New Website is Launched

It has taken me a bit of time to get the project completed. Finally, here it is. 

Please check out my new professional website.

www.drgonzalobearman.com

Probiotics for the Prevention of C.difficile

The prevention of C.difficile associated diarrhea is a growing area of interest, particularly for patient on antibiotic therapy. Here is a systematic review published in the Annals of Internal Medicine on the use of probiotics for the prevention of C.difficile associated diarrhea.

Twenty trials including 3818 participants met the eligibility criteria. Probiotics reduced the incidence of C.difficile associated diarrhea by 66% (pooled relative risk, 0.34 [95% CI, 0.24 to 0.49]; I² = 0%). Of probiotic-treated patients, 9.3% experienced adverse events, compared with 12.6% of control patients (relative risk, 0.82 [CI, 0.65 to 1.05];I² = 17%).

This is reasonable quality evidence to support the use of probiotics to reduce the risk of C.difficile associated diarrhea. The potential harm is minimal.

Who would best benefit from probiotics? This is not clearly defined, however, prescription of probiotics for those receiving prolonged antibiotics (> 2 weeks) or for those on antibiotics with a prior history of C.difficile associated diarrhea seems justifiable.

It may change my practice.

Thrive

Medical Muse- Fall 2012

For those of you with a literary curiosity, a short story I wrote, titled Thrive, was just published in the Fall 2012 edition of Medical Muse magazine.

You can download the Fall 2012 edition here.

The story starts on page 18.

The New 'Pet Scan' - Using Dogs to Sniff Out C.difficile

Here is an article published in the British Medical Journal on a novel 'pet scan', using trained dogs to sniff out C.difficile in stool samples and in hospitalized patients.

Dutch investigators assessed the sensitivity and specificity for detection of C difficile in stool samples and in patients by a trained, 2 year old beagle. 

The dog’s sensitivity and specificity for identifying C difficile in stool samples were both 100% (95% confidence interval 91% to 100%). During the detection rounds, the dog correctly identified 25 of the 30 cases (sensitivity 83%, 65% to 94%) and 265 of the 270 controls (specificity 98%, 95% to 99%)

Impressive, but how would this benefit hospital infection prevention efforts? Early diagnosis of C.difficile infection may lead to prompt isolation and treatment, however, this may not impact cross transmission within the hospital environment. Significant uncertainties such as these must be answered by clinical studies before dogs are routinely employed as an infection prevention strategy. 

At the very least, C.difficile sniffing dogs would give new meaning to the term Dogs on Call.

VCU Medical Students Audrey Le and Jackie Arquiette Recognized by School of Medicine

Congratulations to VCU Medical students Audrey Le and Jackie Arquiette who were recognized by the VCU School of Medicine and on the VCU News website for their work on our Honduras medical relief research program.

Well done ladies.

Jackie Arquiette

Audrey Le

Contact Precautions: Benefits Revisited

It seems like the topic of contact precautions is receiving ongoing attention in the hospital epidemiology literature. The current trend of articles tend to question the benefits of contact precautions and underscore its untoward consequences.

The latest study, published in Infection Control and Hospital Epidemiology, examines the effects of contact precautions on healthcare worker (HCW) activity in acute care hospitals. Using a prospective observational design, a total of 7,743 HCW visits were observed over 1,989 hours. Patients on contact precautions had 36.4% fewer hourly HCW visits than patients not on contact precautions as well as 17.7% less direct patient contact time with HCWs. In addition, patients on contact precautions tended to have fewer visitors 23.6% fewer. HCWs were more likely to perform hand hygiene on exiting the room of a patient on contact precautions (63.2% vs 47.4% in rooms of patients not on contact precautions).

Less than 10 years ago, active detection and isolation for MRSA was all the rage in hospital epidemiology. Times are changing as we learn the potential negative impact of isolation precautions.

An excellent related blog from my colleagues in Controversies in Hospital Infection Prevention can be found here.

We feel it is time to rethink contact precautions for the control of endemic pathogens. By using robust, horizontal infection prevention measures, endemic pathogens such as MRSA and VRE may be effectively controlled without employing contact precautions.

