The Physical Exam and its Transformative Power

Here is a wonderful lecture brought to my attention by my friend and colleague, Dr. Michael Edmond.

The lecturer is celebrated physician-author Abraham Verghese. 

The subject is the physical examination, with a historical perspective and an emphasis on its role as a transformative, doctor-patient ritual.

The lecturer was given a standing ovation. It is well worth watching.

Contact Precautions and Depression

An ongoing infection prevention controversy is the concern about adverse consequence from contact (isolation) precautions.

Contact precautions are employed to reduce the transmission of drug resistant pathogens such as MRSA and VRE.


Recently published in the Journal of Hospital Infection,  a retrospective cohort study of patients admitted to a tertiary care medical center over two years assessed the relationship between contact precautions and depression and anxiety. During the study period, there were 70,275 admissions including 28,564 unique non-intensive-care-unit (ICU), non-psychiatric admissions. 


The result?  After adjusting for potential confounders, contact precautions were associated with depression [odds ratio (OR) 1.4, 95% confidence interval (CI) 1.2–1.5] but not with anxiety (OR 0.8, 95% CI 0.7–1.1) in the non-ICU population. Thus, depression was 40% more prevalent among general inpatients on contact precautions.


Contact precautions are not without adverse consequences. It makes me wonder if alternative measures such as excellent hand hygiene, bare below the elbows inpatient HCW attire, and universal gloving could be successfully employed in lieu of isolation precautions. 

Acute Illnesses Associated With Insecticides Used to Control Bed Bugs

Just the other evening I was called about an infection control issue related to bed bugs. Bed bugs are not considered disease vectors, but they can be a nuisance and cause anxiety, discomfort, and sleeplessness. 


As I was reviewing the literature, I came across this article from the CDC's Morbidity and Mortality Weekly report (MMWR), on the dangers of bed bug eradication with insecticides. 


The majority of the illnesses were fortunately mild and self limited. If bed bugs continue to vex in increasing numbers, then the use and misuse of insecticides will likely climb.  Public health recommendations to prevent illnesses associated with insecticides used to control bed bugs include media campaigns to educate the public about bed bugs, including nonchemical methods to control bed bugs, methods to prevent bed bug infestation (e.g., avoiding the purchase of used mattresses and box springs), and prudent use of effective insecticides. 


Persons who have a bed bug infestation should probably seek the services of a certified professional in pest control. 


This may not be a situation that lends itself to DIY (do it yourself) pest control. 

Weird Science: Chronic Fatigue Syndrome and Off-Label Use of H.I.V. Medications

Source: NY Times

A recent article published in the New York Times reports the off-label use of HIV medications (antiretrovirals). Medications are frequently prescribed for off-label use, however, when used as a treatment for chronic fatigue syndrome, a malady without a clear etiology or pathophysiology, then such prescription practice is even less conventional.


At the heart of the controversy is a 2009 study linking chronic fatigue syndrome to a retrovirus called XMRV.  However, this finding has not been replicated, putting into question the pathophysiologic link between XMRV and chronic fatigue syndrome.  Science, the medical journal that published the original research has even taken the step of asking for a retraction from the study's authors. To my knowledge, there are no clinical studies, case series or even a single case report published on the successful use of antiretrovirals for chronic fatigue syndrome. Prescribing antiretrovirals for chronic fatigue syndrome is simply not supported by even low quality data.


With an estimated 1,000,000 Americans suffering from chronic fatigue syndrome, pharmaceutical companies have a potential financial gain.  Further, the prescription of antiretrovirals for chronic fatigue syndrome appears ethically unsound and may be associated with an opportunity cost especially as many HIV+ patients in the USA still have no access to medications.


Weird science and bad medicine.

Big Plans for Influenza Vaccination this Flu Season

The public apparently has big plans for influenza vaccination this year. 


I have already noticed many patients requesting the vaccine in the clinic. Is this just hype? Will there be higher than usual influenza activity this year? Time will tell.


