Monday, October 31, 2011

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.

Thursday, October 27, 2011

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.

Tuesday, October 25, 2011

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.

Thursday, October 20, 2011

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.

Wednesday, October 19, 2011

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

Tuesday, October 18, 2011

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

Mobile Phones and Mobile Bacteria

A recent British study reported that 1 on 6 mobile phones is fecally contaminated (E.coli). The authors suggest that poor hand hygiene is the culprit. I am inclined to agree. No doubt that similar bacteria is found on other high touch items like computer keyboards or remote controls.

But why should we be surprised? People are notoriously poor at washing their hands. 

I have seen many people leave the bathroom without performing hand hygiene. In one crowded airport bathroom, I overheard a gentleman chatting on the phone while in the toilet booth.  The phone and bacteria were in close proximity indeed.

Monday, October 17, 2011

Doctor and Patient or Provider and Consumer?

Source: WSJ
This is a growing controversy in medicine. Are we still doctor-patient or are we now provider-consumer?

I really hope that the latter is not acquiring permanency. Of course, there is a business side to medicine, even in a large academic center. But, let's be honest, medical encounters are rarely, if ever, a simple business transaction like buying a car or shopping for groceries. A person's well being is at stake, many encounters are urgent or under emergency situations, frequently there are few (no) options in choosing a doctor, and the cost, typically, is borne by a third party (insurance). 

This is no simple seller-buyer deal occurring in the free market.

For more, check out this perspective in the Wall Street Journal.

Friday, October 14, 2011

Global Health: Ideas and Ideals

The last several weeks we have been planning our return to Honduras for our medical relief trip. So, finally, I dove into an Infectious Diseases Clinics of North America publication on global health. A recent article, on the evolving meaning of global health, can be found here.

For those of you who are interested, here are some salient points:

Although the definition of global health is broad, the guiding principal lies in practical approaches to equity, human rights, and evidence-based interventions and actions.

From Julio Frenk’s Address at the Harvard School of Public Health Commencement,
June 7, 2007: Actions are guided by two powerful sources of illumination—ideas and ideals. Ideas take the form of knowledge derived from science. Ideals take the form of values derived from ethics. Ideas can be transforming to the evidence base for sound decision making. Ideals can be transformed into the integrity base for coherent action.

Ain't that the truth.

Wednesday, October 12, 2011

Hand Hygiene-State of the Art

There is scholarly review on hand hygiene in this month's Infection Control and Hospital Epidemiology.

Few, if any, need convincing that hand hygiene is an effective risk reduction strategy for infection prevention. The gold standard for hand hygiene remains trained observers, however, this is time consuming,costly, laborious and likely subject to bias. Measuring the amount of sanitizer consumed is a surrogate and less accurate measure of capturing hand hygiene in a healthcare setting.

I was encouraged to read that electronic hand hygiene monitoring systems  (utilizing wireless systems to monitor room entry and exit of healthcare workers and their use of hand hygiene product dispensers) can provide individual and unit-based data on compliance hand hygiene.These systems are varied and include badges (tags) that can provide healthcare workers with real-time reminders to clean their hands upon entering and exiting patient rooms. We studied one such product. Hand hygiene, in our experience, skyrocketed with electronic surveillance.

Other studies suggest that electronic hand hygiene monitoring systems are associated with increased hand hygiene compliance. 

Of course, these systems are expensive, however, if we are serious about infection prevention and patient safety, then they are worth it.

Tuesday, October 11, 2011

Staphylococcus aureus Decolonization- Variation Abounds

There is a lot of coverage and controversy when it come to Staphylococcus aureus and methicillin-resistant S. aureus (MRSA).

A recent publication in Infection Control and Hospital Epidemiology confirms that significant variation exists, even among infectious diseases specialists, for decolonizing a patient of Staphyloccus prior to an elective procedures. As most staphylococcal infections arise from one's own endogenous strain, reducing the bacterial burden is a proven infection prevention intervention.

