Monday, May 30, 2011

Hemolytic Uremic Syndrome- Not Just from Undercooked Meat

E.coli: not just from hamburger meat
Breaking news from Germany: 10 people killed from an infection by Shiga toxin producing E.coli. The infections came from eating raw tomatoes, cucumbers and lettuce that were bought in northern Germany. The cucumbers were imported from Spain and were sold in supermarkets in Hamburg.

Shiga toxin producing E. coli outbreaks are typically linked to unpasteurized milk and cheese and undercooked beef. Symptoms include high fever, bloody diarrhea, kidney failure and even death (Hemolytic-Uremic Syndrome). Jack in the Box restaurant made E.coli a household word in 1993 with a famous outbreak of serious food borne illness.

Consumption of fruits and vegetables are part of a healthy diet, except when contaminated by bacteria such as Shiga toxin-producing E. coli. Vegetables are typically contaminated by manure fertilizer or by farm water run off. Not thoroughly washing vegetables can be hazardous.

I am off to Honduras for our yearly medical relief trip tomorrow morning, where, among other things, I hope to avoid traveler's diarrhea and dysentery.

Thursday, May 26, 2011

Ditch the Labcoat, Please.

Photo: Mike Edmond
Okay, we are now sounding like a broken record, but please ditch the labcoat during inpatient care.

I refer you to Dr. Michael Edmond's latest blog entry.

If you feel that clothing CAN TRANSMIT pathogens, and are in favor of gowns and gloves for contact precautions, then you should support not wearing long sleeved lab coats during inpatient care. Like other apparel, the sleeves will become contaminated during patient care. The contaminated sleeves come into contact with patient skin, invasive devices and can transmit pathogens. Short sleeves will limit contaminated apparel patient contact and will not hinder hand hygiene to the level of the wrists.

This infection intervention is biologically plausible, simple, inexpensive and not likely to cause harm.

So why the resistance? I suspect that many are still wedded to the symbolism of the labcoat.

Get over it.

Wednesday, May 25, 2011

Congratulations Ellen Gerszten- VCUHS Employee of the Month

Congratulations Ellen Gerstzen-VCUHS Employee of the Month! 

The most dedicated and effective social worker I have ever met. 

Thank you for all you do for our patients. Your work is invaluable to all of us.

With Ellen Gerszten- VCUHS Empoyee of the Month at her Award Reception 5/25/2011 

Tuesday, May 24, 2011

Public Health Implications of Same Sex Marriage

I came across this intriguing title in the American Journal of Public Health.

Of course, there is much controversy about the legalization of same sex marriages. Many argue that same sex marriages are an extension of human rights. This perspective looks at same sex marriage for a medical standpoint.

Reports in the medical and social science literature suggest that legal and social recognition of same-sex marriage has had positive effects on gay and lesbian couples. The health benefits of legalized marriage are significant regardless of sexual orientationThese include significantly less depression and anxiety, better psychological well-being, better access to health insurance and quality health care as well as more consistent family support. Improved access to health care is conferred by marriage benefits under federal or state law and by the decreased effects of institutionalized stigma on gays and lesbians.

Of course, those opposed to same sex marriage are likely not to be swayed by arguments in favor of human rights or improved medical outcomes.

Monday, May 23, 2011

Physicians on Strike?

I refer you to a commentary in Academic Medicine on professionalism, unionization and physicians on strike.

Professionalism is a basis of medicine's social contract with society. In countries where national healthcare exists (obviously, not in the USA), physician unionization and strikes have occurred as part of the negotiation process.
As the USA heads forward with health care reform, these measures of negotiation may come into play.

The authors point out that physicians provide an essential service whose withdrawal is capable of causing great hardship to those they serve (patients), including potential loss of life. Physician strikes could lead to significant erosion of public trust and professionalism. Physician strikes are usually to better their own situation, and not for the sake of better patient care.

Physician strikes should be avoided. To do so, the medical profession must be represented and must influence negotiations at early stages. Discussions on the principles and controversies in physician negotiation should be a part of medical training, to better prepare physicians on these matters. 

In the end, physician strikes conflict with medicine's professional values.

Friday, May 20, 2011

Contaminated Blood Cultures: Pesky Practice

It has been a busy week on the internal medicine service but not so busy that I can fully ignore both playing a game of football (soccer) and blogging.

Although we have had a lot of success in my medical center in significantly reducing the rate of blood culture contamination, unfortunately, blood culture contamination continues to occur here and elsewhere. Contaminated blood cultures are not without consequence. 

A recent publication in Infection Control and Hospital Epidemiology reminds us that contaminated blood cultures result in unnecessary antibiotic administration, additional laboratory tests and procedures, and hospital readmissions.