From my experience with healthcare workers, there is a always a significant fraction who are recalcitrant to seasonal influenza vaccination. The excuses are many, including, fear of needles, too busy, anti-vaccination tendencies, etc. To overcome this, some healthcare systems have made seasonal vaccination for influenza mandatory. 


Will the (seeming) public enthusiasm for the vaccine spill over to healthcare workers?


Your guess is as good as mine.

The Nonclinical Environment and Staphylococcus Bacteria

S.aureus- the bane of humanity since time immemorial

Germophobes beware. The nonclinical (non-hospital) environment is teeming with Staphylococci.

A recent commentary in the American Journal of Infection Control explores the potential role of the nonclinical environment in the transmission of Staphlylococci, including MRSA.

Traditionally, pathogens such as MRSA have been associated with healthcare facility contact,extended patient treatment and decontamination efforts of both patients and inanimate healthcare environments. However, the emergence of community associated MRSA infections raises the question of non-clinical, non-hospital spread of staphylococci.


MRSA has been isolated from pigs, horses, dogs, cats,cattle, chicken, sheep,chinchillas, bats, and parrots. Evidence suggests that MRSA can be transmitted from dogs and cats to their owners.



Inanimate, shared surfaces of 'high frequency touch' are also potential reservoirs. Staphylococci have been isolated from surfaces in commercial airplanes and from household surfaces including kitchen and bathroom sinks, faucet handles,drains, dish sponges, cloths and towels, countertops, tubs, trays on infant chairs, and pet food dishes.Other surfaces include hand rails used in public transportation systems, hygiene items (towels, razor blades) and gear shared among professional athletes and prisoners. Staphylococci are remarkably hardy and can exist on environmental surfaces for days.


So, the extent to which the nonclinical environment is driving staphyloccocal transmission remains unknown. 


If these reservoirs are found to pose a significant risk, then what should be done?


Perhaps common sense will prevail such that we wash our hands more and limit the sharing of high risk items, such as towel, apparel, athletic gear, utensils,razor blades etc.


This could be a germophobe's nightmare.

An Apple a Day?

Source: NY Times

Here is an interesting arcticel published in Stroke: Journal of the American Heart Association and in the New York Times health blog.


The color of the edible portion of fruits and vegetables reflects the presence of pigmented bioactive compounds, (eg, carotenoids, anthocyanidins, and flavonoids). 


The authors sought to define which vegetable color groups contribute most to stroke reduction over a 10 year period. The categories were green (broccoli, kale, spinach and lettuce), orange/yellow (oranges, carrots and peaches), red/purple (cherries, grapes, beets and tomatoes) and white (apples, pears, bananas and cauliflower).

A prospective, population-based cohort study design was employed  and included 20,069 men and women age 20 to 65 years. All participants were free of cardiovascular diseases at baseline. vegetable consumption was assesed via a178-item food frequency questionnaire. Statistical modeling was utilized to adjust for age, sex, lifestyle, and dietary factors.

233 cases of stroke were documented.  Medians of green, orange/yellow, red/purple, and white fruit and vegetable consumption were 62, 87, 57, and 118 g/d, respectively. Green, orange/yellow, and red/purple fruits and vegetables were not related to incident stroke. Only a higher intake of white fruits and vegetables was inversely associated with stroke (up to ). 171 grams of white produce daily  (equal to one medium to large apple) had a 52 percent lower risk of stroke than those who ate less than 78 grams of white fruit a day. On average, every 25 grams of white fruit eaten daily was associated with a 9 percent lower risk for stroke.

Sure, the study has weaknesses, not the least of which is relying on self reported recall of fruit consumption(recall bias), however, the findings are interesting. The actual mechanism for stroke risk reduction is also not known.

Perhaps there is some truth to the adage an apple a day keeps the doctor away. 

