Pornography and Condoms

This article caught my eye this article. 


This June, in Los Angeles, citizens will vote on whether actors in pornographic movies will be required to wear condoms, by law. The ballot is a result of intense lobbying by the AIDS Healthcare Foundation.


Under current regulations by the California Division of Occupational Safety and Health, actors are required to use condoms.  Enforcement, however, is tricky as the agency can only act after it receives a complaint. Sexually transmitted infections, including HIV, are seen as an occupational hazard in this industry. Wearing a condom in an adult movie is akin to mandating that construction workers wear personal protective equipment (hard hats, protective eyewear, protective footwear). 


As I am an infectious diseases physician, you can likely guess my thoughts on the matter.

Patient Interest in Sharing Personal Health Record Information-A New Trend?

Here is an article in the Annals of Internal Medicine that explores sharing the electronic medical record with patients.

The investigators explored preferences about sharing electronic health information among users of the U.S. Department of Veterans Affairs (VA) PHR (personal health record) system, My HealtheVet.  The study was Web-based survey of a 18,471 users of My HealtheVet. 

Almost 4 of 5 respondents (79%) were interested in sharing access to their PHR with someone outside of their health system (62% with a spouse or partner, 23% with a child, 15% with another family member, and 25% with a non-VA health care provider).  

As a consultant, it would be of tremendous assistance to access electronic records from referring providers. At the least, it would make my job easier. The digital age and electronic medical records  should, in theory, reduce information asymmetry between patients and providers. Access to the one's electronic health record should, in theory, engage patients in their care by instilling a sense of ownership and should allow for easier provider to provider communication, thereby making care more efficient and reducing redundancy in testing and treatment. Provided that HIPPA (health information privacy) standards are upheld, a technical breakthrough may be at hand.

All of the proposed benefits, however, remain largely theoretical given that no real body of literature exists to prove the tangible, long term benefits or hazards of a shared, electronic patient record. This must be a focus of research as the use of shared electronic records proliferate.  

My Own Country- My Own Thoughts

I spent the last several days engaged in reading some not so light material, Abraham Verghese's My Own Country, a first person account of an infectious diseases physician's experience with HIV/AIDS in rural Tennessee, in the mid-1980's.


What fascinated me most about the book was not so much the details of the evolving HIV epidemic in the 1980's, but rather, the inherent challenges of managing an infectious disease without primary treatment (pre-antiretrovirals), and the stigma associated with the diagnosis. In Tennessee, much as in other parts of the country during the mid 1980's, to be HIV positive was to suffer in secrecy, lack familial and social support, confront blatant homophobia, and be faced with disdain and refusal of medical care from some physicians and nurses. 


Anyone with an interest in HIV/AIDS epidemiology should give the book a proper perusal.  

Hand Hygiene Surveillance a la George Orwell- Video Surveillance

It seems like a cannot stray too far from the subject of hand hygiene as of late. Apologies to those that find it boring. Here is a related article published in Clinical Infectious Diseases. 

The investigators evaluated healthcare worker hand hygiene with the use of remote video surveillance with and without feedback. The study was conducted in an 17-bed intensive care unit from June 2008 through June 2010. 


Cameras were placed with views of every sink and hand sanitizer dispenser to record hand hygiene of healthcare workers. Individual patients were not visualized. Sensors in doorways identified when a healthcare worker entered/exited a patient room.  Trained, remote video auditors utilized for review of the surveillance data.  Hand hygiene was measured during a 16-week period of remote video auditing without feedback and a 91-week period with feedback of data. Performance feedback was continuously displayed on electronic boards mounted within the hallways, and summary reports were delivered to supervisors by electronic mail.

During the 16-week prefeedback period, hand hygiene rates were shockingly less than 10% (3933/60 542) and in the 16-week postfeedback period it was 81.6% (59 627/73 080). The increase was maintained through 75 weeks at 87.9% (262 826/298 860).

Hand hygiene surveillance by video audit works. The process is not cheap and has associated start up (technology) costs, training of video auditors and, likely, ongoing auditor validation for quality assurance. Of course, conservatives and libertarians will bemoan such Orwellian surveillance tactics. However, as video surveillance is not punitive, respects patient privacy (patients are not visualized),  and is done for the sake of patient safety, their argument is flimsy, at best.


