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Why asking doctors to prescribe fewer antibiotics is futile
Antibiotics are often the fastest and simplest way for doctors to help their patients. But with the threat of drug-resistant bacteria, how do we stop prescribing antibiotics?
An 85-year-old woman with dementia is admitted to hospital with worsening confusion, new urinary incontinence, and constipation.
These symptoms suggest a urinary tract infection, but the doctor treating her has a dilemma because the symptoms also suggest her dementia may be worsening or she has simple constipation. Sending a sample to a lab for analysis could confirm bacteria in the urine, but getting a result takes days, so the doctor decides to play it safe and prescribe antibiotics.
Scenes like that are repeated every day in hospitals around the world, and they are leading to excessive and often unnecessary antibiotic use. The inevitable consequence is the evolution of resistant bacterial strains. Bacterial genes undergo continual mutation. When a colony of bacteria is exposed to an antibiotic, a mutation may eventually occur in a single member of the colony, making it immune to the antibiotic. This lucky mutant will then reproduce rapidly as its mutation spreads through the entire colony — as the video below illustrates.
Antibiotic resistance is a global problem that could render existing drugs ineffective against life-threatening bacterial infections. As such, doctors are being urged to prescribe antibiotics more judiciously. However, our latest research suggests this is unlikely to happen unless special measures are introduced to deal with the problem.
What we proved is that antibiotic prescribing supports the idea that resources that don't clearly belong to an individual or a group are likely to be overexploited (known as “the tragedy of the commons"). In fact, healthcare professionals have suspected this for some time, but it had not been rigorously proved until now.
What it implies is that if doctors act in the best interests of their own patients, then prescribing antibiotics whenever a bacterial infection is suspected is always the preferred treatment, irrespective of whether other doctors are doing the same. What makes it a tragedy of the commons is that if all doctors adopt this strategy, then the outcome is worse for themselves and their patients than if they all exercised restraint.
Like players in a game of prisoner's dilemma, they know that the outcome would be better if they all behaved differently, but prescribing antibiotics whenever a bacterial infection seems possible remains their best strategy. We also showed that the rate of antibiotic prescribing is likely to increase until antibiotics become useless, unless steps are taken to change the payoffs of this potentially deadly game.
We reached these conclusions by using evolutionary game theory and replicator dynamics (a mathematical model). The basic idea behind this type of analysis is straightforward. We begin with an assumption about the preferences of the players — in this case, that doctors invariably prefer to act in the best interests of their own patients. Then we factor in established facts about the effect of prescribing rates on antibiotic resistance, and we work out mathematically the implications for what will happen over time.
There is no point in merely appealing to doctors to change their prescribing behavior, but that doesn't mean nothing can be done about it. Based on a detailed review of the literature, we recently suggested how to mitigate the problem.
Steps to take
Several steps should be taken. Clearly defined antibiotic regulations and access rights need to be established, and the visibility and urgency of the problem need to be heightened. Collective or team-based rather than individual prescribing decisions should be encouraged, and prescribing should be carefully monitored. Also, social and reputational incentives and sanctions to encourage responsible prescribing should be introduced. Finally, perverse incentives that encourage over-prescription should be removed.
In the long run, it's unlikely that the problem of antibiotic resistance can be eliminated entirely, but the steps that we have suggested could slow the process.
Eventually, radically new methods of dealing with bacterial infections will be needed. But if nothing is done immediately, then dangerous pandemics may be just around the corner.
- Bacteria Can Collectively Resist Antibiotics Study Finds - Big Think ›
- Probiotics and antibiotics create a killer combination - Big Think ›
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Richard Feynman once asked a silly question. Two MIT students just answered it.
Here's a fun experiment to try. Go to your pantry and see if you have a box of spaghetti. If you do, take out a noodle. Grab both ends of it and bend it until it breaks in half. How many pieces did it break into? If you got two large pieces and at least one small piece you're not alone.