Physician Handoff of Patients: from the ICU to the Ward

Source : WSJ Health Blog

If you or a family member were unfortunate enough to have been hospitalized in an intensive care unit (ICU), did you ever wonder how your case was 'handed off' to another physician or medical team at the time of transfer out of the unit?
A recent paper in the American Journal of Medicine sheds some light on this topic. 

The underlying concern is that poor physician handoff may be a major contributor to suboptimal care and medical errors.


The investigators performed a hospitalized patient-based observational study in an urban, university-affiliated tertiary care center. The objective was to assess physician handoff practices for ICU-to-ward patient transfer. One hundred twelve adult patients were enrolled. The stakeholders (sending physicians, receiving physicians, and patients/families) were interviewed to evaluate the quality of communication during these transfers. 

During the initial stage of patient transfers, 15.6% of the consulted receiving physicians verbally communicated with sending physicians; 26% of receiving physicians received verbal communication from sending physicians when patient transfers occurred. Poor communication during patient transfer resulted in 13 medical errors and 2 patients being transiently "lost" to medical care. Overall, the levels of satisfaction with communication (scored on a 10-point scale) for sending physicians, receiving physicians, and patients were 7.9±1.1, 8.1±1.0, and 7.9±1.7, respectively.

Despite physician satisfaction with communication at the time of transfer, verbal communication between physicians appears uncommon (15-26%). Medical errors, albeit uncommon, occurred because of poor communication, these included, medication dosing and stoppage errors and diagnostic mistakes.

There is certainly room for improvement, especially for the sake of patient safety.

Here is more on the subject from the WSJ HealthBlog.

Higher Risk of Mortality and Longer Hospital Stays for Inpatients Treated by Physicians with More Years of Practice

Well here is an article that argues, for the sake of the public good, that physicians be re-certified and maintain up to date with their clinical skills

Published in the American Journal of Medicine, the authors examined all inpatients on the teaching service of an urban hospital from July 1, 2002 through June 30, 2004. Patients were assigned to fifty-nine attending physicians quasi-randomly over 6572 admissions. Years in practice was defined as the number of years the attending physician held a medical license. Years in practice was divided into 4 groups;0-5, 6-10, 11-20, and >20 years. Logistic regression analysis was employed to adjust for patient characteristics and estimate associations between years in practice and length-of-stay, readmission, and mortality.

Physicians with more years in practice had longer mean lengths of stay (4.77, 5.29, 5.42, and 5.31 days for physicians with 0-5, 6-10, 11-20, and >20 years in practice, respectively, P=.001). Inpatients of physicians with >20 years in practice had higher risk for both in-hospital mortality (odds ratio 1.71; 95% confidence interval, 1.06-2.76) and 30-day mortality (odds ratio 1.51, 95% confidence interval, 1.06-2.16) than inpatients of physicians with 0-5 years in practice.

The message: re-certification and maintenance of inpatient skills requirements must be universal for all practicing physicians. 

The next time you are hospitalized, the baby-faced residency program graduate may not seem such a bad alternative to the aged professor.

Contagion- a Cautionary Tale of Looming Pandemics

Here is an interesting New York Times editorial on the film "Contagion", a cautionary tale of pandemics past and present. 


The authors is W. Ian Lipkin, a professor of epidemiology and a professor of neurology and pathology at Columbia University, and, a medical consultant for Steven Soderbergh's latest release.


The risks of pandemics are increasing. More than three-quarters of all emerging infectious diseases originate when microbes pass from wildlife to humans (zoonoses). Our vulnerability to such diseases is increased by the growth in international travel and the globalization of food production. Further, deforestation and urbanization continue to displace wildlife, increasing the probability that wild creatures will come in contact with domesticated animals and humans. 


For a scholarly read, I recommend Laurie Garrett's The Coming Plague.


As for the film, perhaps I will skip infectious diseases rounds this week and hit the matinee.

Don't Get Hospitalized in July- The Intern Effect?

