patient.
Discussion: After reviewing the above prescriptions, the pattern of drug prescribing is not based on WHO criteria for rational use of drugs. The system is not at all evidence based. It is thus necessary to make physicians of Dental College aware about the use of drugs from EMLs, importance of prescribing drugs with generic names and, for patients’ point of view, the factor of cost-effectiveness. There is need of CMEs based on GCP and Standard Treatment Guidelines. Every institution must have Drugs and Therapeutic Committees.

Conclusion: For rational prescribing of drugs, there is a need of mass awareness amongst surgeons about good prescribing habit by following five steps of WHO Program on Rational Use of Drugs (RUD).

Free full text

Low Sodium Cooking

Low Sodium Cooking lists a number of Recipies which are low on sodium. It includes:

Appetizers
Meat and Main Dishes
Breakfast
Side Dishes and Salads
Sauces, Marinades and Dressings
Condiments, Spice Mixes and Mixes
Breads
Desserts, Snacks and Sweets

you can access the site at http://www.lowsodiumcooking.com/free/Archive.htm

Sources for funding and grants for Biomedical researchers

The Foundation Center has an extensive subscription database (http://fconline.fdncenter.org), with information on nearly 100,000 foundations, not-forprofit, and corporate giving programs. If your library doesn't subscribe to their services, you can use them for free at any one of their 400 locations nationwide. The site offers guidance on finding and utilizing 990 forms which list an organization's mission, programs, and finances, from smaller grantmakers.

Community of Science (COS) lists over 25,000 funding sources, including international, public, and private funders (www.cos.com). In addition to the typical search activities (free for registered users), COS posts a weekly list of new grants in Health Sciences.

GrantsNet A free compilation site from the American Association of the Advancement of Science (AAAS), this list is especially quick and easy to explore. Users can choose from GrantsNet's thorough list of selection criteria, encompassing 12 experience levels and 38 broad research areas. A quick search for 2009 grants in molecular biology for initial postdocs yielded 50 listings.

University funding pages Some large research universities offer nonrestricted grant information on their Web sites. For example, the funding database from Duke University's medical center is fully accessible to the public at www.researchfunding.mc.duke.edu. Users searching a particular discipline can sort by order of grant amount, or deadline. The Advanced Search function brings up a small, more select list of granters and is simple to specify.

The Medical Foundation (TMF) has advised clients interested in funding outstanding medical researchers for 50 years. They represent a varying number of foundations (currently 11). Several support basic research areas. Grants from most of TMF's funders start at $40,000 per year (www.tmfnet.org).

Source: Finding New Money by Carol Milano. The Scientist.com 23 (4). 70

Novel agents and approaches for breast cancer

Cytotoxic chemotherapy remains an important part of the treatment paradigm for breast cancer. Anthracyclines and taxanes are the most active agents; however, limitations with their use include a maximum lifetime dose and tumor resistance with anthracycline, hypersensitivity reactions and cumulative toxicity with taxanes.

• Therefore, to meet these challenges, the development of new cytotoxics and novel taxane formulations is an important area of active research. Several recent advances have been made. Epothilones represent a novel group of cytotoxic agents, with proven activity in breast cancer.
• Nanoparticle drug delivery systems have led to the development of ABI-007, which has demonstrated superior response rates than 3-weekly paclitaxel, with a lower risk of hypersensitivity reactions.
• To circumvent the problem of taxane resistance, larotaxel, a semisynthetic taxoid, and vinflunine, a synthetic vinca alkaloid, have been developed with encouraging clinical results to date.
• Eribulin, a synthetic derivative of halichondrin has recently entered Phase III trials based on encouraging activity in heavily pretreated patients.
• A further novel approach is the conjugation of cytotoxic agents to targeted agents, such as with trastuzumab-MCC-DM1.

"High Alert" Medications

High Alert Medications are those drugs which bear aheightened risk of significant patient harm if used in error, according to The Institute for Safe Medication Practices. To access the list of 'high alert medications' click here.

"High-Alert" Medications

According to the Institute for Safe Medication Practices, US, high-alert medications are those that bear a heightened risk of causing significant patient harm when used in error.