The investigators surveyed infectious disease physicians to determine their preoperative Staphylococcus aureus screening and decolonization practices. Sixty percent reported preoperative screening for S. aureus. However, specific screening and decolonization practices are highly variable, are focused almost exclusively on methicillin-resistant S. aureus, and do not include testing for mupirocin or chlorhexidine resistance.

Variation on screening and decolonization exist as neither method is fully effective at either detecting or eradicating S.aureus.

At present, we cannot easily detect all staphylococcal carriers and prevent all related infections.

Monday, October 10, 2011

Too Much Care in Primary Care?

Are we a nation that is overtreated by our doctors? Medical writer Shannon Brownlee would agree with this comment and has written extensively on the subject in her book Overtreated. I highly recommend reading it.

Do primary care physicians share a similar point of view? A recent study in the Archives of Internal Medicine explores this theme.

The investigators conducted a nationally representative mail survey of US primary care physicians randomly selected from the American Medical Association Physician Masterfile (response rate, 70%; n = 627).

Forty-two percent of US primary care physicians believe that patients in their own practice are receiving too much care; only 6% said they were receiving too little. The most important factors physicians identified as leading them to practice more aggressively were malpractice concerns (76%), clinical performance measures (52%), and inadequate time to spend with patients (40%). Physicians also believe that financial incentives encourage aggressive practice: 62% said diagnostic testing would be reduced if it did not generate revenue for medical subspecialists (39% for primary care physicians). Almost all physicians (95%) believe that physicians vary in what they would do for identical patients; 76% are interested in learning how aggressive or conservative their own practice style is compared with that of other physicians in their community.

So many primary care doctors believe that their patients are receiving too much care. The cause appears multifactorial and includes fear of litigation, financial incentives and insufficient time with patients. 

Perhaps a peer to peer comparison could affect a change in practice or perhaps it could reinforce collective, non-evidence based practice. Most encouraging, in my view, is that many respondents were interested in feedback on their practice style. 

Thursday, October 6, 2011

A Fat Tax

I have blogged before about our growing obesity epidemic (pun intended).

Here is an article by Mark Bittman on a 'Fat' Tax. Another related article is found here on the Freakonomics website.

Essentially, the Danes have implemented an excise tax on foods high in saturated fat. At play is a similar principle applied to other unfavorable items. As one increases cost (through taxation), consumption of alcohol and cigarettes decreases. The goal is to decrease the consumption of high fat foods by increasing cost to the consumer. 

Now the rate of obesity in Denmark is significantly lower than the USA, so this is forward thinking indeed. It remains to be seen, however, what impact an excise tax will truly have on both decreasing the consumption of foods high in saturated fat and curbing the obesity trend.

One can quit smoking but one simply cannot quit eating.

Time will tell.

Tuesday, October 4, 2011

Football (Soccer) as a Public Health Initiative

The Blogger at a football 'wellness' session
on a windy field in Richmond, Virginia
Okay...this is now too good to be true. My two passions- medicine and football (soccer) in collaboration.

A recent article published in the  European Journal of Applied Physiology explores the health impact of a football 'wellness' program in homeless men.  Read the summary here.

Fifty-five men enrolled in the study and were randomized either to receive soccer training two or three times a week or to serve as a control group. After 12 weeks, the group who regularly played soccer reduced their body fat and lowered their blood pressure and cholesterol levels, compared with the control group. The soccer players also improved other markers of cardiovascular health.

Football as a public health initiative. I love it.

For another interesting read, check out How Soccer Explains the World by Franklin Foer.
A must read.

Monday, October 3, 2011

Calling the Nurse "Doctor"

Source: NY Times
Here is an article in Sunday's New York Times about nurse practitioners with doctorate degrees. The trend extends to pharmacists and physical therapists. It is becoming increasingly routine for patients that someone who is not a physician uses the title of doctor

Rightly, healthcare workers are entitled to introduce themselves as "Doctors" if they have a doctoral degree. However, this could be misleading to the patients. It may not be clear to patients that the "doctor" is a nurse, pharmacist or physical therapist.

At stake is also a potential erosion of physician power. 

It will be interesting to see how this plays out in the long run.