Congratulations Jessica Zuo and Kate Pearson- VCU Summer MIDPH Research Winners

Congratulations to Jessica Zuo and Kate Pearson, our two VCU MIDPH  (Medicine, Infectious Diseases, and Public Health) research students. 


Their respective summer research projects, in Antimicrobial Stewardship and in Healthcare Access and Barriers in Rural Honduras took the top student MIDPH research awards for the summer.


We look forward to supporting them as they present their abstracts at national conferences, and, as they publish their work in peer-reviewed journals.

Jessica Zuo

Kate Pearson

With colleague and collaborator Dr. Michael Stevens, posing with our award winning students.

Surgical Care Improvement Project (SCIP)- Does it Make a Difference?

The other day I was with my colleagues in infection prevention and cardiothoracic surgery discussing our data on post-operative infections and our adherence to SCIP measures. Of particular interest is our adherence to the choice, timing and discontinuation of antimicrobial prophylaxis for surgery. Compliance with SCIP is publicly reported and affects healthcare reimbursement.


SCIP measures are derived from smaller studies identifying best practices for optimizing surgical outcomes. The question remains, however, does implementation of SCIP measures, wide scale, result in improved outcomes (reductions in surgical site infections)?


The two largest studies to address this critical question were published in the Journal of the American College of Surgeons and the Journal of the American Medical Association.  


The conclusion is a mixed bag. Better adherence to infection-related process measures was not significantly associated with better outcomes in one study. In the second study,  SCIP global adherence was associated with a lower postoperative infection risk. However, adherence reported on individual SCIP measures, which is how SCIP is publicly reported, was not associated with a significantly lower infection risk.


So SCIP adherence may decrease the rate of post-operative infection, but the data is not conclusive. 


At the very least, adherence to SCIP reflects an institution's ability to play within a set of patient care guidelines and to track its own performance.

Health Literacy and Health Disparities

Source: ncmedicaljournal.com

The conclusion of this review article  in the Annals of Internal Medicine should come as no surprise.

Approximately 80 million Americans have limited health literacy, which puts them at greater risk for poorer access to care and poorer health outcomes. Health literacy includes the ability to understand instructions on prescription drug bottles, appointment slips, medical education brochures, doctor's directions and consent forms, and the ability to negotiate complex health care system. For a more comprehensive definition click here.

  

A systematic review was performed on all English language articles on health literacy and  relationship to poorer use of health care, outcomes, costs, and disparities in health outcomes. Ninety-six relevant good- or fair-quality studies in 111 articles were identified: 98 articles on health literacy, 22 on numeracy, and 9 on both. 

Low health literacy was consistently associated with more hospitalizations; greater use of emergency care; lower receipt of mammography screening and influenza vaccine; poorer ability to demonstrate taking medications appropriately; poorer ability to interpret labels and health messages; and, among elderly persons, poorer overall health status and higher mortality rates.

Low health literacy is associated with poor health outcomes and sub-optimal use of health care services.

The same can be said of being uninsured.

The Happy Meal- Revamped?

Source NY Times

McDonald's has gone healthy, sort of.

Perhaps bowing to consumer and health advocacy pressure, McDonald's announced Tuesday that it would more than halve the amount of French fries and add fruit to its popular children’s meal in an effort to reduce the overall calorie count by 20 percent. A step in the right direction.

Happy Meals will still have the toy or trinket, which serves as a strong inducer of demand by children.

I mean, how could a parent possibly say no to their child's request for a Happy Meal with a 'Toy Story' figure included?

Employment and Physical Activity-Positively Correlated

We know that there is an obesity crisis in the USA. I have heard it over and over; I work too much and have no time for exercise.

True?

A recent article published in the American Journal of Preventive Medicine would suggest otherwise.

Investigators assessed how employment status (full-time, part-time, or not employed) and job type (active or sedentary) were related to daily physical activity levels.

Cross-sectional data from the National Health and Nutrition Examination Survey (NHANES) were collected in 2003–2004 and analyzed in 2010. 

In men, full-time workers were more active than healthy nonworkers (p=0.004). Even workers with sedentary jobs were more active (p=0.03) and spent less time sedentary (p<0.001) than nonworkers. In contrast with men, women with full-time sedentary jobs spent more time sedentary (p=0.008) and had less light and lifestyle intensity activity than healthy nonworkers on weekdays. Within full-time workers, those with active jobs had greater weekday activity than those with sedentary jobs (22% greater in men, 30% greater in women).

So, in men, full-time work (even sedentary work) was positively associated with increased physical activity. 

Some of us are addicted to both work and exercise....

Nasal Methicillin-Resistant Staphylococcus aureus Status, Surgical Prophylaxis, and Surgical Site Infection Risk

I am a bit late today with my posting.