Adverse metabolic and cardiovascular consequences of not maintaining circadian rythm

The following studies signify the importance of maintaining a regular routine of sleeping, eating and other daily activities.
In a recent study, Ciprian and colleagues found increased pathological remodeling and vascular injury in mice with aberrant circadian rhythms, Bmal1-knockout and Clock mutant. In addition, naive aortas from Bmal1-knockout and Clock mutant mice exhibit endothelial dysfunction. Akt and subsequent nitric oxide signaling, a pathway critical to vascular function, was significantly attenuated in arteries from Bmal1-knockout mice. The authors concluded that their data reveal a new role for the circadian clock during chronic vascular responses that may be of significance in the progression of vascular disease.
In another study by Scheer et at, Ten adults (5 female) underwent a 10-day laboratory protocol, wherein subjects ate and slept at all phases of the circadian cycle—achieved by scheduling a recurring 28-h “day.” Subjects ate 4 isocaloric meals each 28-h “day.” For 8 days, plasma leptin, insulin, glucose, and cortisol were measured hourly, urinary catecholamines 2 hourly (totaling ≈1,000 assays/subject), and blood pressure, heart rate, cardiac vagal modulation, oxygen consumption, respiratory exchange ratio, and polysomnographic sleep daily. Core body temperature was recorded continuously for 10 days to assess circadian phase. Circadian misalignment, when subjects ate and slept ≈12 h out of phase from their habitual times, systematically decreased leptin (−17%, P <>P <>P = 0.006), completely reversed the daily cortisol rhythm (P <>P = 0.001), and reduced sleep efficiency (−20%, P <0.002).>
Sources:
Vascular Disease in Mice With a Dysfunctional Circadian Clock
Ciprian B. Anea, MD; Maoxiang Zhang, PhD; David W. Stepp, PhD; G. Bryan Simkins, BS; Guy Reed, MD; David J. Fulton, PhD; R. Daniel Rudic, PhD
From the Department of Pharmacology and Toxicology (C.B.A., M.Z., G.B.S., D.J.F., R.D.R.), Department of Physiology (D.W.S.), Vascular Biology Center (D.W.S., D.J.F.), and Cardiology Division, Department of Medicine (G.R.), Medical College of Georgia, Augusta.
Circulation. 2009;119:1510-1517
Published online before print March 9, 2009, doi: 10.1161/CIRCULATIONAHA.108.827477
Adverse metabolic and cardiovascular consequences of circadian misalignment
Frank A. J. L. Scheer, Michael F. Hilton, Christos S. Mantzoros, and Steven A Shea
Division of Sleep Medicine, Brigham and Women's Hospital, Boston, MA 02115
Harvard Medical School, Harvard University, Boston, MA 02115; and
Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215
Published online before print March 2, 2009, doi: 10.1073/pnas.0808180106
PNAS March 17, 2009 vol. 106 no. 11 4453-4458

Hepatocellular carcinoma: Promising results of dendritic cell-based immunotherapy

HCC is a promising target for immunotherapy because tumor-infiltrating lymphocytes are actively recruited to HCC lesions. However, these lymphocytes fail to kill tumor cells, possibly because T-cell maturation is prevented.
Dendritic cells process antigens and present them to naive T and B cells. Dr Palmer et al. isolated dendritic cells from 35 patients with advanced HCC who were not amenable to curative resection, transplantation, local ablation or chemoembolization. Dendritic cells were pulsed with lysates from Hep G2, a liver-tumor cell line with many antigens in common with HCC. Patients received well-tolerated, multiple intravenous infusions of mature, pulsed dendritic cells. Of 25 patients who received at least two vaccinations, one achieved radiological partial response and six disease stabilization for 6–16 months. Of the 17 patients eligible for serological assessment, four achieved partial serological response and four disease stabilization.

Source: Palmer, D. H. et al. A phase II study of adoptive immunotherapy using dendritic cells pulsed with tumor lysate in patients with hepatocellular carcinoma. Hepatology 49, 124–132 (2009).

Targeted cancer therapy

Treatment options for inoperable or progressive malignant pancreatic endocrine tumors (PETs) are limited, but new evidence suggests that the epidermal growth factor receptor (EGFR) and cyclo-oxygenase 2 (COX2) should be investigated as potential chemotherapeutic targets.