Stay tuned.

Global Burden of Disease Report: Obesity Rises to the Top

Source: The Lancet

The recent Global Burden of Disease compilation published in The Lancet is eye opening. This is the largest systematic study to describe the global distribution and causes of a wide array of major diseases, injuries, and health risk factors.

The good news: infectious diseases, maternal and child illness, and malnutrition now cause fewer deaths and less illness than 20 years ago.

The bad news: there has been a massive shift (pun intended) in obesity as a cause of morbidity and mortality. Over the last 20 years, there is an estimated 82% increase in obesity rates worldwide. The health consequences are increases in diabetes, stroke and heart disease.

Back in 1985, I watched the famous Live Aid concert to benefit the victims of starvation. 

Times have changed. 

The next such benefit concert, ObesityAid, will need to raise awareness and assistance for over-nutrition.

What Makes an Excellent Clinician?

What makes an excellent clinician, at least at an academic medical center? Explanations and theories abound. 

Here is an qualitative study on the above question published in Academic Medicine.

The  high performance of excellent clinicians is characterized by clinical skills, cognitive ability, people skills, engagement, and adaptability. These high achievers are driven by a core philosophy of high motivation, passion for patient care and are engaged in deliberate activities resulting in reflective clinical practice and scholarship.

Patient care, reflection, reading and writing. This is time consuming and there are no short cuts.

Nostalgic Professionalism- Be Gone!

The concept of professionalism is changing in medicine, particularly in the era of duty hour restrictions. Here is a viewpoint on professionalism recently published in JAMA.

Marcus Welby, MD: Nostalgic Professional

The implementation of duty hour restrictions for physicians in training has raised the concern about a potential erosion in professionalism. Old school physicians (old school includes me and is defined by anyone who was trained prior to duty hour restrictions) cling on to the now 'antiquated' notion of 'nostalgic professionalism.' This form of professionalism is defined as consistently placing the patient's needs or the profession's needs above one's own personal needs. 

These values conflict with the current model of training. The newly proposed model of professionalism emphasizes the recognition of physician limits as humans, emphasizing the importance of physicians' health and alertness. I have certainly heard much about 'work-life balance' from residents and students at the university hospital where I work. When one is in training, there really is no substitute for direct patient care. Learning the practice and art of medicine requires long hours.

The solution? Per the authors, the new professionalism paradigm would be best served by a residency training system that fully adopted a team based model of patient care, one in which patient ownership was not delegated to a single resident/physician, but shared among a group of team members.

I am not necessarily opposed to the new paradigm of professionalism. However, I am not fully sold on the concept either. My concern is that, across a team, not all team members will really know the patient in full. I find it difficult to comprehend how a team will truly understand a patient, as an individual physician does through a history, a physical examination and careful reading of the patient's disease and personal narrative. That is how the doctor-patient relationship is built, enriched and sustained.

If we rely on the new paradigm of professionalism, one grounded in the 'team-patient' relationship, we may fall short of our goals of genuine patient ownership and responsibility. 

Those close to me know that I am not a conservative guy, but on this point, call me old fashioned.

Killer Bugs- We Need New Antibiotics

Killer Bugss- Source NY Times

Although it may ring a bit alarmist, this article,  published in the New York Times, is worth a read. 

Although we have learned much about infection prevention over the last several decades, difficult to treat, or multi-drug resistant organisms exist.

Now, more than ever, we need novel antibiotics.

8th Annual RCFC Copa Navidad- Benefitting the Fan Free Clinic

It is December 9th and time for the Richmond City FC Copa Navidad.  The charity match was held to benefit the Fan Free Clinic.

Once again, we partook in an epic clash of the Richmond City FC Blues vs the Richmond City FC Maroons. The most historic comeback in Copa Navidad history unfolded as the Maroons edged the Blues 10-9 in the waning minutes of the match. Thankfully, there were no bruised egos.  

A special thank you is in order to Tim Krout and SCOR-Sports Center of Richmond for generously donating the use of the indoor soccer field and to Scott Zawadzki, the CVSRA referee who lent his officiating services pro bono to the event.