It has long been a running, dark joke in medicine: the worst day to get hospitalized is on July 1st, the first day of internship across the country.


Is there some truth to this statement?


Published in the Annals of Internal Medicine, a recent study investigated the effect of intern changeover in the month of July. The authors systematically reviewed studies describing the effects of trainee changeover on patient outcomes. Thirty-nine studies were included in the final analysis:  27 (69%) reported mortality, 19 (49%) reported efficiency (length of stay, duration of procedure, hospital charges), 23 (59%) reported morbidity, and 6 (15%) reported medical error outcomes; all studies focused on inpatient settings.


Of the 13 studies with higher-quality designs and larger sample sizes, increased mortality and decreased efficiency was observed at time the time of intern changeover in the month of July. For the higher-quality studies showing an association between changeover and mortality, the effect size ranged from a relative risk increase of 4.3%  to 12.0% or an adjusted odds ratio of 1.08  to 1.34. Not a huge difference, but not insignificant either


Other outcomes, such as morbidity and medical error outcomes, produced inconsistent results.


Mortality increases and efficiency decreases in hospitals because of year-end, intern changeovers. The authors were careful to point out several important caveats to this conclusion. The articles reviewed were English-language only, ambulatory settings were excluded, definitions of changeover and supervision structure varied significantly, likely resulting in confounding and bias.


Regardless, I will be sure to have my appendicitis later in the academic year.

Disinfection Wipes- Impact on MRSA

Environmental contamination with methicillin-resistant Staphylococcus aureus (MRSA) and other bacteria (C.difficile, VRE)  pose an infection prevention risk. 


A recent study in the American Journal of Infection Control assessed the effectiveness of nondisposable, disinfection wipes in clinical areas. The environmental disinfection procedures of 8 MRSA-positive hospitalized patients in 2 orthopedic wards were evaluated and  56 pre- and postdisinfection samples from the bed rails as well as pre- and postuse wipes samples were collected. 


The average MRSA loads on the bed rails before and after disinfections were 4.4 colony-forming units (cfu)/cm2 and 0.4 cfu/cm2. The mean difference of MRSA survival detected on the wipes after each wiping ranged from 0.13 to 0.42 log.


So disinfection wipes can reduce yet not eliminate MRSA on inanimate surfaces. With use, the wipes themselves can concentrate MRSA and can become potential vectors for cross transmission, especially if they are not thoroughly rinsed between use.


Disinfection is tricky business. Perhaps disposable wipes would serve better.

The Public Health Implications of Resource Wars

Source: The Guardian

Here is a thought provoking commentary in the American Journal of Public Health.

It is no surprise that war takes a tremendous toll on public health. Resource wars are violent conflicts that are largely driven by control over vital natural resources- petroleum, land, key minerals, gold silver etc.


Competition for petroleum is likely to trigger armed conflict because petroleum is a highly valuable and increasing demand. Resource wars frequently occur in remote or poor areas, affecting populations already vulnerable to inadequate public health resources.  Thus, wars fought over petroleum and other resources can create public health concerns by causing morbidity and mortality, damaging societal infrastructure, diverting resources, uprooting people, and violating human rights.


The authors call for increased advocacy by public health authorities to protect vulnerable population during resource wars. The call may seem a bit quixotic, nevertheless, the points made are of relevance.


Public health workers and the organizations can help prevent resource wars and minimize their consequences by: (1) promoting renewable energy and conservation (2) documenting the impact of past and potential future resource wars, (3) protecting the human rights of affected noncombatant civilian populations during armed conflict, and (4) developing and advocating for policies that promote peaceful dispute resolution.


Thoughtful.

One Donor- Many Offspring

I am well out of my medical comfort zone on this posting. Nevertheless, the title of this article from the New York Times, about one sperm donor fathering 150 children, was intriguing. Wow.

