Wednesday, August 31, 2011

HCW Attire- A Source of Pathogens?

Well, this is a topic that has interested us for quite some time. Uniforms and attire worn by many HCWs are really nothing more than street wear as they are not sterile and frequently laundered at home. We have a submitted manuscript in review, on this topic, which I hope to be able to share with you in the near future. 

A paper recently published in the American Journal of Infection Control investigated the rate of potentially pathogenic bacteria present on uniforms worn by hospital staff, as well as the bacterial load of these microorganisms. Cultures were obtained from uniforms of nurses and physicians at the abdominal zone, sleeve ends, and pockets. 

A total of 238 samples were collected.  Potentially pathogenic bacteria were isolated from at least one site of the uniforms from 63% of participants. Not surprisingly, 58% of participants claimed to change their uniform every day, and 77% defined the level of hygiene of their attire as fair to excellent. 

Once again, we have evidence that uniforms are colonized with potentially pathogenic bacteria. It remains unclear, however, what impact this may have in cross transmission of pathogens to patients. 
Clearly, more studies are needed to assess this last point.

Tuesday, August 30, 2011 Digital Epidemiology

HealthMap: image source- The Guardian (UK)
I have been incommunicado now for nearly 9 days, relaxing in Cape Cod and tuning out from the world, until, of course, Hurricane Irene hit the Eastern coast of the USA.

Now back in Richmond and attempting to pick up where I left off.

Social media and the web are useful beyond the obvious. They can also be potent sources of epidemiologic data providing clues and leads on emerging diseases and outbreaks.  

Here is an interesting article in Time Magazine titled -using the web to track infectious diseases in real time.

Highlighted is the HealthMap project. HealthMap automatically trolls news sites, eyewitness reports, government data, even wildlife-disease cases to identify new patterns in outbreaks, presenting the results on a clickable map.

Owing to internet and cell phones, a new level of interconnectedness has arisen, allowing for instantaneous digital data mining of every corner of the globe.

Global, digital epidemiology is born, so, go ahead and tweet, post and upload your malady into the the may be of significance.

Friday, August 19, 2011

Cigarette Companies File Suit Over Warnings

The US Government has released new images that will cover the upper half of the front and back of cigarette packages produced after September 2012. I have previously blogged about this before.

Predictably, tobacco manufacturers are up in arms and have made a legal motion to stop it, as reported in an article in the New York Times. Lawyers for the tobacco companies are arguing that the labels and pictures violate the First Amendment protections for commercial speech.

Protection of commercial speech should not safeguard the sale of product of significant public health (negative) impact.  When you produce and sell a product that remains the leading cause of preventable death, killing 443,000 Americans a year according to the Centers for Disease Control and Prevention, and costs us (through increasing insurance premiums, Medicare and Medicaid) untold millions, then the Government does indeed have the right to use cigarette packages as mini-billboards for the government’s antismoking campaign.

I will be on vacation next week and hence will be blogging 'lightly'. I also plan to do some napping, to enhance my sense of well being during the break.

Wednesday, August 17, 2011

Norovirus on a Commercial Airline- Not Just for Cruise Ships

Flying has become troublesome enough already with security checks, having to remove your shoes, pat downs, etc. Now, one can add norovirus (diarrheal infection) to the list of potential inconveniences. Recurring norovirus infection on an airplane was recently reported in Clinical Infectious Diseases.

During October 2009, an outbreak of diarrhea and vomiting occurred among different groups of flight attendants who had worked on separate flights on the same airplane

The investigation identified a passenger who vomited on a Boeing 777-200 airplane.  Sixty-three (82%) of 77 flight attendants who worked on the airplane during 13-18 October provided information, and 27 (43%) met the case definition for norovirus infection. The attack rate among flight attendants decreased significantly over successive flights from 13 October onward (P < .001). Working as a supervisor was independently associated with development of illness (adjusted odds ratio, 5.8; 95% confidence interval, 1.3-25.6).  

The investigation suggested that the vomiting incident was the inciting step. Transmission to flight attendants may have occurred through direct contact with vomit or virus aerosolized by vomiting or indirectly by contact with the contaminated environment.

Passengers were not investigated. Nevertheless, the potential for foodservice contamination with norovirus, by flight attendants, is real and could lead to disease in passengers. That could make for an uncomfortable situation, especially on a long flight.

