Pornography and Condoms

This article caught my eye this article. 


This June, in Los Angeles, citizens will vote on whether actors in pornographic movies will be required to wear condoms, by law. The ballot is a result of intense lobbying by the AIDS Healthcare Foundation.


Under current regulations by the California Division of Occupational Safety and Health, actors are required to use condoms.  Enforcement, however, is tricky as the agency can only act after it receives a complaint. Sexually transmitted infections, including HIV, are seen as an occupational hazard in this industry. Wearing a condom in an adult movie is akin to mandating that construction workers wear personal protective equipment (hard hats, protective eyewear, protective footwear). 


As I am an infectious diseases physician, you can likely guess my thoughts on the matter.

Patient Interest in Sharing Personal Health Record Information-A New Trend?

Here is an article in the Annals of Internal Medicine that explores sharing the electronic medical record with patients.

The investigators explored preferences about sharing electronic health information among users of the U.S. Department of Veterans Affairs (VA) PHR (personal health record) system, My HealtheVet.  The study was Web-based survey of a 18,471 users of My HealtheVet. 

Almost 4 of 5 respondents (79%) were interested in sharing access to their PHR with someone outside of their health system (62% with a spouse or partner, 23% with a child, 15% with another family member, and 25% with a non-VA health care provider).  

As a consultant, it would be of tremendous assistance to access electronic records from referring providers. At the least, it would make my job easier. The digital age and electronic medical records  should, in theory, reduce information asymmetry between patients and providers. Access to the one's electronic health record should, in theory, engage patients in their care by instilling a sense of ownership and should allow for easier provider to provider communication, thereby making care more efficient and reducing redundancy in testing and treatment. Provided that HIPPA (health information privacy) standards are upheld, a technical breakthrough may be at hand.

All of the proposed benefits, however, remain largely theoretical given that no real body of literature exists to prove the tangible, long term benefits or hazards of a shared, electronic patient record. This must be a focus of research as the use of shared electronic records proliferate.  

My Own Country- My Own Thoughts

I spent the last several days engaged in reading some not so light material, Abraham Verghese's My Own Country, a first person account of an infectious diseases physician's experience with HIV/AIDS in rural Tennessee, in the mid-1980's.


What fascinated me most about the book was not so much the details of the evolving HIV epidemic in the 1980's, but rather, the inherent challenges of managing an infectious disease without primary treatment (pre-antiretrovirals), and the stigma associated with the diagnosis. In Tennessee, much as in other parts of the country during the mid 1980's, to be HIV positive was to suffer in secrecy, lack familial and social support, confront blatant homophobia, and be faced with disdain and refusal of medical care from some physicians and nurses. 


Anyone with an interest in HIV/AIDS epidemiology should give the book a proper perusal.  

Hand Hygiene Surveillance a la George Orwell- Video Surveillance

It seems like a cannot stray too far from the subject of hand hygiene as of late. Apologies to those that find it boring. Here is a related article published in Clinical Infectious Diseases. 

The investigators evaluated healthcare worker hand hygiene with the use of remote video surveillance with and without feedback. The study was conducted in an 17-bed intensive care unit from June 2008 through June 2010. 


Cameras were placed with views of every sink and hand sanitizer dispenser to record hand hygiene of healthcare workers. Individual patients were not visualized. Sensors in doorways identified when a healthcare worker entered/exited a patient room.  Trained, remote video auditors utilized for review of the surveillance data.  Hand hygiene was measured during a 16-week period of remote video auditing without feedback and a 91-week period with feedback of data. Performance feedback was continuously displayed on electronic boards mounted within the hallways, and summary reports were delivered to supervisors by electronic mail.

During the 16-week prefeedback period, hand hygiene rates were shockingly less than 10% (3933/60 542) and in the 16-week postfeedback period it was 81.6% (59 627/73 080). The increase was maintained through 75 weeks at 87.9% (262 826/298 860).

Hand hygiene surveillance by video audit works. The process is not cheap and has associated start up (technology) costs, training of video auditors and, likely, ongoing auditor validation for quality assurance. Of course, conservatives and libertarians will bemoan such Orwellian surveillance tactics. However, as video surveillance is not punitive, respects patient privacy (patients are not visualized),  and is done for the sake of patient safety, their argument is flimsy, at best.