Apart from proper phlebotomy and blood culture collection technique, the first step in reducing this wasteful and potentially harmful result is to order blood cultures only when clinically necessary.

This last point seems self evident, however, this principle is violated over and over.

Wednesday, May 18, 2011

Never Learn Your Medicine From a Pharmaceutical Representative

Source: Time
Here is an insightful article on how the prescribing patterns of physicians are monitored and used by pharmaceutical companies to direct 'detailing', essentially drug promotion and sales calls by slick sales people.

The article underscores how doctors may have to be more proactive about keeping their prescription histories from marketers. Also, physicians must be proactive, much like the VCU Division of Infectious Diseases, in prohibiting pharmaceutical sales in clinical areas and teaching conferences.

As a former mentor of mine from the University at Buffalo School of Medicine once sagaciously taught me: 'never learn your medicine from a pharmaceutical representative.'

Tuesday, May 17, 2011

10 (Infectious) Diseases That Totally Changed the World

Yersinia pestis: agent of the plague
I received this interesting link from a reader. 

Although not sure how this list was compiled (popular vote, expert opinion, consensus etc), I am proud to see that infectious diseases comprises 8 out of the 10!

  1. Smallpox
  2. Tuberculosis
  3. Autism
  4. Influenza
  5. Malaria
  6. Cholera
  7. Bubonic plague
  8. Epilepsy
  9. Polio
  10. Yellow Fever

Monday, May 16, 2011

The Power of Positive Deviance and Why I am Still Confused

I have blogged before about positive deviance.  My colleague, Dr. Michael Edmond, comments here.

The truth is, I am not fully getting it. 

This is by no means a criticism of the papers published on the topic, merely an observation.

By definition, positive deviance is a social and behavioral change process based on the premise that in most organizations and communities there are people or groups of people who solve problems better than colleagues with the exact same resources. For hospital infection prevention, the premise is that infection control issues (such as hand hygiene) can be best solved by individuals with new, creative and pragmatic solutions. These individuals are not necessarily top management or even hospital unit leaders. Positive deviants find answers to problems that others (the masses) fail to conquer. 

So is this sort of problem solving really something new? Haven't there always been individuals who excel in creativity, administration and problem solving? Why is this now classified as a new phenomenon?

In my organization, I have seen some infection prevention efforts fail when hospital units craft unit specific responses to infection prevention rather than adopting a top down intervention. 

So are these then negative deviants or simply inept? 

Perhaps I am simple minded and fail to grasp the self-evident.

Friday, May 13, 2011

Bed Bugs With MRSA- More Malignant?

I have blogged before about bedbugs.

Here is a new twist on them. Researchers in Vancouver isolated MRSA from bedbugs. The bedbugs were from indigent, hospitalized, patients. It is not clear if the MRSA was on the bedbugs or in the bedbugs or if they transmitted MRSA to the patients (or, conversely, the patients to the bedbugs).

Somehow, I do not think that this heralds the next modern plague. I don't see bedbugs as potent vectors, such as the human body louse, which transmits typhus.

Theoretically, bedbugs could transmit MRSA to humans. This would result in colonization, and possibly, consequent infection (skin infections, pneumonias). 

To date, however, scant evidence exists supporting bedbugs as vectors of MRSA or bloodborne pathogens.

The nuisance factor is unquestionable.

Have a nice weekend.

Thursday, May 12, 2011

Overtreated- Again

Overtreatment (or overtesting) has been an interest of mine as of late.

There is an interesting article with book review published this week in the Lancet on the perils of excessive medical care. The article cleverly refers to President Barack Obama's recent yearly physical examination. At age 48, he was deemed to be in excellent health. However, he underwent testing not routinely recommended for a 48 year old man by the US Preventive Services Task Force : an electron-beam CT scan of the coronary arteries (to look for heart disease), a three-dimensional CT scan of the large bowel (to look for colon cancer), and a blood test for prostate-specific antigen (to look for early prostate cancer).

The implications are clear: even evidence-based guidelines should be ignored if the patient is important enough, and, more care is better.

Wednesday, May 11, 2011

Overweight? Thank Your Doctor for Calling it Out.

Body Mass Index: the 5th Vital Sign (Source: Time Magazine)
We know that physician counseling can have an impact on healthy behavior- such as smoking cessation. With the growing obesity problem in the USA, physicians should focus not only on smoking cessation but also weight control as part of healthy behavior counseling. Not all physicians choose to focus on weight.

So here are two related articles. In the Archives of Internal Medicine, investigators analyzed data from the  2005-2008 National Health and Nutrition Examination Survey data on adults aged 20 to 64 years with a body mass index (BMI) of at least 25.0. Using logistic regression analysis,among patients who were overweight/obese, patient reports of being told by a physician that they were overweight were associated with more realistic perceptions of one's weight, desire to lose weight, and recent attempts to lose weight.