One has to wonder what sort of disinfection practices are in place in the event of a vomiting episode(s) on a commercial airline....

Tuesday, August 16, 2011

Reinventing the Toilet- A Public Health Mission

Having spent a fair amount of time in rural Honduras, I have seen the impact of poor sanitation and have gained a greater appreciation for functional plumbing. Much of the world is without proper sanitation and forced to use makeshift holes in the ground or latrines. This has an impact on the incidence of diarrheal infections, particularly in children.

The modern toilet requires massive infrastructure and water. Both are scarce commodities in resource poor settings.

The Bill and Melinda Gates Foundation is sponsoring a "Reinvent the Toilet" competition. See video below.

For an informative article on "Reinventing the Toilet" click here

For a video on the  on the solar powered toilet, click here.

It is time to get our S#@! together for a just public health cause.

Monday, August 15, 2011

Loss of Empathy- Disturbing Trend

Over the last year, I have heard much about the decline of empathy during medical training. A recent meta-analysis, published in Academic Medicine, is a systematic review of studies dealing with the decline of empathy among medical students and residents.

Three longitudinal and six cross-sectional studies of medical students demonstrated a significant decrease in empathy during medical school; one cross-sectional study found a tendency toward a decrease, and another suggested stable scores. The five longitudinal and two cross-sectional studies of residents showed a decrease in empathy during residency. 

Assuming that the empathy self-assessment tools employed in this type of research are valid, then the decline appears real. 

The authors propose a model to account for a decline in empathy. Factors attributed include individual personality types, inappropriate learning environment, inappropriate role models, excessive duty hours, mistreatment of trainees, high workload, and loss of peer support.  All contribute to burnout, lower quality of life and depression. The result is a decline in empathy.

The loss in empathy may be a coping mechanism. Could a decline in empathy be a normal reaction to distressing aspects of the human condition? If so, is the current decline in empathy any different than that experienced by our medical predecessors?

If, in fact, we are becoming globally less empathetic as a profession, then the quality of medical care may be at stake. 

We have much still to learn about ourselves as healthcare providers.

Friday, August 12, 2011

Alarming Trend in Syphilis Rates Across the USA- Racial Disparities Abound

Treponema pallidum- the agent of syphilis: Source
As an infectious diseases physician in an urban, tertiary care, university hospital, I am still struck by the seemingly endless cases of new HIV and syphilis diagnoses seen in young men. These  men, many of whom are gay, were born after the HIV epidemic began. Shouldn't they be practicing safe sex?

A recent publication in the Annals of Internal Medicine highlights an alarming trend in the rates of syphilis.
From 2005 to 2008, 27 states from all U.S. census regions reported data on the sex of sex partners for 70% or more of male cases of primary and secondary syphilis. Regression analysis revealed significantly different trends in rates of primary and secondary syphilis: Absolute increases in rates among black MSM and Hispanic MSM were, respectively, 8.0 times and 2.4 times the absolute increase in rate among white MSM. By region, rates among MSM increased 30% in the Midwest, 48% in the South, 73% in the Northeast, and 77% in the West. By age group, the largest absolute increase in rates occurred among MSM aged 20 to 29 years.
Rates of primary and secondary syphilis disproportionately increased among young, black and Hispanic MSM.

Sure, these findings have implications for point of care safe sex counseling by healthcare providers. But, they also reflect, in my opinion, a public health failure, the result of inconsistent education (by schools, health departments and parents) on sexual risks and safe sex counseling, including an under promotion of condom use. 

Until this is addressed, we are destined for more of the same.

Wednesday, August 10, 2011

What Does it Take to be a Successful Clinical Department Chair?

What does it take to be a successful clinical department chair? Also, do teaching hospital CEOs and medical school deans agree on attributes for clinical department chair success? 

One would hope that the agendas of CEOs and Deans would always align, but, with clinical, educational, financial and research goals at play, this may not always be the case. 

An article published in Academic Medicine offers some insight into this question.

The authors surveyed the deans of 126 U.S. medical schools and the CEOs of the primary teaching hospitals in the schools' academic health centers. All were queried on 34 items about clinical department chair performance in six categories -mission prioritization, leadership responsibilities, leadership values, skill sets, barriers to success, and competitive differentiators.