But science loves a good challenge<p>The mystery remained unsolved until 2005, when French scientists <a href="http://www.lmm.jussieu.fr/~audoly/" target="_blank">Basile Audoly</a> and <a href="http://www.lmm.jussieu.fr/~neukirch/" target="_blank">Sebastien Neukirch </a>won an <a href="https://www.improbable.com/ig/" target="_blank">Ig Nobel Prize</a>, an award given to scientists for real work which is of a less serious nature than the discoveries that win Nobel prizes, for finally determining why this happens. <a href="http://www.lmm.jussieu.fr/spaghetti/audoly_neukirch_fragmentation.pdf" target="_blank">Their paper describing the effect is wonderfully funny to read</a>, as it takes such a banal issue so seriously. </p><p>They demonstrated that when a rod is bent past a certain point, such as when spaghetti is snapped in half by bending it at the ends, a "snapback effect" is created. This causes energy to reverberate from the initial break to other parts of the rod, often leading to a second break elsewhere.</p><p>While this settled the issue of <em>why </em>spaghetti noodles break into three or more pieces, it didn't establish if they always had to break this way. The question of if the snapback could be regulated remained unsettled.</p>
Physicists, being themselves, immediately wanted to try and break pasta into two pieces using this info<p><a href="https://roheiss.wordpress.com/fun/" target="_blank">Ronald Heisser</a> and <a href="https://math.mit.edu/directory/profile.php?pid=1787" target="_blank">Vishal Patil</a>, two graduate students currently at Cornell and MIT respectively, read about Feynman's night of noodle snapping in class and were inspired to try and find what could be done to make sure the pasta always broke in two.</p><p><a href="http://news.mit.edu/2018/mit-mathematicians-solve-age-old-spaghetti-mystery-0813" target="_blank">By placing the noodles in a special machine</a> built for the task and recording the bending with a high-powered camera, the young scientists were able to observe in extreme detail exactly what each change in their snapping method did to the pasta. After breaking more than 500 noodles, they found the solution.</p>
The apparatus the MIT researchers built specifically for the task of snapping hundreds of spaghetti sticks.
(Courtesy of the researchers)
What possible application could this have?<p>The snapback effect is not limited to uncooked pasta noodles and can be applied to rods of all sorts. The discovery of how to cleanly break them in two could be applied to future engineering projects.</p><p>Likewise, knowing how things fragment and fail is always handy to know when you're trying to build things. Carbon Nanotubes, <a href="https://bigthink.com/ideafeed/carbon-nanotube-space-elevator" target="_self">super strong cylinders often hailed as the building material of the future</a>, are also rods which can be better understood thanks to this odd experiment.</p><p>Sometimes big discoveries can be inspired by silly questions. If it hadn't been for Richard Feynman bending noodles seventy years ago, we wouldn't know what we know now about how energy is dispersed through rods and how to control their fracturing. While not all silly questions will lead to such a significant discovery, they can all help us learn.</p>
A study looks at the performance benefits delivered by asthma drugs when they're taken by athletes who don't have asthma.
- One on hand, the most common health condition among Olympic athletes is asthma. On the other, asthmatic athletes regularly outperform their non-asthmatic counterparts.
- A new study assesses the performance-enhancement effects of asthma medication for non-asthmatics.
- The analysis looks at the effects of both allowed and banned asthma medications.
