Are families of people in the ICU silenced by the law?

Doctors rushed an ill-fated motorcyclist with severe injuries to the head and chest to the ICU.   

In the difficult weeks that followed, the prognosis was progressively more and more grim. Family members were sure the patient "would not want to live like that" on a mechanical ventilator. 

But the law prevented them from speaking on his behalf.  

Read my full article at Scientific American blogs.

I was also interviewed on NHPR about this story as part of a three piece series on end-of-life decision-making. 

How can mothers with HIV breastfeed safely? Lessons from the saris of Bangladesh

Kids who breastfed for at least six months had higher IQ's in later life, according to a recent article in JAMA Peds.  

But US mothers with HIV are taught not to breastfeed their babies for fear they will transmit HIV. The HIV transmission risk to babies from breastfeeding is ~15%.

That means HIV-infected mothers in the US must choose between higher baby IQ's, and a host of other health benefits of breastfeeding, or safety. 

The breastfeeding choice is even more complicated for mothers with HIV in the developing world. There, in countries with unsafe drinking water, HIV isn't the only threat to babies: diarrheal illness is a major pediatric killer. As a result, feeding babies with formula risks infections that can kill in days instead of years like HIV. 

As a result, breastfeeding recommendations in the US and the developed world are the opposite of those in the developing world:

(1) in the US and the developed world mothers with HIV are taught to use formula and avoid breastfeeding; whereas 

(2) in developing countries mothers breastfeed and hope for HIV therapy to reduce the risk of transmission. In the new consolidated WHO treatment guidelines released 30 June 2013, universal HIV treatment is recommended for pregnant and breastfeeding mothers.

This means that a great way to prevent HIV transmission in the developing world is to make drinking water safer. 

But wait, it gets more complicated. A new UNC study has confirmed that breast milk  actually protects from oral transmission of HIV. That means it is the HIV within breast milk that endangers babies, not the breastmilk itself.

If breast milk protects from oral HIV transmission, and has myriad health benefits, then perhaps we can find a way to remove HIV from breast milk? The solution will need to be low tech since the greatest need is in developing countries - no $83,000 NASA filters, please. 

That's where Rita Colwell comes in. A microbiologist at the University of Maryland, and former head of the National Science Foundation, Colwell studied cholera - a diarrheal disease transmitted by contaminated water - in Bangladesh. She showed that water filtered through a folded sari was far less likely to transmit cholera, meaning families could filter drinking water through a cheap piece of clothing and keep themselves safe.  

Might developing world mothers with HIV use the same trick to protect their babies from HIV? An effective filter for drinking water in the developing world could not only prevent pediatric diarrheal disease, sure, but what if it could prevent HIV transmission. 

What? "Filter breastmilk?" you say. Not so crazy after all -  many investigators are studying creative ways of making breast milk safer by nipple shields and other ingenious ways of filtering HIV out of breast milk.  

Over 1,000 children are infected with HIV every day; let's hope we find an answer soon.

Earlier Is Better

For years now there has been controversy about whether early HIV infection should be treated. Could the immune system be spared the ravages of the HIV virus through early therapy? Or does early therapy just make treatment last longer? The jury has been out, and might still be deliberating, but a new piece of evidence has emerged. 

 Deeks et al have shown that, compared to people treated later in HIV disease, those treated within 6 months of initial infection show less immune system damage over time. This might be a sign that early treatment is good.  

We still lack clear evidence that such benefits of early treatment outweigh the downsides of HIV treatment. The side effects, costs and other risks are real. So, we still await a clear sign. 

When face-to-face with a patient with early HIV infection, I tell them what we know, and what we don't, and we share the decision-making. Does the possibility of ongoing immune damage scare them enough to make taking an HIV pill or two daily worth it? Or  does the prospect of starting decades of therapy freak them out more? We talk through it, and most (but not all) start therapy. 

Someday, let's hope we know more.

Quoted @ MIND/Shift

Holly Korbey has a great new article about the death of lectures in which I was quoted. Okay, maybe not the death of lectures - but definitely their dethroning. 

Teachers are wrong to assume that their role is to only convey information, and that merely saying the magic words will translate into learning for students.

Click here to read Holly Korbey's "Anyone Still Listening? Educators Consider Killing the Lecture" @ MIND/shift

HIV Cures: Where We Are, Realistically

Newswires remain abuzz around two reports of "functional" HIV cures.  What does "functional cure" mean? Should the Nobel Committee be dusting off medals?

Click here to read my full article at The Atlantic

How Middle School Failures Lead to Medical School Success

At the end of a long day -- Jessica teaching middle school and Tim teaching medical students -- we settled into bed and began trading war stories.

We discovered we were both reading the same author, and that this linked middle school failures to success in medical school better than we could have predicted.

Click to read our full article at The Atlantic. 

Children's medication preferences in the developing world

The palatability and convenience of children's medicines have a huge impact on their potency, and thus on pediatric health.

Yet it's a amazing how little is known about what children, and their parents, prefer in the developing world.  

I worked with a team who surveyed children and caregivers about their preferences and habits.

Check out our article in PLoS ONE. 

Your Kid Probably Doesn't Need Antibiotics

 How to help everyone prevent the looming "antibiotic apocalypse"

We're looking for a new pediatrician, and, over coffee with friends, recommendations started flying. When it came out that our 14-year-old son had never taken antibiotics, the conversation stopped on a dime.

"What about for ear infections?" one said.

"Hasn't he ever had strep?" said another.

"Never?" said the third.

Read our full article at The Atlantic.

New paper about HIV-related tuberculosis

We found that HIV-infected adults who had tuberculosis before had double the risk of getting tuberculosis again. We should target preventive interventions here.

Click here to read my article in Clinical Infectious Diseases