Here is an article on MRSA colonization and surgical site infection published recently in Infection Control and Hospital Epidemiology.


Using a retrospective cohort study design of Veterans Affairs (VA) Boston patients, the investigators determined whether preoperative nasal MRSA carriage was a significant predictor of postoperative infections, after accounting for surgical infection risk and surgical prophylaxis. 


Multivariate analysis of risk factors for each outcome was performed.  Among 4,238 eligible patients, 279 (6.6%) were positive for preoperative nasal MRSA. After adjustment for surgery type, vancomycin prophylaxis, chlorhexidine/alcohol surgical skin preparation, and SSI risk index, preoperative nasal MRSA was significantly associated with postoperative MRSA cultures (infections).  Strikingly, Vancomycin prophylaxis was associated with an increased risk of total SSI in nasal MRSA negative patients (RR, 4.34; 95% CI, 2.19-8.57) yet was protective for patients positive for nasal MRSA (RR 0.61; 95% CI 0.06-5.75). 


So, preoperative nasal MRSA colonization was independently associated with MRSA clinical cultures in the postoperative period. Vancomycin prophylaxis increased the risk of total SSI in nasal MRSA-negative patients yet was protective in MRSA positive patients.


This was an observational, retrospective study, so causality cannot be determined. 


Regardless, this is perplexing.

Cognitive Benefits of Physical Activity in the Elderly

Here is another example of why I plan to keep exercising right up until the nursing home. 


A recent publication in the Archives of Internal Medicine reported that physically active people have reduced risk of incident cognitive impairment in late life. The investigators studied the relationship between activity energy expenditure (AEE), an objective measure of total activity, and incidence of cognitive impairment.


The authors calculated AEE as 90% of total energy expenditure minus resting metabolic rate in 197 men and women (mean age, 74.8 years) who were free of mobility and cognitive impairments at study baseline (1998-1999). Cognitive function was assessed at baseline and 2 or 5 years later using the Modified Mini-Mental State Examination. 

After adjusting for baseline Modified Mini-Mental State Examination scores, demographics, fat-free mass, sleep duration, self-reported health, and diabetes mellitus, older adults in the highest tertile of AEE had lower odds (risk) of incident cognitive impairment than those in the lowest tertile (odds ratio, 0.09 [91% decreased odds]). This appeared to have a significant dose-response association.


This study suggests that findings greater physical activity (AEE) may protect against cognitive impairment.


What's next? Determining the maximal cognitive benefit from different levels of physical activity. 

Hopefully this will be sorted out before I reach my golden years.

Accuracy of Reported Energy Contents of Restaurant Foods?

Probably more calories than you imagine....

Do you ever wonder about the accuracy of calorie counts on restaurant food? Researchers recently examined and reported the accuracy of stated energy contents of foods purchased in restaurants.


The goal was to measure the difference between restaurant-stated and laboratory-measured energy contents.


A validated calorimetry technique was used to measure dietary energy (calories) in food from 42 restaurants. A total of 269 food items and 242 unique foods were assessed. The restaurants and foods were randomly selected from restaurants in Massachusetts, Arkansas, and Indiana.


Of the 269 food items, 50 (19%) contained measured energy contents of at least 100 kcal/portion more than the stated energy contents. Of the 10% of foods with the highest excess energy in the initial sampling, 13 of 17 were reanalyzed. In the first analysis, these foods contained average measured energy contents of 289 kcal/portion (95% CI, 186 to 392 kcal/portion) more than the stated energy contents; in the second analysis, these foods contained average measured energy contents of 258 kcal/portion (95% CI, 154 to 361 kcal/portion) more than the stated energy contents (P <.001 for each vs 0 kcal/portion difference). 


Foods with lower stated energy contents contained higher measured energy contents than stated, while foods with higher stated energy contents contained lower measured energy contents (P <.001).


Good news: stated energy contents of restaurant foods were (mostly) accurate overall.


Bad news:  there was inaccuracy for some individual foods. Low calorie food items may not be as low calorie as stated.


Vexing.

Measles Revisited

Back in the USA.

Source: The Lancet

This one will be brief. An effective vaccine against measles has been available for the past 40 years, however, measles has returned in North America and Europe. The subject is neatly reported in the Lancet.

From January 1 to May 20, 118 cases were reported in the USA. 46% of the cases were imported, most from European Countries.Ideally, two doses of MMR vaccine given to 95% of children are required to halt the spread of the virus. By 2009 only 60% of countries worldwide had achieved 90% coverage with at least one vaccine dose. Difficulty accessing services, religious beliefs, and vaccine scepticism are part of the reasons for low coverage. Better organisation of vaccination systems is suggested by the authors.

In a wealthy countries, such as in the United States and Western Europe, I have to wonder what impact the anti-vaccine movement may have had on the reappearance of measles.