Of greater interest is a handful of medical and ethical concerns raised by the above situation. There appear to be reasonable concerns among parents, donors and medical experts about potential negative consequences of having so many children fathered by the same donors.  This includes the possibility that genes for rare diseases will be spread more widely through the population. Some experts are even calling attention to the increased odds of accidental incest between half sisters and half brothers. Apparently, offspring of donors often live close to one another, making this scenario not a far fetched thought.

Countries such as Britain, France and Sweden, limit how many children a sperm donor can father.  No such limit exists in the United States.

Perhaps it is time to reassess this policy.

Improved Glove Usage: Impact on Hand Hygiene

One would think that improving compliance with glove usage would significantly impact compliance with hand hygiene. After all, greater attention to glove usage suggests heightened awareness of infection prevention, no?


A recent publication in the American Journal of Infection Control suggests that improved gloving by healthcare workers does not necessarily translate into significant gains in hand hygiene compliance.


The authors assessed the impact of improving glove using on the hand hygiene (HH) compliance in a multicenter study . If gloves had been used correctly during the evaluation, the overall compliance with hand hygiene measured after contacts with patients or environment would have only increased from 66.3% to 68.7%. 


Healthcare workers may simply feel that their hands do not become soiled or contaminated during patient care when donning gloves. There is a body of literature reporting that gloves, even when properly worn, can have micro-tears, allowing for HCW hand contamination.


We published a paper on universal gloving in 2007, where, during the universal gloving phase of the protocol, HCW adherence with hand hygiene decreased  after patient contact.


Gloves are, without doubt, of use as personal protective equipment. Nevertheless, the message to me is clear, improving glove usage cannot be used as alternative to improving hand hygiene.

How Much is Enough, or Rather, How Much is Too Much?- Assigned Reading for Medical Students

Although I am no longer the internal medicine clerkship director at my institution, the topic of medical education still interests me. During my tenure, I recall modifying assignments, changing textbooks and pairing down assigned reading in response to student feedback.

A recent publication in Academic Medicine explores the dilemma of assigned readings in the medical school curriculum.

The authors calculated the total amount of reading assigned during the basic science curriculum at an American medical school for the 2009–2010 academic year. In September 2010, they surveyed the 351 enrolled students, asking them to estimate their reading rates, number of hours spent reading each day, and the amount of the assigned reading they had completed. The authors then estimated the time required to complete the reading assignments and compared these rates with previously published reading rates.

During the academic year,  29,239 pages of reading were assigned. The 104 respondents (30% response rate) reported they could read an average of 6 hours per day. The authors calculated that 17% of the students read no faster than 150 words per minute, whereas another 66% did not exceed 100 WPM. At this rate students would need to read 496 pages per week, which would require 28 to 41 hours per week to complete the assigned reading only once.

So the time commitment for reading is significant, at least when assessed in this fashion. 

Yes, faculty should take into account time constraints when assigning reading. However, many students do not complete the reading assignments but, rather, choose to rely on lecture notes and recordings. This too should be taken into account in the curriculum planning.

A mature learner must learn how to effectively study and prioritize assignments.

No one ever said that medical school was going to be easy.

Hand Hygiene and Patient Safety- A Novel Psychological Motivator?

Source: WSJ

Here is a recent WSJ Health Blog on hand hygiene. I am not going to bore you with my perspective on how we have increased hand hygiene in my place of employment.I  will, however, pay kudos to a soon to be published study in the journal Psychological Science, cited in the article above. 


The investigators approached the hand hygiene compliance dilemma from a psychological perspective- emphasizing patient health. The study authors describe two experiments that pitted a sign stating that “Hand hygiene prevents you from catching diseases” against one stating that “Hand hygiene prevents patients from catching diseases.”


Hand hygiene adherence increased significantly (to 89.2% from 80.7%) with the patient-consequences sign but didn’t change significantly with the personal-consequences sign.


Interesting and simple enough in approach. Will the effect last on a long term basis? Will the incremental benefit still hold in the event that HH adherence is already at 90%.


I look forward to reading the fine details of the study once published