Newer technologies for hand hygiene surveillance seem promising. I have blogged about this before.

Voltaire on Medicine

Voltaire

The other day I was reviewing a power point slide of mine and came across this quote by Voltaire:



“The art of medicine consists in amusing the patient while nature cures the disease.”

Infection Prevention Without Emotional Zealotry: Michael Edmond

With Mike Edmond, in 2006, as he ponders infection prevention

Kudos to my close friend and colleague, Dr. Michael Edmond, for recognition as one of the 20 most influential health leaders in the USA by the Health Leaders Media Council. 


Under his guidance, our focus is common sense, evidence based, infection prevention efforts that target all pathogens.


Infection prevention policies devoid of ''emotional  zealotry'', an approach welcomed here. It may be a polarizing stance on the issue of MRSA control and infection prevention, but the progressively lower infection rates substantiate the process.

The 2011 Richmond City FC Copa Navidad- Passion and Purpose on the Pitch

Football for a medical charity with passion and purpose on the pitch.


The 7th annual  Richmond City FC Copa Navidad, our charity football match, took place on Sunday, December 11th, at SCOR. All proceeds go the the Fan Free Clinic, caring for Richmond's medically under served. 


The event was one of our most successful to date with Richmond City FC White defeating Richmond City FC Blue 6-5 in a hard fought, drudge match.


Thank you to all the footballers, the volunteer referees from CVSA and to SCOR.


Event photos below- click to enlarge.

RCFC Blue Copa Navidad 2011

RCFC White Copa Navidad 2011

RCFC 2011 Copa Navidad Participants

The Blogger, with footballing friends at the 2011 Copa Navidad

Dirty Hands in the Gloves

Just because latex gloves are worn during clinical care does not mean that the hands are clean. An article recently published in Infection Control and Hospital Epidemiology is revealing on this matter.


The observational study was performed in a large and likely representative sample of British hospitals. The investigators  observed hand hygiene and glove usage (7,578 moments for hand hygiene) during 249 one-hour sessions. Gloves were used in only 26% of the 7,578 moments for hand hygiene and in17% of 3,292 low-risk contacts; gloves were not used in 21% of 669 high-risk contacts. 


The rate of hand hygiene compliance with glove use was low 41% and the rate without glove use was 50.0%. After statistically adjustment, glove use was strongly associated with lower levels of hand hygiene (adjusted odds ratio, 0.65 [95% confidence interval, 0.54-0.79]


Hand hygiene is low, gloves are not worn when indicated and glove use is associated with a decrease in hand hygiene.


We observed a similar hand hygiene reduction during a universal gloving study that we published several years ago.


We need a better understanding of what motivates healthcare workers to wash their hands before and after glove use. 

Postcards From Honduras- Kate Pearson and Gabriela Halder

Here is a nice article and brief interview with Gaby Halder and Kate Pearson, published in the VCU School of Medicine website.

Kate and Gaby: medical field research, La Hicaca, Honduras, June 2011

The article summarizes their important contributions as medical relief workers and field researchers.


We are gearing up for another successful trip in June 2012 and will be in Honduras next month (January 7th-10th) to layout the final plan. More to follow on this blog. 


Stay tuned.

Beliefs About Hand Hygiene: A Survey of Medical Students

What do 1st year medical students think about the hand hygiene practices of their presumed mentors?


A study recently published in the American Journal of Infection Control is a bit disconcerting. Eighty-five medical student from a German medical school answered an anonymous questionnaire. Only 21% of all respondents marked all of the indications for hand hygiene correctly. Respondents guessed that average physician compliance with hand hygiene was 52% (not far off the mark). In the opinion of the students, compliance with hand hygiene decreases with increase in physician rank.


It appears that we lack hand hygiene role models.

Footballing for Charity-Richmond City FC Copa Navidad

Today was the Richmond City FC Copa Navidad, our charity football match. All proceeds go the the Fan Free Clinic, caring for Richmond's medically under served.


Match photos and details to appear soon on the City website, and on my blog.