Happy Holidays.

RCFC Blues

RCFC Maroons

RCFC at the Copa Navidad

RCFC: 40 +....the old guys

The Photographer- Doctors Without Borders/Médecins Sans Frontières (MSF)

For those of you interested in medical relief work, here is a fascinating book titled The Photographer. 

This highly creative, graphic and pictorial book chronicles the covert medical mission of Doctors Without Borders/Médecins Sans Frontières (MSF) into war torn Afghanistan of the 1980s.

What unfolds throughout the book's pages is a glimpse of  rugged, back country medicine, in its grittiest and most elemental form, with a true human focus.  Well worth the read.

I highly recommend it. 

Syphilis, Sex, Drugs and the Internet

Source: UMKC.com

The incidence of syphilis is on the rise, particularly in men who have sex with men (MSM).  I am seeing this far too frequently in the HIV clinic.

Here is an article published in the American Journal of Public Health on the dangerous mix of drugs, in particular methamphetamies, and the use of the internet to meet sexual partners in a cohort of MSM with syphilis.

Using multivariable analysis, methamphetamine use and searching for sexual partners on the internet was significantly associated with an increased number of sexual encounters. Not unexpected.

This underscores the need for comprehensive sexual education, as reviewed here in Sexuality Research and Social Policy. Common sense interventions such as sexual education and the promotion of condom use can have positive public health benefits.  

Hospital Privacy Curtains: Vectors of Contagion?

Well it has been an exceedingly busy week in the hospital on the infectious diseases consult service, keeping me away from many things, including blogging and reading.

Here is an article from the American Journal of Infection Control that caught my eye this morning. Neither the methodology nor the outcome is anything novel. Regardless, the results are worth mentioning.

In the above study, 92% of privacy curtains sampled during the study showed contamination. Forty-one of 43 curtains (95%) demonstrated contamination on at least 1 occasion, including 21% with MRSA and 42% with VRE. Eight curtains yielded VRE at multiple time points: 3 with persistence of a single pulse field gel isolate type and 5 with different types, suggesting frequent recontamination.

Here is a CBS News article related to hospital curtain bacterial contamination study mentioned above.

Privacy curtains between patients in rooms, like much of the hospital's inanimate environment, are teeming with potential pathogens. The relative contribution of curtains to the development of hospital acquired infection is not known.

Perhaps newer technologies, such as antimicrobial textiles, may help limit the bioburden on hospital curtains. Hand hygiene immediately prior to touching a patient is likely of greater benefit.

Wash those hands.

Moth Flies in the Hospital and Pesky Pathogens

Moth fly- a vector for pesky pathogens

Flies in healthcare settings are general markers of uncleanliness.

Here is an article published in the Journal of Hospital Infection on the Mediterranean moth fly (Clogmia albipunctata) in German hospitals. 

Many bacteria were isolated from these moth flies including Acinetobacter baumannii, Aeromonas hydrophila, Alcaligenes faecalis, Bacillus cereus, Escherichia coli, Klebsiella pneumoniae ssp. pneumoniae, Pseudomonas aeruginosa,P. fluorescens and Stenotrophomonas maltophilia.

Moth flies are potential vectors of hospital acquired pathogens. 

If your hospital has moth flies, be concerned. 

Zero Infections in Healthcare- Revisited

I spent much of the weekend updating a lecture of infection prevention. The theme of 'zero' healthcare infections is one of the themes covered in the lecture.

Can all healthcare associated infections be prevented? This is a controversial subject and the current data suggest that the goal of zero infections is illusory. Here is a an important paper published in Infection Control and Hospital Epidemiology on estimating the proportion of healthcare associated infections that are reasonably preventable. As many as 65%-70% of cases of CABSI and CAUTI and 55% of cases of VAP and SSI may be preventable with current evidence-based strategies.

In my opinion the state of infection prevention science is not robust enough to prevent all infections. The goal should be to fully and consistently implement evidence based infection prevention best practices to maximally reduce infection risk. 

For a scholarly perspective on 'Getting to Zero,' I refer you to this publication by my friend and colleague Dr. Michael Edmond.

