END-OF-LIFE ISSUES
Going green
One of my patients who has metastatic cancer told me he's made plans to have a green burial. Because he believes strongly in protecting the environment, it's given him great peace of mind. What can you tell me about this practice?-H.C., MONT.
According to the Green Burial Council, a green or natural burial includes those practices that help conserve natural resources, reduce carbon emissions, protect workers' health, and restore or preserve natural habitat.1 With this type of burial, caskets, shrouds, and urns are made of nontoxic, biodegradable materials. The materials used for the burial are harvested to impact the natural environment as little as possible.1 Formaldehyde-free embalming fluids, such as those made of nontoxic biodegradable essential oils, can be used to prevent dangerous exposures to funeral home workers.2 Although concrete burial vaults may be used in some green burial grounds, avoiding their use saves a large amount of energy.1
Cremation is one option for a green burial. Even though cremation has less impact on the environment than most other burial options, it does require burning fossil fuel, and mercury from dental fillings may be released in the process. Newer facilities are more energy-efficient than older ones, and filters to mitigate mercury may be available soon. A contribution to a carbon fund can help offset the carbon emissions.1
For more information, visit https://greenburialcouncil.org.
REFERENCES
1. Green Burial Council. What is green burial? https://greenburialcouncil.org/home/what-is-green-burial. [Context Link]
2. Hauptmann M, Stewart PA, Lubin JH, et al Mortality from lymphohematopoietic malignancies and brain cancer among embalmers exposed to formaldehyde. J Natl Cancer Inst. 2009;101(24):1696-1708. [Context Link]
INFECTION PREVENTION
When does practice need to change?
In the obstetrics and gynecology clinic where I work, we use ortho-phthalaldehyde (OPA) disinfectant to clean vaginal speculums, even though some research shows OPA disinfectant doesn't kill oncogenic human papillomavirus (HPV) types 16 and 18.1 Currently, the CDC guideline recommends cleaning semicritical instruments (such as rectal probes, vaginal probes, and cryosurgical probes) with OPA, but the goal of course is to be free from microbes.2
I've brought this to the attention of the facility's infection control committee and our department's chief healthcare provider. Their response is that we're following CDC guidelines and that more research is needed. I think this serious patient-safety issue risks infecting patients with cancer-associated HPV types. What should I do?-R.V., MO.
For years HPV was believed to be a nonenveloped virus that's easily killed by disinfectants, including OPA and glutaraldehydes. The findings of Meyers et al. raised questions about that belief.3 Their study claimed to show OPA to be ineffective against HPV even though their findings were inconsistent with research about other nonenveloped viruses, such as poliovirus, rhinovirus, and echovirus.3 The FDA reviewed these findings and relevant data and decided to continue to allow the use of OPA with devices that could be contaminated with HPV while it funded research to reproduce the study. Although Meyers has reproduced these findings, the two labs researching the issue haven't yet delivered results to refute or support the claim that OPA is ineffective against HPV.
In medicine, new research often calls into question previous beliefs about a subject. Many of these studies can't be replicated and are eventually dismissed, but occasionally they're reproduced and adopted. If your facility is reprocessing the vaginal speculums in accordance with the OPA manufacturer's guidelines and the speculum's instructions for use, it's complying with all federal guidelines for protecting patients. Disposable speculums could also be considered. Some organizations are switching to a chemical proven to kill HPV, but at this point, you're complying with the most recent federal guidelines. Be sure to continue to monitor for the issuance of newer guidelines to keep your practice in compliance should those guidelines be revised.
REFERENCES
1. Ryndock E, Robison R, Meyers C. Susceptibility of HPV16 and 18 to high level disinfectants indicated for semi-critical ultrasound probes. J Med Virol. 2016;88(6):1076-1080. [Context Link]
2. CDC. Disinfection and sterilization. Guideline for disinfection and sterilization in healthcare facilities (2008). Updated 2016. http://www.cdc.gov/infectioncontrol/guidelines/disinfection/index.html. [Context Link]
3. Meyers J, Ryndock E, Conway MJ, Meyers C, Robison R. Susceptibility of high-risk human papillomavirus type 16 to clinical disinfectants. J Antimicrob Chemother. 2014;69(6):1546-1550. [Context Link]
UNAPPROVED INDICATIONS
Stem cell therapy: Not a cure-all
I keep seeing ads in my local newspaper promoting stem cell therapy for a whole range of indications, from autism to joint pain. What should I tell patients who ask me about these ads and their claims?-C.K., PA.
On August 28, 2017, the FDA announced that it would issue new policies and enforcement measures to oversee stem cell therapies and regenerative medicine. Although these new therapies hold promise for a wide range of diseases, unscrupulous people are preying on patients with serious illnesses by making deceptive or fraudulent claims about unproven or even dangerous products. To increase its ability to enforce fraudulent claims about stem cell therapy, the FDA plans to put forth a comprehensive policy framework with clearer rules. This will also help consumers distinguish promising treatments from those with significant risks or little chance of benefit.
Another goal of the FDA is to help responsible product developers more readily gain FDA approval for new products in a less difficult and less expensive process. Advise your patients to discuss any such treatments they're considering with their healthcare provider. For more information, direct your patients to reputable websites such as this one: http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm286155.htm.
Source: FDA Statement. Statement from FDA Commissioner Scott Gottlieb, M.D., on the FDA's new policy steps and enforcement efforts to ensure proper oversight of stem cell therapies and regenerative medicine. 2017. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm573443.htm.