The Blogger, with footballing friends, at the 2011 RCFC Copa Navidad

Transmission Based Precautions-Web Based Compliance Monitoring

Source: healthunit.org

We typically concern ourselves with hand hygiene compliance in healthcare settings but what about compliance with transmission based isolation precautions? 


A new study published in the American Journal of Infection Control explores the use of a web based, electronic, real time data collection mechanism for adherence monitoring. A total of 13,000+ observation rooms were observed in 2009. Data entry, at the point of observation, on a web-based tablet PC, was associated with increased start-up costs. The process, however, was significantly more streamlined and efficient. In times of increasing infection control mandates, efficiency is a boon to any infection prevention program.


One thing not reported in the manuscript: what impact did enhanced (web based) surveillance have on adherence with isolation precautions and was it sustained?

The Comeback of the House Call?

Source: NY Times

Making house calls may no longer be a medical anachronism. Here is a recent perspective in the NY Times. The article underscores the need for continuity of coordinated, longitudinal care and cites evidence that patients may have better outcomes with home based, primary care visits.

Not too long ago, I inadvertently made a 'house call' on a patient. While out for a very early morning jog, I came across a homeless, HIV positive patient on a local park bench. After the initial surprise of meeting up with his doctor, we had a brief yet pleasant encounter. While sitting with him on the park bench, he pulled out his retrovirals from his backpack and subsequently convinced me of his ongoing medication adherence. 

An unconventional house call, admittedly, and unlikely to affect his outcome. Regardless, the visit did further establish rapport, which may lead to a better doctor-patient relationship in the long run.

Kate and Gaby at ASTMH 2011

Once again, Kate Pearson and Gabriela Halder, invaluable members of our Honduras medical relief and research team, are presenting their work and making us proud.


This time,the duo is at the The American Society of Tropical Medicine and Hygiene annual meeting, Philadelphia, Pennsylvania.

Kate and Gaby at ASTMH, earlier today

Kudos to these VCU School of Medicine standouts.

Misdiagnosis: TB vs Aspergillosis

Pulmonary aspergillosis
Source: Radiopaedia.org

Pulmonary tuberculosis continues to be the scourge of humanity. After treatment, recurrent disease can be vexing to diagnose and in a not insignificant number of cases, per a WHO report, 22% of TB recurrences were actually a fungal disease (chronic pulmonary aspergillosis). This report is summarized in Infection Control Today. For the original paper, I refer you to the Bulletin of the World Health Organization.

Both TB and aspergillosis can be difficult to confirm. The radiographic (x-ray) changes are similar, cultures are frequently difficult to obtain, and the pathogens are not rapidly identified in the laboratory. Additionally, couple these challenges with resource poor settings where diagnostic testing is frequently not feasible, and confirmation of either pathogen proves even less realistic.

The treatments for these diseases are very different and misdiagnosis can result in a catastrophic outcome. Better mechanisms for differentiating TB from pulmonary aspergillosis, especially in resource poor settings, are needed.  

HIV Epidemic in the USA-2011: Vital Signs

Here is a report from the MMWR worth reading. It is a state of the art update on the HIV epidemic in the USA.


Some of the statistics are truly eye opening, even for an infectious diseases specialist like me.


The graph below speaks volumes.

Source: CDC-MMWR

• About 1.2 million people are HIV positive in the USA; 80 % are aware of their infection and 20% are not.
• 77% of HIV infected adults are linked to care but only 51% remain in care.
• Only about 28% of people with HIV will have successful treatment (suppressed viral load)

Clearly, tremendous strides are needed to curb the HIV epidemic and include increased testing for HIV, ongoing (retention of) HIV medical care and increased adherence to treatment.

Acne-A New Perspective?

Source: Telegraph.UK

Here is a brief article on acne that I came across while speedily perusing my Google Reader. 


For the full reference click here.

Proprionobacterium acnes is apparently not the only causative agent of acne. For successful women in their mid-twenties or older, stress, in particular, can be the cause of acne. This process is hormone driven and differs from the acne of the teenage years.

Not everything can be infectious, after all.

Medical Education and Better Health for Individuals and Populations

This month's Academic Medicine is dedicated to the theme of medical education and improved health on a population level. The Editor's introduction sets the tone and the issue is explored through 15 essays. The essays are online and are free.