Hospital Bed Alarms- What is the Benefit?

There is much discussion in my line of work on improving patient safety, particularly related to hospital acquired infections. But patient safety is not limited to infectious diseases.

Patient falls are a major safety issue and hospitals are required to implement and evaluate a falls reduction program for ongoing accreditation by the Joint Commission. Decreased patient falls are associated with hospital Magnet status and quality of nursing.

It seems like we are always searching for new technologies to enhance patient safety in healthcare. One such related technology are bed alarms.

Are bed alarms useful for the actual prevention of patient falls? Here is a single center, cluster-randomized trial on the effectiveness of bed alarms on patient falls published in the Annals of Internal Medicine.  Although the intervention was successful in increasing the use of bed alarms, there was no significant impact on fall-related events or the use of patient restraints.

This paper may serve as a warning on technology over reliance and reminds us that minimizing patient fall risk is multifactorial, requiring a coordinated effort, as outlined here by the Veterans Affairs National Center for Patient Safety.  

No one said it would be easy.

UN Global Aids Report 2012

World AIDS Day 2012 is around the corner so please pay attention to the related events in your area.

Source: UNAIDS.org

Here is a link to the the UN AIDS Global AIDS report 2012.

Here are my comments at the VCU School of Medicine 2009 World AIDS Day Luncheon-Lecture.

Isolation of HIV Positive Inmates: Not based on Science

Source: CBSnews.com

The Alabama Department of Corrections has a policy to isolate all HIV positive prisoners. HIV positive inmates are housed in special dorms with air conditioning and a private cell. However, there are restrictions. Inmates eat alone, not in the cafeteria and must  wear white plastic armbands identifying them as H.I.V. positive. Also, inmates are not allowed to work around food. Read about it here in this NY Times Article.

I suspect  that any infectious diseases specialist will tell you that this isolation policy of HIV positive inmates is misguided. HIV is not spread by casual contact or by airborne transmission. Prison officials fear that HIV will spread through consensual sex, through rape or through blood when inmates give one another tattoos.

For a data driven approach to limit the spread of HIV, either in prison or elsewhere, diagnose the disease early by offering voluntary, accessible testing and treat to prevent disease transmission and disease progression.

Going Truly Organic: Unpasteurized Milk and Infectious Diseases

Source: CDC.gov

Like many, I prefer the organic foods section of the grocery store, however, I do have my limits. 

Here is an interesting article, published in Clinical Infectious Diseases, that reminds us of the perils of consuming unpasteurized, straight from the farm, organic milk.  In this case, an outbreak of Q fever was reported from a Michigan dairy.

Raw milk consumption has increased in popularity with many people purchasing milk directly collected from a dairy milking parlor. Although direct purchase of raw milk is illegal, purchase through a cow share arrangement is not. Such dairies are not inspected by regulatory authorities and are not expected to meet minimum safety standards.

Consuming raw, unpasteurized milk is associated with infectious diseases health risks. But, don't just take my word for it, read about it here from the CDC.

Congratulations Jackie Arquiette: American Society of Tropical Medicine and Hygiene Annual Meeting 2012

Jackie Arquiette at ASTMH 2012

Congratulations to VCU 2nd year medical student Jackie Arquiette for presenting her work at the American Society of Tropical Medicine and Hygiene Annual Meeting  on November 14, 2012. 

Jackie's  work focused on measuring clinical and microbiological efficacy of water filtration systems in rural, mountainous Honduras. 

Her research is referenced in our most recent Internal Medicine Grand Rounds presentation.

Kudos!

Congratulations Audrey Le: American Society of Tropical Medicine and Hygiene Annual Meeting 2012

Audrey Le at ASTMH 2012

Congratulations to VCU 2nd year medical student Audrey Le for presenting her work at American Society of Tropical Medicine and Hygiene Annual Meeting  on November 12, 2012. 

Audrey's work focused on indoor air pollution in rural Honduran homes, as part of our ongoing medical relief work. Her research is referenced in our most recent Internal Medicine Grand Rounds presentation.

Kudos!