In Buenos Aires

In Buenos Aires.

Will be taking a night flight to the USA tonight.

I can't say that I won't miss my native Argentina terribly.

Soon, back to work, back to medical blogging, back to the grind.

Tea and Coffee Consumption and MRSA Nasal Carriage

Cafe con leche- mi pasion

For those of you who are tea/coffee consumers and possible germophobes, here is an interesting article for you.

Tea and coffee consumption reduces the risk of MRSA nasal carriage, per a recent study published in the  Annals of Family Medicine .In an adjusted logistic regression analysis controlling for age, race, sex, poverty-income ratio, current health status, hospitalization in the past 12 months, and use of antibiotics in the past month, individuals who reported consuming hot tea were one-half as likely to have MRSA nasal carriage relative to individuals who drank no hot tea (odds ratio = 0.47; 95% confidence interval, 0.31-0.71). Similarly, individuals who reported consuming coffee had about a one-half reduction in the risk of MRSA nasal carriage relative to individuals who drank no coffee (odds ratio = 0.47; 95% confidence interval, 0.24-0.93).

I am going to have a second cup of cafe con leche, of course, as  I am still in Argentina.

Positive Deviance- Again

I have blogged about positive deviance before both here and here.

An abstract presented at the International Conference on Prevention & Infection Control (ICPIC)  reported the effect of positive deviance in 5 acute care hospitals. The volume of alcohol handrub and soap used, and the number of gowns and gloves used, were collected at baseline and then for 12 months prospectively. Social network mapping was conducted at the project start and end. Adherence with process of care measures was recorded.

Three of the five sites sustained decreases in resistant organism-related infection rates of 25 percent, 41.2 percent and 63.9 percent. Rates at the fourth site were unchanged, while the fifth site had a VRE outbreak, which resulted in a large increase in the overall resistant organism-related infection rate. HA-MRSA decreased by 100 percent at two hospital sites; HA-VRE decreased by 100 percent at two sites; and healthcare-acquired C. difficile decreased at three sites by 53 percent, 51.9 percent and 23 percent. The one site that measured hand hygiene compliance had a 53.2 percent rate increase.

Good. 

So is this sort of problem solving really something new? We will have to wait for the manuscript to fully delve into the details and to better understand the 'deviance' employed.

I am still in Argentina. Going to go for a country drive today.

Hasta luego.

Estadio (Stadium) Mario Alberto Kempes

I am really off topic now, but hey, this is my blog so I can choose the content, right?

In Estadio Mario Alberto Kempes-last night's view of Brasil vs. Ecuador

I came across this article in the New York Times about Stadium (Estadio) Mario Alberto Kempes, in Cordoba, Argentina. Named after famed Argentine footballer, Mario Kempes, the newly renovated stadium is within walking distance from my Argentine home. 


I have been there 3 times in the last 5 days for the Copa America.


Not a bad way to pass the time.


Back to medical blogging, sometime in the near future.

Effect of Healthcare Reform: An Interrupted Time Series Analysis

The effect of healthcare reform is neatly studied here, using an interrupted time series design. The investigators evaluated the effects of reforms on healthcare access, affordability, and disparities.The intervention was the Massachusetts 2006 healthcare reform, which included an individual health insurance mandate.


Living in Massachusetts in 2009 was associated with a 7.6 percentage point (95% CI=3.9, 11.3) higher probability of being insured; 4.8 percentage point (–0.9, 10.6) lower probability of forgoing care because of cost; and a 6.6 percentage point (1.9, 11.3) higher probability of having a personal doctor.


The absolute effects of the reform were greater for disadvantaged populations.  


Isn't that the point of healthcare reform?


I am off to the football stadium tonight, for the Brasil-Ecuador match in Cordoba, Argentina, sure to be a Copa America thriller.


Hasta luego

Personality Test- Medical School Interview

Photo: NY Times

This week is 'blogging light' as I am back in Argentina...attempting to avoid any real responsibility.


From the NY times, an article about a new medical school applicant interview technique, a 'people skills test' of sorts by way of multiple mini-interveiw. At Virginia Tech Carilion, a new US medical school, applicants undergo a series of 8 mini interviews, each with a different ethical conundrum, in rotating rooms with individual interviewers. The candidates are given eight minutes to discuss that room’s situation. The applicant then moves to the next room, for the next surprise conundrum and the next interviewer, and is scored with a number and comments.


The goal is to identify applicants with good social and communication skills. Seems innovative and promising. 


I hope that some objective measure is in place to effectively judge the success of this tactic. For now, it succeeds on a theoretical basis.


Hasta luego

Chillin' in Cordoba

The Blogger: back in his native Cordoba, Argentina....passing time.

Well, I am back in my native Cordoba, Argentina, passing the time with family, food, and football (soccer).