I find this perspective both thought provoking and timely. Traditional medical training focuses almost exclusively on the individual doctor-patient relationship. Clearly, this is a critical foundation for the practice of medicine. However, many (even in the USA) see medicine as a societal good. In that regard, medical students and young doctors must view public health as an integral part of the practice of medicine. For more, click here. 


The tension between patient care and public health should be explored in medical school curricula so that physicians have a sophisticated understanding of health promotion, preventive medicine and the provision of individual care, to increasing numbers of patients, under finite resources. 


This is no small task and the time is now.

MRSA Screening- The Scottish Experience

Source: NHS.UK

Here is a paper on MRSA screening published in the Journal of Hospital Infection.


The study was a  large one-year prospective cohort study of MRSA screening was carried out in six acute hospitals in NHS Scotland, incorporating 81,438 admissions. Outcomes (MRSA colonization and infection rates) were subjected to multivariable analyses, and trends before and after implementation of screening were compared.


MRSA colonization prevalence decreased from 5.5% to 3.5% by month 12 of the study (P < 0.0001). Colonization was associated with the number of admissions per patient, specialty of admission, age, and source of admission (home, other hospital or care home). Patients who were MRSA screen positive on admission were 12 - 18 times to develop and MRSA infection. MRSA infections (7.5 per 1000 inpatient-days overall) also reduced significantly over the study year (P = 0.0209).


So universal screening for MRSA in Scottish Hospitals resulted in decreased MRSA colonization and disease burden? Possibly. As with many similar studies, it is difficult to control for the impact of confounders such as hand hygiene, chlorhexidine bathing of patients, invasive devices bundles,  head or bed elevation of patients on ventilators or any other infection prevention intervention that could have impacted the MRSA rates.


The authors noted that there were no changes in MSSA infections during the study time. What about other pathogens? What about the overall rates of device associated infections across the ICUs? We have a different perspective on active surveillance and detection and have been able to reduce MRSA infections in an ICU without employing that strategy.

I feel that infection prevention efforts, especially if implemented universally,  are best judged in toto. I see limited benefit and value in focusing tremendous resources on a single pathogen, which causes the minority of hospital acquired infections, if no commensurate reduction is seen across other pathogens and infections.

Holiday Season- Keep the Kitchen Clean

For those of you following my blog in North America, the Thanksgiving Holiday is upon us. Hopefully, no one's Thanksgiving feast will be foiled by a foodborne illness.

Here are some quick tips from Infection Control Today on how to minimize the kitchen of microbes during the holiday festivities. 


It would also be best to keep the staphylococcal carriers away from food preparation activities. 

Eat well, be merry, and avoid those pesky enteric pathogens.

Stupid Deaths- Preventable Morbidity and Mortality Abounds

Here is an opinion paper by Paul Farmer published in the Washington Post on preventable deaths in the developing world.  Millions of people, many of them young and poor, will die around the world this year from diseases for which safe, effective and affordable treatments exist. Farmer refers to these as “stupid deaths."


"Stupid deaths" are preventable only if lawmakers and leaders show the grit and commitment commensurate to the challenge at hand. A 'scraps from the table' approach is insufficient. Resources must be preferentially allocated to help the poor and disenfranchised to overcome preventable and treatable diseases of poverty.


For a more in depth perspective, I refer you to Pathologies of Power and Infections and Inequalities, both by Paul Farmer.

Hand Hygiene- A Novel Approach?

Here is a journal article recently published in the American Journal of Infection Control.
There is little disagreement in healthcare regarding the importance of hand hygiene. The question remains, how can hand hygiene efforts be both promoted and sustained? Some have argued for electronic surveillance, others have found answers in positive deviance, some have even turned to psychological motivators. We have successfully implemented a hand hygiene program using roaming, trained hand hygiene observers and data collectors.

The authors of this study created small teams consisting of a representative from Quality Assessment, an Infection Prevention Practitioner, and staff from a particular unit. Teams identified barriers to hand hygiene success. Next, the teams set their own goals for hand hygiene compliance. Using the WHO guidelines for hand hygiene, teams diagrammed detailed workflows for several of their most common patient care tasks. Wherever hand hygiene was indicated, the workflow was marked with a number corresponding to one or more of the WHO’s “5 moments for hand hygiene.” At the end of the 12-week period, staff members were trained to observe each other and began officially collecting and submitting data to Infection Prevention.