Another article, in Time magazine, suggests that you should thank your doctor for calling you fat.

Tuesday, May 10, 2011

Why I Exercise....Well, Not Really

Those that know me well understand that I am compulsive about my morning workouts, playing soccer etc. The truth is, I enjoy it, however, this latest article in the American Journal of Preventive Medicine serves as positive reinforcement.

The investigators compared the relative mortality risks of U.S. adults who met the 2008 US Department of Health and Human Services Guidelines for physical activity with adults who did not meet the recommendations.

The adult physical activity guidelines at a glance:
  • Adults should do 2 hours and 30 minutes a week of moderate-intensity, or 1 hour and 15 minutes (75 minutes) a week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic physical activity. Aerobic activity should be performed in episodes of at least 10 minutes, preferably spread throughout the week.
  • Additional health benefits are provided by increasing to 5 hours (300 minutes) a week of moderate-intensity aerobic physical activity, or 2 hours and 30 minutes a week of vigorous-intensity physical activity, or an equivalent combination of both.
  • Adults should also do muscle-strengthening activities that involve all major muscle groups performed on 2 or more days
Meeting the recommendations for aerobic activity was associated with substantial survival benefits (decreased mortality) especially among the population having chronic conditions, with estimated hazard ratios (for death) ranging from 0.65 to 0.75 (p<0.05).  Weight lifting activities by themselves did not appear to reduce mortality risk. The reduction in mortality was significant after controlling for sociodemographic characteristics, BMI, smoking, and alcohol use.

So, I will still enjoy my workouts, now more than ever, with the added hope of avoiding a premature trip to the cardiac catheterization lab or the nursing home.

Monday, May 9, 2011

Bullying in the Hospital- Unacceptable

Source: NY Times
Yesterday's New York Times has an insightful article on yelling and bullying of staff, nurses in particular, by doctors.The article is timely as we are officially in National Nurses Week.

Yelling and intimidation go beyond the occasional tantrum in an operating room or hospital ward. The article explores how an intimidating environment can significantly impact patient safety: rather than bring their questions about patient care to a difficult doctor, many health care personnel would rather keep silent.

Nurses are better trained than ever before and are an integral part of the patient care team. Without them, the process would simply not work. As I have blogged before, they do all the work so that we can take the credit.

In an attempt to minimize this unacceptable behavior,  many hospitals have policies specifically addressing bullying.

Perhaps our guiding principle, as physicians, should be: never yell at the staff, only yell at the department heads.

Friday, May 6, 2011

Congratulations Kate Pearson!

Congratulations to VCU medical student, Kate Pearson, recipient of the 2011 AOA (Alpha Omega Alpha) 2011 Carolyn L. Kuckein Student Research Fellowship award. This prestigious national award will provide research support for a continual period of a minimum of 8 to 10 weeks clinical investigation in epidemiology and health services research. 

Kate Pearson: 2011 AOA Student Research Award Winner

Kate will be part of our 2011 Honduras Medical Relief Trip and will take the lead in on of our IRB approved studies titled: Accessing Healthcare in a Rural Developing Nation: A Comparison of Two Communities in Northern Honduras, and The Role of the Honduras Outreach Medical Relief Brigada (HOMBRE) in Providing Medical Care.

To learn more about the VCU Honduras Global Health Initiative- click here.

MCAT: New and Improved?

The Medical College Admission Test (MCAT) remains a rite of passage for any doctor or want-to-be doctor.

A recent New York Times article titled A Better Medical School Admission Test reports on the 5th major revision of the test. As a test of knowledge, the MCAT functions well, however, it has a major short coming: it has been unable to consistently predict the personal and professional characteristics becoming a good doctor.

A good MCAT performance does not predict an empathic, personable and ethical physician. We all know that these too are essential professional qualities. I have trained many students who are good test takers but who are mediocre in patient care. 

The new exam will also test analytical and reasoning skills in ethics, philosophy and cross-cultural studies.

Progress? Possibly.

Thursday, May 5, 2011

Nursing Homes and Infection Prevention: Trouble on the Horizon?

Infection prevention programs have traditionally focused on inpatient, critically ill patient populations. There is a growing body of literature on the special infection prevention needs in nursing homes and long term care facilities. This is with good cause.

The Centers for Medicare and Medicaid Services (CMS) requires that “the facility must establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection”  An infection control program should include the following components: “(1) investigates, controls, and prevents infections in the facility; (2) decides what procedures, such as isolation should be applied to an individual resident; and (3) maintains a record of incidents and corrective actions related to infections."

