Friday, March 30, 2012

Dollars for Docs

Concerned about an ethical conflict of interest in a given doctor?  

Here is a website that tracks payments made to physicians by pharmaceutical companies.

Drug companies make payments to doctors and health professionals for the promotion of their drugs and products.The medical-industrial complex industrial complex can have a strong influence on medical practice. 

As always, there is a quid pro quo. Remember, there is No Free Lunch.

Wednesday, March 28, 2012

The Positive Effects of Double Gloving- Revisited

Here is a paper on double gloving in the OR, published in AORN.

Source: Infection Control Today
The primary reason to double glove is to limit the risk of percutaneous injuries to operator, thereby reducing the risk of transmission of blood borne pathogens such as HIV, Hepatitis B and C.

Double gloving or double gloving with an indicator glove system may provide greater protection to the surgeon. During a 24 month survey, the investigators utilized a  comparative design to examine the effect of double gloving with inner indicator gloves on the durability of inner gloves and the detection of glove tears or perforations during surgery. The study was conducted in 2 major medical centers and a shock-trauma center. Twenty one surgical specialties were included and 8,723 pairs of double gloves were analyzed

The detection of blood on the hand after surgery was greater with single gloving (75%) than with double gloving (75% vs 25%) and the frequency of changing gloves during surgery was significantly higher among those who double gloved with an indicator glove system (70%) versus double gloving alone (59%). The majority of health care providers studied expressed favorable views about double gloving

In brief, double gloving results in fewer blood exposures and results in early detection of a perforated outer glove if a colored, indicator underglove is donned.

Of course, these finding are not all that new, but, they do add to the body of literature in support of double gloving as a safety measure. 

So why isn't uptake universal? Some surgeons are skeptical about practice changes and some have a disregard for evidence based practice. However, across healthcare systems, there are active resistors and organizational constipators blocking infection prevention and safety efforts. This is likely at play too.

 The evidence is mounting. Time to hop on the safety-wagon.

Tuesday, March 27, 2012

Sexual Health: The Importance of Taking a Sexual History

Source: NYC Department of Health and Mental Hygiene
Today I am invited to give a lecture on the importance of taking a sexual history in the clinic. Sexually transmitted infections (STIs) are on the rise so the timing seems relevant. Click here for an excellent pictorial summary of STI rates from the CDC.

The benefits of taking a proper sexual history seem self evident. The purpose is to diagnose and treat sexual dysfunction AND STIs. Here is an informative full text review on the matter.

Many physicians do not delve into the sexual history as part of a patient encounter. Obstacles include inadequate training, lack of confidence, time pressure and perceived patient discomfort. I have always felt that a professional, non-judgmental, confidential, matter of fact discussion on sexual habits as a part of routine patient care facilitates the process. A certain way to make a patient uneasy is for the physician to appear uncomfortable while taking a sexual history. 

In addition, a discussion on sexual health serves to counsel and promote safe sex. Condom use cannot eliminate and prevent all STIs, however, the risk reduction can be significant (up to 90+%). The New York City Department of Health and Mental Hygiene has a novel and aggressive program for condom promotion. Learn about the NYC Condom by clicking on the corresponding hyperlink. 

Monday, March 26, 2012

Barefoot Running- Orthopedic Benefit?

Barefoot running has received increased attention and gained popularity. 

For those of you interested in an enjoyable and thought provoking read, I suggest Born to Run by Christopher McDougall.

A disclaimer: I am an infectious diseases physician and not an orthopedist or sports medicine specialist. 

After my perusal of the peer reviewed medical literature, there is reason to suggest that running barefoot can result in gait alteration, shorter strides, decreased impact and strengthening of the feet musculature(relieving stress on the arches). There is no credible, peer reviewed data confirming that barefoot running has actually resulted in fewer, orthopedic running injuries. High quality studies to address this last point apparently have not (yet) been done. 

For a thorough, scholarly and scientific review on the matter, I refer you to this paper in the Journal of the American Podiatric Association.

Well, I am off for my morning run now, with my feet still properly shod......

Thursday, March 22, 2012

Sudden Cardiac Death in Athletes

Well it is no secret to those that know me that I still have a boyhood obsession for football (soccer),  

I get a little nervy when a cardiac event occurring on the football pitch makes international headlines, raising the question about cardiac risks in athletes. Here is an article in the BBC on the case of a recent English Premier League footballer who collapsed during a match.