Between 2006 and 2008, the institutional hand hygiene compliance was 60%-70%. After the new program was launched in 2008, compliance increased to 97% and was reportedly sustained. 

So hospital units were empowered to promote and perform hand hygiene surveillance, after identifying unit specific barriers and opportunities for hand hygiene.  Isn't this another spin on positive deviance?  Is it really all that novel? A few concerns arise. Data on hand hygiene compliance observation was sparse, with no reported numerator and denominator. Only employees on day shift were observed. No doubt that, with intensive hand hygiene observation, the Hawthorne Effect was at play, especially for the day shift crew. These may have skewed the positive results of the study.

In the end, whatever intervention is reasonable, feasible and acceptable for sustaining hand hygiene should be given consideration for implementation. 


Give it a go.

Starting a Running Program? Here is Some Sound Advice, Sort Of.

Source: NY Times

I took yesterday off and plan to be back in the swing of things soon.


I came across this interesting article in the NY Times on running. Despite its popularity, there is little sound evidence to best guide a beginner on taking up and sticking with a running program. About half of beginners will end up quitting regardless.


As common sense would suggest, it is likely best to start low and go slow. This is about the only advice that I am comfortable giving my patients when it comes to starting any exercise regimen.


.....off for my morning jog now.

Occupy! Activism and Germs

Source: NY Times

Here is a brief article in the New York Times on the potential health risks of Occupy Wall Street. 


Anytime you mix closely and for prolonged periods with masses of people, contagion is a concern.


Happy 11.11.11!

Gabriela Halder at APHA!

Kudos to VCU medical student, Gabriela Halder, for her phenomenal work as part of our Honduras medical research team.

Gabriela presented her Honduras medical research at the American Public Health Association yearly meeting last week and was awarded 1st place in the International/Global Health Student Assembly’s poster presentation.

Well done Gaby!

Ms. Halder at APHA

The Glittering Prize

Targeted HIV Screening in the Emergency Department

The last few weeks have been ludicrously busy on the Internal Medicine service keeping me away from my PC and the football pitch. But I am back, sort of.

Fingerstick HIV testing

There is a a push for non-targeted (or universal) HIV screening in clinical setting. How effective is this practice in capturing new diagnoses of HIV, especially in an emergency department setting? A paper published in the Archives of Internal Medicine suggests that non-targeted HIV screening may be of modest benefit.

During a randomly assigned 6-week period in 29 participating French emergency departments, 18- to 64-year-old patients were offered a fingerstick HIV test. Among 138,691 visits, there were 78,411 eligible patients, 20 962 of whom (27.0%) were offered HIV testing; 13 229 (63.1%) accepted testing and 12 754 (16.3%) were tested.


Only eighteen patients received new HIV diagnoses. These patients belonged to a high-risk group (n = 17), were previously tested (n = 12), and were either symptomatic or had a CD4 lymphocyte count lower than 350/µL, suggesting late-stage infections (n = 8); 12 patients were linked to care.

So nontargeted HIV testing in French emergency departments was feasible yet identified only a few new HIV diagnoses. The authors suggest that this approach may be of little benefit. 


I am not sure that I fully agree. If non-targeted HIV screening were employed in emergency rooms and primary care clinics, more and more undiagnosed cases would be detected. This would be one more step forward in curbing the HIV epidemic. 

Fecal Transplantation- Not As Far Fetched As You May Think

I may have blogged about fecal transplantation before...or so I think.

C.difficile -source: WSJ

Here is an interesting piece on fecal transplantation in the WSJ. 


I realize that fecal transplantation may sound both bizarre and unappealing, however, if you are faced with multiple recurrences and relapses of C.difficile colitis, this last ditch therapy may be curative. Faced with this situation, you may think twice about not undergoing fecal transplantation.


Back to the Internal Medicine ward service, where my patient list continues to expand.........

Daily Cleaning with Bleach Wipes and Clostridium difficile Infection

I am on the Internal Medicine ward service, so time and blogging are extremely limited.