Eyeglasses for the Developing World- A Vision for the Future

The developing world is full of health problems. One of the many is the lack of prescription eyeglasses. Last year we took 170 pairs of glasses to Honduras on our medical relief trip. They were a hot commodity.

How could prescription glasses be delivered to millions of people in resource poor countries in a cheap and simple fashion? Below is an informative TED video on the subject brought to my attention by a colleague at VCU Medical Center.

Could we do the same for water filters? Specifically, could we teach the campesinos targeted by our yearly medical relief trips to make and maintain their own clay water filters for enhanced water sanitation? This is worth exploring.

To learn more about our ongoing clinical work, public health projects and research in Honduras, visit the the GH2DP website or peruse the slides from our latest presentation, at VCU Internal Medicine Grand Rounds.

Asymptomatic Bacteriuria in Young Women with Recurrent Urinary Tract Infections: Is treatment Necessary

Here is an article that I will discuss with our infectious diseases trainees later in the week.The clinical question is as follows: in young women with recurrent urinary tract infections, should asymptomatic bacteriuria (bacterial colonization of the urine) be treated?

The investigators used a prospective, non-blinded,  randomized  methodology to compare treatment to no-treatment of asymptomatic bacteriuria in a total of 637 women. 

The result? At the last follow-up, 41 (13.1%) in the no treatment group and 169 (46.8%) in treatment group showed showed symptomatic urinary tract infection recurrence (RR, 3.17; 95% CI, 2.55-3.90; P < .0001).

The message: don't treat urinary colonization with bacteria, only treat active infections! 

The indiscriminate use of antibiotics leads to selection of resistant pathogens and likely alters the normal colonic and vaginal flora. The intestinal and vaginal bacteria are important defense mechanisms against invasion of the urinary tract by E.coli.

Fluoroquinolones and the Risk of Cardiac Arrythmia

Fluoroquinolones have been suspected to cause cardiac arrhythmia. I was intrigued by this article that assessed the risk of serious arrhythmia, defined as ventricular arrhythmia or sudden/unattended death related to fluoroquinolones.

The investigators used a cohort of patients treated for respiratory conditions from 1990 to 2005. A nested case-control analysis was performed within this cohort. Cases were matched with up to 20 controls. Conditional logistic regression was used to compute adjusted rate ratios (RRs) of serious arrhythmia associated with fluoroquinolone use.

Of the 605,127 subjects, 1838 cases of arrythmia were identified (incidence = 4.7/10 000 person-years). The rate of serious arrhythmia was elevated with fluoroquinolone use (RR = 1.76; 95% confidence interval [CI], 1.19-2.59), in particular with new current use (RR = 2.23; 95% CI, 1.31-3.80). 

Gatifloxacin use was associated with the highest rate (RR = 7.38; 95% CI, 2.30-23.70); moxifloxacin and ciprofloxacin were also associated with elevated rates of serious arrhythmia(RR = 3.30; 95% CI, 1.47-7.37 and RR = 2.15; 95% CI, 1.34-3.46, respectively).

I have yet to see a case of cardiac arrythmia attributed to a fluroquinolone antibiotic and these are used quite frequently. The risk is very small yet real. Nevertheless, the above study serves to remind us that antibiotics should not be used indiscriminately as there is potential for serious harm.

Like the scalpel, the prescription pad can be lethal if used inappropriately.

VCU Global Health in Rural Honduras: A 7 Year Journey

Today Dr. Stevens and I presented our 7 year Honduras journey at VCU Internal Medicine Grand Rounds.

The lecture, in PDF format, can now be found here.

Disparity in Infection Control Practices for Multi-Drug Resistant Gram Negative Rods

The application of contact isolation precautions can be disparate. Here is a previous blog related to contact isolation uncertainties. 

Today I came across this manuscript reporting on the disparities in infection control practice for the control of multi-drug drug resistant gram negative rods (extended-spectrum β-lactamase-producing Enterobacteriaceae [ESBL-E] and carbapenem-resistant Enterobacteriaceae [CRE]).  The study was a survey based across 15 hospitals in Toronto, Canada. There was wide variation in the use infection control practices including admission screening (53% and 53%), contact precautions (53% and 100%), and isolation (60% and 100%) for ESBL-E and CRE, respectively. For  the hospitals performing admission screening, 75% used risk factor-based screening for ESBL-E and CRE.