Dr Bergmann et al. analyzed 110 tumor samples from 74 patients who underwent resection of PETs between 1991 and 2006. EGFR was expressed in 57% of malignant PETs and in 26% of nonmalignant (benign tumors or those with uncertain behavior) PETs. Malignant PETs were characterized by significantly higher average expression of EGFR than nonmalignant PETs. By contrast, no significant differences were observed between nonmalignant and malignant PETs regarding COX2 expression, which was uniformly high across tumor categories.
Administration of the EGFR antagonist AG1478 and of the COX2 inhibitor celecoxib to the human pancreatic carcinoid cell line BON and to the mouse pancreatic insulinoma cell line -TC-3 resulted in significant, dose-dependent decreases of cell viability. Administered in combination, celecoxib and AG1478 displayed additive effects on cell viability in both cell lines.
Evidence suggests that EGFR and COX2 are potential chemotherapeutic targets for PETs that should be further investigated.

Source: Bergmann, F. et al. Expression pattern and functional relevance of epidermal growth factor receptor and cyclooxygenase-2: novel chemotherapeutic targets in pancreatic endocrine tumors? Am. J. Gastroenterol. 104, 171–181 (2009).

Outsourcing clinical trials-Implications of the Globalization of Clinical Research

Economics of clinical trials

The shift towards conducting trials in eastern Europe, South America, India and China is related to issues of costs and regulatory hurdles, which have become intertwined.

• Labor costs (physicians, nurses and coordinators) can be up to 90% lower outside the US
• costs associated with the time required to recruit participants and conduct a trial are reduced by the availability of large pools of potential participants
• regulatory barriers to performing clinical trials in North America and western Europe are becoming increasingly bureaucratic and expensive

Benefits of conducting trials in developing countries

• cost-efficient evaluations of efficacy and safety of drugs or devices
• fostering global relationships among clinicians, and between clinicians and industry.
• Trials completed in lesser time

Ethical issues

the rights of trial participants may be jeopardized by "disparities in education, economics, social standing, and health care systems" if they

• do not understand the investigational nature of the products being tested
• do not understand the implications of placebo controls
• receive a disproportionate financial compensation for participation
• have limited access to alternative therapies.

Other Concerns

• Does the trial respond to or prioritize the health needs of the country or region?
• After the study ends, will patients have access to the best proven therapy identified by the trial, as expected by the Declaration of Helsinki?
• Is the ethical conduct of the trial undermined by financial incentives for investigators?

Scientific issues

• the need for transparency with regard to access to data
• publication rights for investigators from developing countries
• Are the results applicable to other populations with regard to genetic diversity or baseline characteristics (many patients enrolled in developing countries differ from their counterparts in developed nations in relation to disease stage or concomitant therapies)?
• The clinical trial setting (hospital versus outpatient, academic center versus private clinic) requires scrutiny as to whether results can be extrapolated to other groups of patients.

Source: Glickman et al. Ethical and scientific implications of the globalization of clinical research. N Engl J Med. 2009 Feb 19;360(8):816-23.

Stephen B. Hanauer. Outsourcing clinical trials. Nature Reviews Gastroenterology and Hepatology 6, 191 (April 2009) doi:10.1038/nrgastro.2009.57

Indian polypill study

The TIPS study was headed by Dr. Prem Pias Dean, SJMCH. Dr. Denis Xavier HOD, Dept of Pharmacology, SJMC And

Dr. Alben Sigamani Trial Manager Division of Clinical Trials St. Johns Research Institute Bangalore.

The concept of Polypill in Cardiovascular Diseases was by Dr. Salim Yusuf (Graduate from St. John's), Now the Director of PHRI Mc. Master university Canada.

The Study was funded by Cadila Pharmaceuticals.

The results of the study are published in Lancet Mar 30th 2009.

This team is now heading forward to conduct one more large clinical outcome based study with polypill, the clinical end points such as All cause mortality and CV mortality. This future study will answer the question such as.

1) Which particular patient can take the poly pill

2) Patient with certain risk factors needs to take which combination of Ploy pill. etc

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60611-5/abstract

Indian scientists discover 'superpill' to combat heart disease Hindu - ‎Mar 31, 2009

'Polypill' could reduce heart disease, stroke: Researchers Calgary Herald

5-in-1 pill passes first major test Times of India

Five-in-one pill cuts heart attack risk Calcutta Telegraph

Circumcision reduced the incidence of human immunodeficiency virus (HIV), HSV 2, HPV infections

Male circumcision significantly reduced the incidence of HIV and herpes simplex virus type 2 (HSV-2) infection and the prevalence of human papillomavirus (HPV) infection, suggesting potential public health benefits, according to the results of a randomized controlled trial reported in the March 26 issue of the New England Journal of Medicine.