Recently published in Infection Control and Hospital Epidemiology, (read the SHEA abstract here)daily and terminal cleaning of hospital rooms with 0.55% bleach wipes resulted in an 85% decrease in hospital-acquired Clostridium difficile infection over a 12-month period. 


The study has limitations including a single center design with a before/after methodology. The authors focused on 2 hospital units with high rates of endemic Clostridium difficile infection so it is unknown if a hospital wide daily cleaning with bleach wipes would be cost effective. 


Regardless, the intervention seems both simple and safe. 
One caveat: the effectiveness of bleach wipes for the reduction of Clostridium difficile bioburden in the inanimate environment is likely technique and operator dependent. So, train your environmental services well, engage them in patient safety, and retain them.

The Physical Exam and the Doctor-Patient Relationship

Rene Laennec- inventor of the stethoscope

and master of the physical examination

Here is a brilliant article on the physical exam and its transformative role in the doctor-patient relationship, published recently in the Annals of Internal Medicine.


For many physicians, the physical exam is falling by the wayside, in favor of technology and diagnostic imaging.  The authors argue that patients expect some form of bedside evaluation when visiting a physician. When physicians complete the physical exam in an expert manner, it may have an important, beneficial effect. If done poorly or not at all, it can undermine the physician-patient relationship. 


Perhaps the goal should be to recognizing the importance of the bedside evaluation as both a healing ritual and a powerful diagnostic tool, especially when paired with selective use of technology. 


That would be good medicine.

Drinking Games in Medical School

If one thinks that drinking games are a thing of college parties only, then think again. Here is a paper that reports on drinking games and harassment in Japanese medical schools.

A multi-institutional survey was completed across seven medical schools in Japan. A self-report anonymous questionnaire was distributed to 1152 medical students and the response rate was high ( 951 respondents [82.6%]). The  following types of alcohol-related harassment among medical students by senior medical students or doctors: (i) being coerced into drinking alcohol; (ii) being compelled to drink an alcoholic beverage all at once (the ikki drinking game); (iii) being deliberately forced to drink until unconscious, and (iv) being subjected to verbal abuse, physical abuse or sexual harassment in relation to alcohol. The prevalence of becoming a harasser among medical students was also measured.

An astounding 821 respondents (86.3%) experienced alcohol-related harassment and 686 (72.1%) had harassed others.  In multivariate regression, having an experience of alcohol-related harassment correlated with both being harassed (odds ratio [OR] 14.22, 95% confidence interval [CI] 8.73-23.98) and being a harasser (OR 13.19, 95% CI 8.05-22.34). The presence of senior members of medical college clubs who were regular drinkers also correlated with both being harassed (OR 2.96, 95% CI 1.88-4.67) and being a harasser (OR 2.97, 95% CI 2.06-4.27).

Heavy drinking and associated harassment is common among Japanese medical students. What impact  this may have on depression, burnout and even alcoholism is unknown.

MRSA at the Dentist

We frequently associate MRSA with hospital settings. What about dental offices?


A recent study in the American Journal of Infection Control reports MRSA carriage by dental students and frequently touched dental clinic surfaces.


Sixty-one dental students and 95 environmental surfaces from 7 clinics were sampled.Thirteen (21%) dental students and 8 (8.4%) surfaces were MRSA positive. The MRSA-positive samples were from 4 of 7 dental clinics.  The 21% of MRSA carriage by dental students  is > 10 times higher than the general public and twice as frequent as in other university students. 


Hopefully, this will not deter you from going to the dentist.

VCU Watts Research Symposium- Gabriela Halder

Congratulations to VCU medical student standout, Gabriela Halder, for her Honduras research presentation today at the VCU Watts Research Symposium.


Gaby will present her work next month at the American Public Health Association annual meeting.


We are proud of her accomplishment as part of our research team.

With Mike Stevens and Gabriela Halder, VCU Medical Campus

Gabriela Halder

VCU Watts Research Symposium- Kate Pearson

Once again, Kate Pearson, making us proud, this time presenting her Honduras research at the VCU Watts Research Symposium.  The manuscript will be submitted soon for publication. 

Stay tuned.

With Mike Stevens and Kate Pearson on the VCU Medical Campus

Kate Pearson's poster at poster board #1