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.........