Why? Most likely because high quality data and consensus guidelines are lacking on how best to detect and isolate patients colonized or infected with these pathogens. In addition, effective decolonization methods and evidence based protocols for discontinuing isolation are still undefined.

For our recent perspective on contact precautions, click here. 

It is November 6 and the polls just opened. I am walking out to vote. Who will get my presidential vote? You will just have to guess.

Orthorexia nervosa

I am treading well beyond my area of medical expertise today, hence, I will be brief. This morning I came across an article on orthorexia nervosa in an Argentine newspaper.

There are people overly concerned about having a perfect diet, resulting in a maniacal obsession for healthy foods, as summarized here in the journal of Eating and Weight Disorders. I also came across this article, published in Appetite, on the prevalence of orthorexia nervosa in resident physicians in a Turkish hospital. The prevalence seemed disturbingly high.

It is clear from my brief search of PubMed that orthorexia is a relatively new diagnosis with a small corresponding body of medical literature. The adverse health consequences of orthorexia have yet to be fully detailed in the peer reviewed literature. 

Regardless, when seeking healthy foods becomes an overwhelming drive with obsessive-compulsive components, it is time to seek help.

Racial Disparities in HIV Infection in the USA

Here is a recent article that speaks volumes and accurately reflects my day to day observations in the HIV clinic. There is a growing disparity in the rate of HIV/AIDS diagnoses in young men, particularly young, black men ages 15-24. 

This is a sad and disturbing trend, particularly as risk reduction interventions, HIV testing and treatment are all more accessible than ever.

Our ongoing efforts to reduce the incidence and burden of HIV must be focused and prioritized for this high risk group.

Scrutinizing Short Term Medical Relief Trips- Ethical Considerations

I have been preparing a summary presentation of our ongoing Honduras medical relief program with my colleague  Dr. Michael Stevens. This program is under the auspices of the VCU Global Health and Health Disparities Program.

The ethical aspects of medical relief work have particularly interested us. These concerns are concisely summarized in the following paper, published by the Hastings Center.

•Who really benefits? Is it the recipients or the participants?

  Do these relief trips simply serve to make us feel better about ourselves?

•Has the community been involved in the planning?

•Is the program culturally sensitive?

•Is the program sustainable and will it truly benefit the recipients?

•Are lasting collaborations in place?

•Is there a risk for harm?

The above issues have driven us to collaborate with community leaders and the local Ministry of Health to develop a sustainable clinical/public health program in a rural and mountainous area of Honduras. 

For last year's mission detail and for an informative interview with a collaborator, click here.

The Peer Review Process: Assessment of Quality and What Makes a Good Journal Reviewer?

Peer Review
Source: columbia.edu

Academics pride themselves in the peer review process but what measures exist to assess its quality?

Here is a study published in the American Journal of Infection Control that attempts to tackle the above question.The study utilized 2 online surveys, one for authors (n = 102) and one for Editorial Board members (n = 20) to assess their perspectives on the quality and timeliness of peer review. 

Authors of accepted manuscripts were significantly more likely to rate the review as the same or better than other peer reviews they had received when compared with authors of rejected manuscripts (93.3% vs 47.4%, respectively, P = .001).Board members were significantly more likely to rate reviewers as fair and unbiased (91.4% and 70%, respectively, P = .04). 

But what make a good reviewer? Well the data are sparse.Here is a perspective (free, fulltext) in JAMA on the assessment of a good journal reviewer. Surveys of reviewers of 420 manuscripts were completed by journal editors and authors.  Using logistic regression analysis, the only significant factor associated with higher-quality ratings by both editors and authors was reviewers trained in epidemiology or statistics and younger age (40-60 yrs).

I review a fair number of manuscripts, am trained in epidemiology and am young (between 40-60). Let's hope that the quality of my journal reviews do not disappoint.