Newer technologies for hand hygiene surveillance seem promising. I have blogged about this before.

Voltaire on Medicine

Voltaire

The other day I was reviewing a power point slide of mine and came across this quote by Voltaire:



“The art of medicine consists in amusing the patient while nature cures the disease.”

Infection Prevention Without Emotional Zealotry: Michael Edmond

With Mike Edmond, in 2006, as he ponders infection prevention

Kudos to my close friend and colleague, Dr. Michael Edmond, for recognition as one of the 20 most influential health leaders in the USA by the Health Leaders Media Council. 


Under his guidance, our focus is common sense, evidence based, infection prevention efforts that target all pathogens.


Infection prevention policies devoid of ''emotional  zealotry'', an approach welcomed here. It may be a polarizing stance on the issue of MRSA control and infection prevention, but the progressively lower infection rates substantiate the process.

The 2011 Richmond City FC Copa Navidad- Passion and Purpose on the Pitch

Football for a medical charity with passion and purpose on the pitch.


The 7th annual  Richmond City FC Copa Navidad, our charity football match, took place on Sunday, December 11th, at SCOR. All proceeds go the the Fan Free Clinic, caring for Richmond's medically under served. 


The event was one of our most successful to date with Richmond City FC White defeating Richmond City FC Blue 6-5 in a hard fought, drudge match.


Thank you to all the footballers, the volunteer referees from CVSA and to SCOR.


Event photos below- click to enlarge.

RCFC Blue Copa Navidad 2011

RCFC White Copa Navidad 2011

RCFC 2011 Copa Navidad Participants

The Blogger, with footballing friends at the 2011 Copa Navidad

Dirty Hands in the Gloves

Just because latex gloves are worn during clinical care does not mean that the hands are clean. An article recently published in Infection Control and Hospital Epidemiology is revealing on this matter.


The observational study was performed in a large and likely representative sample of British hospitals. The investigators  observed hand hygiene and glove usage (7,578 moments for hand hygiene) during 249 one-hour sessions. Gloves were used in only 26% of the 7,578 moments for hand hygiene and in17% of 3,292 low-risk contacts; gloves were not used in 21% of 669 high-risk contacts. 


The rate of hand hygiene compliance with glove use was low 41% and the rate without glove use was 50.0%. After statistically adjustment, glove use was strongly associated with lower levels of hand hygiene (adjusted odds ratio, 0.65 [95% confidence interval, 0.54-0.79]


Hand hygiene is low, gloves are not worn when indicated and glove use is associated with a decrease in hand hygiene.


We observed a similar hand hygiene reduction during a universal gloving study that we published several years ago.


We need a better understanding of what motivates healthcare workers to wash their hands before and after glove use. 

Postcards From Honduras- Kate Pearson and Gabriela Halder

Here is a nice article and brief interview with Gaby Halder and Kate Pearson, published in the VCU School of Medicine website.

Kate and Gaby: medical field research, La Hicaca, Honduras, June 2011

The article summarizes their important contributions as medical relief workers and field researchers.


We are gearing up for another successful trip in June 2012 and will be in Honduras next month (January 7th-10th) to layout the final plan. More to follow on this blog. 


Stay tuned.

Beliefs About Hand Hygiene: A Survey of Medical Students

What do 1st year medical students think about the hand hygiene practices of their presumed mentors?


A study recently published in the American Journal of Infection Control is a bit disconcerting. Eighty-five medical student from a German medical school answered an anonymous questionnaire. Only 21% of all respondents marked all of the indications for hand hygiene correctly. Respondents guessed that average physician compliance with hand hygiene was 52% (not far off the mark). In the opinion of the students, compliance with hand hygiene decreases with increase in physician rank.


It appears that we lack hand hygiene role models.

Footballing for Charity-Richmond City FC Copa Navidad

Today was the Richmond City FC Copa Navidad, our charity football match. All proceeds go the the Fan Free Clinic, caring for Richmond's medically under served.