WADA uncertainty<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yMzUzNzU0OS9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYxMDc4NjUwN30.fFTvRR0yJDLtFhaYiixh5Fa7NK1t1T4CzUM0Yh6KYiA/img.jpg?width=980" id="01b1b" class="rm-shortcode" data-rm-shortcode-id="2fd91a47d91e4d5083449b258a2fd63f" data-rm-shortcode-name="rebelmouse-image" alt="urine sample for drug test" />
Image source: joel bubble ben/Shutterstock<p>When inhaled β-agonists first came out just before the 1972 Olympics, they were immediately banned altogether by the WADA as possible doping substances. Over the years, the WADA has reexamined their use and refined the organization's stance, evidence of the thorniness of finding an equitable position regarding their use. As of January 2020, only three β-agonists are allowed — salbutamol, formoterol, and salmeterol —and only in inhaled form. Oral consumption appears to have a greater effect on performance.</p>
The study<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yMzUzNzU0Ny9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTY1MTIzMDQyMX0.Gk4v-7PCA7NohvJjw12L15p7SumPCY0tLdsSlMrLlGs/img.jpg?width=980" id="d3141" class="rm-shortcode" data-rm-shortcode-id="ebe7b30a315aeffcb4fe739095cf0767" data-rm-shortcode-name="rebelmouse-image" alt="runner at starting position on track" />
Image source: MinDof/Shutterstock<p>Of primary interest to the authors of the study is confirming and measuring the performance improvement to be gained from β-agonists when they're ingested by athletes who don't have asthma.</p><p>The researchers performed a meta-analysis of 34 existing studies documenting 44 randomized trials reporting on 472 participants. The pool of individuals included was broad, encompassing both untrained and elite athletes. In addition, lab tests, as opposed to actual competitions, tracked performance. The authors of the study therefore recommend taking its conclusions with just a grain of salt.</p><p>The effects of both WADA-banned and approved β-agonists were assessed.</p>
Approved β-agonists and non-asthmatic athletes<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yMzUzNzU1MC9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYxMzkxODk0M30.3RssFwk_tWkHRkEl_tIee02rdq2tLuAePifnngqcIr8/img.jpg?width=980" id="39a99" class="rm-shortcode" data-rm-shortcode-id="b1fe4a580c6d4f8a0fd021d7d6570e2a" data-rm-shortcode-name="rebelmouse-image" alt="vaulter clearing pole" />
Image source: Andrey Yurlov/Shutterstock<p>What the meta-analysis showed is that the currently approved β-agonists didn't significantly improve athletic performance among those without asthma — what very slight benefit they <em>may</em> produce is just enough to prompt the study's authors to write that "it is still uncertain whether approved doses improve anaerobic performance." They note that the tiny effect did increase slightly over multiple weeks of β-agonist intake.</p>
Banned β-agonist and non-asthmatic athletes<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yMzUzNzU1Mi9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYzNjI3ODU5Mn0.vyoxSE5EYjPGc2ZEbBN8d5F79nSEIiC6TUzTt0ycVqc/img.jpg?width=980" id="de095" class="rm-shortcode" data-rm-shortcode-id="02fdd42dfda8e3665a7b547bb88007ef" data-rm-shortcode-name="rebelmouse-image" alt="swimmer mid stroke" />
Image source: Nejron Photo/Shutterstock<p>The study found that for athletes without asthma, however, the use of currently banned β-agonists did indeed result in enhanced performance. The authors write, "Our meta-analysis shows that β2-agonists improve anaerobic performance by 5%, an improvement that would change the outcome of most athletic competitions."</p><p>That 5 percent is an average: 70-meter sprint performance was improved by 3 percent, while strength performance, MVC (maximal voluntary contraction), was improved by 6 percent.</p><p>The analysis also revealed that different results were produced by different methods of ingestion. The percentages cited above were seen when a β-agonist was ingested orally. The effect was less pronounced when the banned substances were inhaled.</p><p>Given the difference between the results for allowed and banned β-agonists, the study's conclusions suggest that the WADA has it about right, at least in terms of selection of allowable β-agonists, as well as the allowable dosage method.</p>
Takeaway<p>The study, say its authors, "should be of interest to WADA and anyone who is interested in equal opportunities in competitive sports." Its results clearly support vigilance, with the report concluding: "The use of β2-agonists in athletes should be regulated and limited to those with an asthma diagnosis documented with objective tests."</p>
Certain water beetles can escape from frogs after being consumed.
- A Japanese scientist shows that some beetles can wiggle out of frog's butts after being eaten whole.
- The research suggests the beetle can get out in as little as 7 minutes.
- Most of the beetles swallowed in the experiment survived with no complications after being excreted.