Eighty-four deans (67%) and 57 CEOs (45%) responded. Both deans and CEOs ranked good patient care as the chair's primary responsibility; agreement between CEOs on that responsibility was much stronger than among deans. CEOs placed greater emphasis on getting results whereas mentoring was a higher priority for deans. 

CEOs identified the inability to work within budgeted resources as a barrier to success more than did deans. CEOs reported that high-quality care and cutting-edge technologies gave hospitals a competitive edge, whereas deans put more emphasis on clinical and translational research and educating future physicians. 

Fortunately, for the sake of a pleasant working environment, the majority of deans and CEOs rated the alignment and relationship between themselves and their counterpart as "excellent" or "good".

So, CEOs favor a Clinical Department Chair focused on patient care, clinical quality, and results, whereas deans prefer the Department Chair to focus on research, education, and mentoring.

The findings are less than surprising.

Tuesday, August 9, 2011

Procalcitonin to Guide Duration of Antimicrobial Therapy- Breakthrough?

Source: Infectious Diseases News
Serum levels of procalcitonin (PCT), the precursor to calcitonin, are elevated in certain cancers neoplasms and in inflammatory conditions, including bacterial infections and sepsis. PCT elevation occurs within 2–4 hours after onset of the inflammatory disorder, often peaks in the second day, and falls rapidly during clinical recovery. PCT elevation may correlate with prognosis.

Can the use of serum procalcitonin levels safely reduce antimicrobial use in intensive care unit (ICU) patients? A systematic literature review  study published in Clinical Infectious Diseases addressed this question.

The review identified 6 published randomized controlled trials comparing PCT-guided antimicrobial therapy to usual care in ICU patients. Procalcitonin guidance was associated with significantly reduced antimicrobial exposure (effect sizes, 19.5%–38%) in all 5 studies assessing its impact on treatment duration.  Length of ICU stay was significantly decreased in 2 studies but was unchanged in the others. No significant difference infection relapse or mortality was observed. 

Procalcitonin guidance of antimicrobial duration appears to decrease antimicrobial use in the ICU patients. 

Could this be the next great breakthrough for antibiotic stewardship programs as they oversee and guide antimicrobial usage in attempt to maximize benefit and minimize harm and antimicrobial resistance?

Monday, August 8, 2011

Work Hour Restriction for Medical Interns: No More Hospital Hazing

Big changes took foot last month in teaching hospital across the USA.

Photo: New York Times Magazine
Gone, are the days, of 'hospital hazing' the interns. The 30-hour overnight shifts for interns have been abolished. I still remember the long days (not so) fondly.  

Interns, nationwide, are now limited to 16 hour shifts, an 80 hour work-week and 1 day off in 7.  The changes were contentious and evolved with much debate and opposition from nearly every major medical organization and from the majority of residency-program directors. 

Unfortunately, there is scant robust evidence to support that duty hour restrictions will necessarily result in a safer patient care environment. This last point is nicely explored in a recent New York Times Magazine article

As pointed out in the article, work hour restrictions may not be sufficient to ensure greater patient safety across American hospitals. The duty hours must be applied uniformly, supervision by senior physicians must be present, sign-outs at shift change must be systematic and meticulous, and medical records (electronic) with medication safety alerts must be in widespread use. All of these limit errors in medical practice and none are sufficient when applied in isolation.

Perhaps, when all of these factors are in place, we can then reap the benefits of a more humane system of training young doctors, one that also benefits patients by providing a safer environment of care.

Thursday, August 4, 2011

Does Vacationing Affect Health and Well Being ?

An idyllic beach scene....with plenty of opportunity for a nap
Does taking a vacation improve health and well being? The conventional wisdom is 'yes', however is there empiric data to support this conclusion?

Published in Psychology and Health, Dutch investigators attempted to answer the following; does every worker experience a positive effect of vacation on health and well being (H&W) AND which vacation activities and experiences explain changes in H&W during vacation? 

Using  a 7-week longitudinal field study, 96 workers reported their H&W 2 weeks before, during, 1 week, 2 and 4 weeks after a winter sports vacation on 6 indicators (health status, mood, fatigue, tension, energy level and satisfaction).

Sixty percent of respondents experienced substantial improvement of H&W during and after vacation. A small group, however, experienced no (23%) or a negative effect of vacation (17%). Spending limited time on passive activities, pleasure derived from vacation activities, and the absence of negative incidents during vacation explained 38% of the variance in the vacation effect. 