"Male circumcision significantly reduced the incidence of...HIV infection among men in three clinical trials," write Aaron A.R. Tobian, MD, PhD, from Bloomberg School of Public Health, Johns Hopkins University in Baltimore, Maryland, and colleagues. "We assessed the efficacy of male circumcision for the prevention of...HSV-2 and...HPV infections and syphilis in HIV-negative adolescent boys and men."

Two trials of male circumcision to prevent HIV and other sexually transmitted infections in a rural Ugandan population enrolled a total of 5534 HIV-negative, uncircumcised male subjects aged 15 to 49 years. Of 3393 subjects (61.3%) who were HSV-2 seronegative at enrollment, 1684 had been randomly assigned to undergo immediate circumcision (intervention group) and 1709 to undergo circumcision after 24 months (control group). Subjects were tested for HSV-2 and HIV infection and syphilis and underwent physical examinations and interviews at baseline and at 6, 12, and 24 months. A subgroup of subjects was also evaluated for HPV infection at baseline and at 24 months.

The cumulative probability of HSV-2 seroconversion by 24 months was 7.8% in the intervention group vs 10.3% in the control group. High-risk HPV genotypes were present at 24 months in 18.0% of the intervention group vs 27.9% of the control group.

"In addition to decreasing the incidence of HIV infection, male circumcision significantly reduced the incidence of HSV-2 infection and the prevalence of HPV infection, findings that underscore the potential public health benefits of the procedure," the study authors write. "These findings, in conjunction with those of previous trials, indicate that circumcision should now be accepted as an efficacious intervention for reducing heterosexually acquired infections with HSV-2, HPV, and HIV in adolescent boys and men. However, it must be emphasized that protection was only partial, and it is critical to promote the practice of safe sex."

Points to remember

• Uncircumcised men may be at higher risk for sexually transmitted infection because of greater exposure of the lightly keratinized inner preputial mucosa during intercourse, a higher risk for microtears, and a favorable environment in the subpreputial cavity for incubation of infection.
• In the current study, circumcision reduced the risk for infection with HSV-2 and HPV

(ClinicalTrials.gov numbers, NCT00425984 [ClinicalTrials.gov] and NCT00124878 [ClinicalTrials.gov] .)

Aaron A.R. Tobian et al. Male Circumcision for the Prevention of HSV-2 and HPV Infections and Syphilis. New England Journal of Medicine. 360 (13) :1298-1309, March 26, 2009

Patient Sharing Among Hospitals Common, Likely Source of spread of Infectious Pathogens

Patient sharing is common among hospitals, and it likely presents an avenue for infectious-disease transmission, according to a study presented here at the Society for Healthcare Epidemiology of America (SHEA) 19th Annual Scientific Meeting.

The study found that only 1 in 9 of these shared patients were directly transferred from one hospital to another; most of the patients were discharged and then readmitted to another hospital within 1 year. This amount of patient sharing between hospitals might increase the spread and transmission of infectious pathogens, such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE).

To assess the frequency of interfacility sharing in 1 county (Orange County, the third-most-populous and largely suburban county in California), the direct and indirect transfers among 31 acute-care hospitals were assessed in a retrospective evaluation using 2005 California hospital-discharge data. The study evaluated the likelihood that adult patients admitted to each hospital in 2005 would subsequently be transferred or admitted to another hospital in the county within 1 year of discharge.

Dr. Huang and colleagues found that in 2005, 239,456 adult patients were admitted to Orange County hospitals, with a median length of stay of 3 days. The study found that patients were widely shared among the hospitals, sharing at least 1 patient with a median of 28 other hospitals; only 16% of interfacility patient sharing occurred by direct patient transfer. Among those discharged, 22% were readmitted to a median of 2 hospitals in the subsequent year; median time to readmission was 23 days.

According to Dr. Rupp, the following bacilli are of concern:

• Pseudomonas aeruginosa is a gram-negative rod that belongs to the family Pseudomonadaceae, and is a pathogen of increasing clinical relevance and a frequent cause of nosocomial pneumonia, especially in intensive-care units. Several epidemiologic studies that have tracked its occurrence as a nosocomial pathogen indicate that antibiotic resistance is increasing in clinical isolates.
• Acinetobacter strains are nosocomial pathogens that have caused a number of American military casualties to develop serious infections.
• Klebsiella pneumoniae causes serious infections in the critically and chronically ill and is rapidly developing resistance to all available antibiotics.

Source:

Society for Healthcare Epidemiology of America (SHEA) 19th Annual Scientific Meeting: Abstract 59. Presented March 20, 2009.