Match photos and details to appear soon on the City website, and on my blog.

The Blogger, with footballing friends, at the 2011 RCFC Copa Navidad

Transmission Based Precautions-Web Based Compliance Monitoring

Source: healthunit.org

We typically concern ourselves with hand hygiene compliance in healthcare settings but what about compliance with transmission based isolation precautions? 


A new study published in the American Journal of Infection Control explores the use of a web based, electronic, real time data collection mechanism for adherence monitoring. A total of 13,000+ observation rooms were observed in 2009. Data entry, at the point of observation, on a web-based tablet PC, was associated with increased start-up costs. The process, however, was significantly more streamlined and efficient. In times of increasing infection control mandates, efficiency is a boon to any infection prevention program.


One thing not reported in the manuscript: what impact did enhanced (web based) surveillance have on adherence with isolation precautions and was it sustained?

The Comeback of the House Call?

Source: NY Times

Making house calls may no longer be a medical anachronism. Here is a recent perspective in the NY Times. The article underscores the need for continuity of coordinated, longitudinal care and cites evidence that patients may have better outcomes with home based, primary care visits.

Not too long ago, I inadvertently made a 'house call' on a patient. While out for a very early morning jog, I came across a homeless, HIV positive patient on a local park bench. After the initial surprise of meeting up with his doctor, we had a brief yet pleasant encounter. While sitting with him on the park bench, he pulled out his retrovirals from his backpack and subsequently convinced me of his ongoing medication adherence. 

An unconventional house call, admittedly, and unlikely to affect his outcome. Regardless, the visit did further establish rapport, which may lead to a better doctor-patient relationship in the long run.

Kate and Gaby at ASTMH 2011

Once again, Kate Pearson and Gabriela Halder, invaluable members of our Honduras medical relief and research team, are presenting their work and making us proud.


This time,the duo is at the The American Society of Tropical Medicine and Hygiene annual meeting, Philadelphia, Pennsylvania.

Kate and Gaby at ASTMH, earlier today

Kudos to these VCU School of Medicine standouts.

Misdiagnosis: TB vs Aspergillosis

Pulmonary aspergillosis
Source: Radiopaedia.org

Pulmonary tuberculosis continues to be the scourge of humanity. After treatment, recurrent disease can be vexing to diagnose and in a not insignificant number of cases, per a WHO report, 22% of TB recurrences were actually a fungal disease (chronic pulmonary aspergillosis). This report is summarized in Infection Control Today. For the original paper, I refer you to the Bulletin of the World Health Organization.

Both TB and aspergillosis can be difficult to confirm. The radiographic (x-ray) changes are similar, cultures are frequently difficult to obtain, and the pathogens are not rapidly identified in the laboratory. Additionally, couple these challenges with resource poor settings where diagnostic testing is frequently not feasible, and confirmation of either pathogen proves even less realistic.

The treatments for these diseases are very different and misdiagnosis can result in a catastrophic outcome. Better mechanisms for differentiating TB from pulmonary aspergillosis, especially in resource poor settings, are needed.  

HIV Epidemic in the USA-2011: Vital Signs

Here is a report from the MMWR worth reading. It is a state of the art update on the HIV epidemic in the USA.


Some of the statistics are truly eye opening, even for an infectious diseases specialist like me.


The graph below speaks volumes.

Source: CDC-MMWR

• About 1.2 million people are HIV positive in the USA; 80 % are aware of their infection and 20% are not.
• 77% of HIV infected adults are linked to care but only 51% remain in care.
• Only about 28% of people with HIV will have successful treatment (suppressed viral load)

Clearly, tremendous strides are needed to curb the HIV epidemic and include increased testing for HIV, ongoing (retention of) HIV medical care and increased adherence to treatment.

Acne-A New Perspective?

Source: Telegraph.UK

Here is a brief article on acne that I came across while speedily perusing my Google Reader. 


For the full reference click here.

Proprionobacterium acnes is apparently not the only causative agent of acne. For successful women in their mid-twenties or older, stress, in particular, can be the cause of acne. This process is hormone driven and differs from the acne of the teenage years.

Not everything can be infectious, after all.