So it seems like the QUALITY of the vacation is important. As such, choose an especially pleasant vacation activity and avoiding negative incidents (?). Incorporating passive activities during active vacations seems to contribute positively on H&W.

Well, that settles it. I plan on vacationing in paradise only and napping more (passive activity) during my next vacation.

Wednesday, August 3, 2011

Cranberries vs Antibiotics to Prevent Urinary Tract Infections

Cranberry capsules or antibiotics?
The antimicrobial effects of cranberry juice, for the prevention of urinary tract infections (UTIs) in women is well known. But which is more effective for the prevention of UTIs, cranberry capsules or antibiotics?

Published in the Archives of Internal Medicine, a recent study sought to compare, in a prospective head to head trial, the effects of cranberry capsules vs antibiotics for the prevention of UTIs in women.  In a double-blind, double-dummy noninferiority trial, 221 premenopausal women with recurrent UTIs were randomized to 12-month prophylaxis use of trimethoprim-sulfamethoxazole (TMP-SMX), 480 mg once daily, or cranberry capsules, 500 mg twice daily. 

After 12 months, the mean number of patients with at least 1 symptomatic UTI was higher in the cranberry than in the TMP-SMX group (4.0 vs 1.8; P = .02), and the proportion of patients with at least 1 symptomatic UTI was higher in the cranberry than in the TMP-SMX group (78.2% vs 71.1%). Median time to the first symptomatic UTI was 4 months for the cranberry and 8 months for the TMP-SMX group. 

However, there is one caveat. Use of antibiotics lead to resistance.  Antibiotic resistance did not increase in the cranberry group. After 1 month, in the cranberry group, 23.7% of fecal and 28.1% of asymptomatic bacteriuria E coli isolates were TMP-SMX resistant, whereas in the TMP-SMX group, 86.3% of fecal and 90.5% of asymptomatic bacteriuria E coli isolates were TMP-SMX resistant.

So, antibiotics are superior to cranberry capsules,for preventing cystitis but at a cost. That cost is the development of antimicrobial resistance. 

It is a zero sum game, of sorts.

Tuesday, August 2, 2011

HIV Lab on a Chip- Diagnostic Breakthrough at Hand?

Source: BBC
Imagine a credit card sized lab kit that can accurately detect the presence of HIV or even syphilis from a small, point of care blood sample. Couple this with low cost and ease of use and a true diagnostic breakthrough may be at hand. 

Too good to be true? Perhaps not.

Published in Nature Medicine, the mChip has arrived.  You can also read about it on the BBC. The researchers tested prototypes of the credit card-sized lab-on-a-chip with hundreds of patients in Rwanda, reporting nearly 100 percent accuracy. With an estimated production cost of a dollar per unit, the mChip would be far cheaper to administer than current lab-based tests and it would allow rapid, simple testing right at the point of care (rather than requiring patients to go to a clinic or having to transport samples to a special lab).

One major hurdle in HIV control is identifying asymptomatic, infected patients. Once identified, these patients may be offered treatment and further educated about the risk of disease transmission. 

If a quick, accurate, simple and inexpensive diagnostic test were available, especially in resource poor settings, then a major advance may be imminent. 

Monday, August 1, 2011

Calorie Labels in Fast Food Restaurants- Any Impact Yet?

Source: WSJ
After a week of covering infectious diseases consults in the hospital, I am saturated with infectious diseases medicine and am going to break from the ID crowd with this posting.

Here are two interesting and related articles on the impact of mandatory menu-labeling law that took effect in New York City a few years ago. One article is published in the Wall Street Journal, the other in British Medical Journal.

The impact of food labeling in NYC  has not (yet) objectively resulted in significant changes in calorie consumption. 

Could it be that people completely ignore the calorie information? As reported in the British Medical Journal study, in a 2009 survey, 15% (1288/8489) of customers reported using the calorie information, and these customers purchased 106 fewer kilocalories than customers who did not see or use the calorie information (757 v 863 kcal, P<0.001).

Those who read and use the calorie information on fast food menus appear to make a calorie conscious decision on food choices.

I see no reason to conclude that food labeling in NYC restaurants has failed. Even if the impact is small, some benefit is to be gained, with little to no harm, risk or detriment. 

One can only wish that all medical interventions were generally this safe.