A recent paper published in AJIC reports on nursing home deficiencies in infection control. Data was obtained  from 2000-2007 from the Online Survey, Certification, and Reporting data base, which contains information on both deficiency citations and facility characteristics. Using multivariable analysis, low staffing levels were highly predictive of infection prevention deficiencies. An average of 15% of all nursing homes received a deficiency citation for infection control each year from 2000 to 2007.
Source:AJIC: American Journal of Infection Control Volume 39, Issue 4 , Pages 263-269, May 2011- average number of deficiency citations used per nursing home in each state.
With a growing elderly population, resources for infection prevention in nursing homes must be made available.

Old age is looking less and less appealing.

Wednesday, May 4, 2011

Liposuction: Fat Lost and Found

Source: NY Times
Last Sunday, the New York Times published an article on liposuction by writer Gina Kolata.

The paper highlights an important finding from a recent study in the journal Obesity. In a prospective, randomized trial of abdominal liposuction in women, body fat was restored and redistributed mostly in the upper abdomen, shoulders and triceps of the arms, within the course of one year. What fat was lost was later found in new anatomic areas. It should be noted that participants agreed not to make any lifestyle changes that could potentially impact body fat.

Much of medical practice is not supported by robust evidence, rather by anecdotes of success and case series of low quality and questionable follow up time. As such, this study was novel in the body of literature for cosmetic surgery/liposuction.

Although I am no means an expert in this field of medicine, durable weight loss appears not amenable to a quick fix and matters of lifestyle changes still play a paramount role.

Tuesday, May 3, 2011

Another Day in the Hospital!

They do all the work so that we can take the credit. 

Acute Care Medicine Nursing Staff- Virginia Commonwealth University Medical Center

Antiretrovirals: A Hairy Proposition

The title of this paper definitely caught my eye.

What if physicians could measure adherence to HIV medications by a method analogous to HgB A1C testing for diabetics? Enter antiviral concentration sampling in patients on HIV medications as a predictor of viral load suppression.

424 female participants (51% African-American, 31% Hispanic) contributed occipital hair samples for analysis of atazanavir concentration levels. After adjusting for age, race, treatment experience, pretreatment viral load, CD4 count and AIDS status, and self-reported adherence, hair levels were the strongest predictor of viral load suppression. Women with atazanavir levels in the highest quintile had odds ratios (ORs) of 59.8 (95% confidence ratio, 29.0-123.2) for virologic suppression. Adequate atazanavir hair levels predictive of viral suppression were > 1.78ng/mg of hair.  

Hair Sampling for Atazanavir Analysis-Clin Infect Dis 2011 May; 52(10):1267-75

Possible benefits of hair sampling:
 -Hair analysis provides a measure of average serum atazanavir concentration over weeks to months rather than a single point of time such as with a serum viral load
- Hair collection is simple and non-invasive and does not require specific skills and poses little risk for percutaneous injury or exposure to blood and body fluids
- Hair can be store for prolonged periods of time, without precautions for biohazardous materials

However, does this method work with other retrovirals and non-protease inhibitor based regimens?

Also, what if the patient suffers from severe alopecia (male pattern baldness)?

Must retrovirals be prescribed with Rogaine for maximal benefit of hair analysis?   

Monday, May 2, 2011

Clinical Rotations: Traditional vs Longitudinal Approach?

Medical students, in many ways, are apprenticed doctors. Much of their time, especially in the 3rd and 4th years, is spent on direct patient care in the hospital and clinics. Mandatory rotations in surgery, medicine,pediatrics, neurology, obstetrics/gynecology and family medicine are completed typically in the 3rd year. With a change in rotation discipline comes a change in supervising physicians and mentors lending itself to a fragmented clinical experience.

It is no surprise that a recent paper in Medical Education comparing preceptors’ and students’ perceptions of student evaluation in block clerkships and longitudinal integrated clerkships favored longitudinal integrated clerkships.
Longitudinal integrated clerkships are core clinical experiences that include longitudinal ambulatory preceptorships to facilitate continuity in students’ relationships with preceptors and patients over periods of 6 months to 1 year. This is in contrast to the traditional 4-12 week rotation. Both preceptors and students favored evaluation in the longitudinal clerkships on three factors: validity of evaluation process, quality of clinical skill evaluation, and willingness to provide constructive feedback.

There is no evidence, however, that a longitudinal clerkship experience will produce a more learned, better skilled and more empathic physician come graduation time. 

The finding is nevertheless important and highlights an important challenge. A student cannot complete a longitudinal experience across all specialties as this is simply not feasible given time and faculty constraints. The challenge lies in how to best choose a longitudinal clerkship such that the educational and future specialty choice of the student is best met without compromising meaningful learning experiences across the other required rotations.

Administratively and logistically, this is much easier said than done.