Tonight, to the football stadium for Argentina-Costa Rica, in the Copa America.


I plan to get back to medical blogging soon.


Sorry.

Stranded in Chile

Well things have not gone per schedule. My flight was diverted from Buenos Aires to Santiago de Chile owing the ashes from Puyehue volcano in southern Chile blowing into Argentina.

Being stranded in a top class South American city has its perks. I was able snap a few choice photos as I wandered the streets, with the snow capped Andes as a backdrop.

Off to Cordoba, Argentina, tomorrow- for the Copa America.

Sign Off on the Signout

Here is a perspective on the physician signout (passing on a patient to a colleague at the end of a shift). Some authorities are urging that the signout be made an official part of the electronic medical record.

By summarizing patient care data(signout) into electronic medical record, rich, up-to-date clinical information typically cordoned off in the stand-alone signout note is made available to all providers and services. A centralized, official signout note would enable summary information to flow from other parts of the medical record into the signout note.

As information is important for decision making during cross-coverage, it should probably be in the patient's record, for quick and easy access by all providers.

Speaking of signout....i am signing off for now. I am flying to Argentina later today where I plan to visit family, relax and watch a lot of the Copa America football (soccer) tournament.

 I will blog periodically while in the Southern Hemisphere.

Food (and Drug) Labels

Source: NY Times

Food packages are clearly labeled with nutritional information so why shouldn't medications have plain language labels too?


Here is a perspective worth reading.


A significant information asymmetry exists between doctor-pharmaceutical company- patient. 


The proposal is to require fact boxes, similar to those that appear on food packaging, in every ad drug makers produce and along with every package of medication they sell. This would potentially minimize some of the information asymmetry and spin around the effectiveness of the drug.

Patients, consumers and physicians would likely support this measure. 

Pharmaceutical companies? Not so much.

Antibiotics for Cellulitis: An Effective Clinical Guideline?

It is well known that antibiotics are overused. 

Source: cellulitispictures.com

A recently published article in the Archives of Internal Medicine reports how implementation of a clinical guideline in a hospital can positively affect management and outcome of complicated skin and soft tissue infection.

A total of 169 patients (66 with cellulitis, 103 with abscess) were included in the baseline cohort, and 175 (82 with cellulitis, 93 with abscess) were included in the intervention cohort. The intervention led to a significant decrease in use of microbiological cultures (80% vs 66%; P = .003) and fewer requests for inpatient consultations (46% vs 30%; P = .004). The duration of antibiotic therapy decreased from 13 days to 10 days (P < .001) and fewer patients received antimicrobial agents with broad aerobic gram-negative activity (66% vs 36%; P < .001), antipseudomonal activity (28% vs 18%; P = .02), or broad anaerobic activity (76% vs 49%; P < .001). No differences were observed in clinical failure (7% vs.7.4% of cases (P = .93). 

A major obstacle in changing clinical practice is obtaining quality data to support a change in practice.

This is a step in the right direction.

Alcohol Abuse Disorders and Healthcare Associated Infections

Congratulations to colleague and fellow collaborator, Dr. Marjolein de Wit, on her recently published article assessing the impact of alcohol abuse disorders on healthcare associated infections. The Science Daily press release can be found here.

The paper, published  in Alcoholism, Clinical and Experimental Research, can be accessed here.

From a total cohort of 149,892 patients who developed HAI,  8,830 (5.9%) had a codiagnosis of alcohol abuse disorder (AUD). People with AUDs who developed healthcare associated infections had longer hospital stays, thousands of dollars of higher hospital costs, and, by logistic regression modeling, much greater odds of dying  (OR=1.71 [71% greater odds] ).

Alcohol abuse and healthcare infections do not mix well.

Criminal Background Checks for Entering Medical Students

I have never given this much thought, but it should likely come as no surprise that criminal background checks are being used prior to medical school matriculation. It seems like background checks are employed in many other fields and professions so why should medicine be entirely immune to the trend?


I am still not clear on the burden of the problem with respect to 'criminals' applying to medical school. Here is a recent review article on the topic in Academic Medicine.


113 medical schools use a criminal background check; 92 schools use the AAMC-facilitated process, and 21 schools use an independent process. Only a small number of acceptances have been reconsidered based on the results of criminal background checks. For classes entering medical school between 2008 and 2010, 58,108 out of 127,242 applicants were accepted by at least one medical school. AAMC-facilitated criminal background checks were conducted on 24,085 of these accepted applicants. Only 3% of these applicants did not matriculate for a combination of reasons, including withdrawals, deferments, and rescinded offers of acceptance.  Lacking is detailed information on the very small number of rescinded offers of acceptance.


I am not sure how much of an impact this will have, but I suspect that the criminal background check will become routine nevertheless.