Fortunately, sudden death in young athletes is a rare event. Most deaths in young athletes are not secondary to conventional coronary artery disease. Genetic abnormalities, such as hypertrophic cardiomyopathy,  are usually associated with arrhythmias - irregular heart beats and sudden death. Having a genetic abnormality and playing a sport at a high level may increase the risk. These abnormalities may be difficult to detect, despite comprehensive testing.

For a more complete medical review on the matter, I defer you to this article, published in Current Opinion in Critical Care.

Tuesday, March 20, 2012

Backpack and Pain in the Back

I live down the street from a private school and regularly see young boys and girls carrying backpacks of gargantuan size. I don't recall having a backpack that big as a schoolboy.

Fortuitously, I came across this recent article in Archives of Disease in Children on my daily review of medical titles.

In an analysis of 1403 children,  61 % were carrying backpacks that exceeded 10% of their body weight. This was significantly associated with back pain but not back pathology. The long term effects of heavy backpacks is not known, however, I suspect that it is not significant.

Assuming that the packs are filled with books, perhaps as the use of i-Pads and e-readers proliferate, the heavy textbooks will take a digital format and lighten the load.

As for me, I will pass on the backpack, and opt for the over-the-shoulder 'man bag'.

Monday, March 19, 2012

Hepatitis C: On the Rise

Hepatitis C, a bloodborne viral infection which can lead to chronic liver disease, cirrhosis and liver cancer, has now surpassed HIV as a cause of death in the USA. An eye opening article, published in the Annals of Internal Medicine, can be found here.

Much like HIV, these findings call for a more comprehensive public health strategy that focuses on a) early detection (screening and testing) and b) treatment. This would take a coordinated healthcare system, which we do not have, and resources, which are in short supply. 

It is Monday, back to the grind.

Wednesday, March 14, 2012

Those Pesky Bedrails! Vectors of Contagion.

Bedrails and other hospital surfaces- vectors of contagion
We all know that the hospital environment is teeming with pathogens. Here is an article in the Journal of Hospital Infection that confirms the ease of hospital bedrail colonization. In a controlled, laboratory environment, bacterial transfer from fingertips to rail ranged from 38% to 64%. Transfer from rail to fingertip ranged from 22% to 38%. 

Of course, the prevention of hospital acquired infections requires diverse strategies, including hand hygiene, of which I refer you to this posting. Checklists, such as for central lines, are also important. Disinfection of the inanimate environment is vitally important too.

The relative contribution of healthcare worker hands, invasive devices, inanimate environment, antibiotic (mis)use and inherent patient characteristics (illnesses, colonization with drug resistant pathogens etc.)  to the acquisition of a healthcare associated infection remains unclear and debatable. 

This knowledge would be the equivalent of infection prevention enlightenment.

Tuesday, March 13, 2012

Reviews of Physicians on the Web- of Limited Use

Source: NY Times
The world wide web is meant to limit information asymmetry. There are reviews on nearly everything, especially consumer goods. Reviews on physician performance appear not to be so robust or helpful. Here is an informative article in the New York Times.

In my opinion, it is important for the healthcare system to have feedback. If this data is to be publicly reported, however, then some measures to ensure validity must be present. First, a few comments or responses from anonymous patients will clearly not represent a physicians practice and are thus potentially misleading. More importantly, patient reviews of their doctor are not coupled with patient outcomes in his/her practice. This a vital piece of missing information that is not likely to be available anytime soon. As a result, web-based reviews of physicians are of minimal value and utility in their current state.

This reinforces a personal belief of mine: healthcare is not a simple commodity. People do not 'consume' healthcare as they would a television or automobile.

Monday, March 12, 2012

Syphilis Abounds! Sexually Transmitted Infections in the USA

Just the other day I was called for a consult on a patient with a genital ulcer. The patient was admitted for an unrelated, elective surgery, however, an attentive surgeon noticed the abnormality and gave me a ring.The final diagnosis was primary syphilis. Not unusual. 

Syphilis abounds! Primary and Secondary Syphilis—Rates by State, United States and Outlying Areas, 2010

Source : CDC
I was reminded, however, about how unsuspecting people are of the ongoing dangers of sexually transmitted infections. HIV and other sexually transmitted infections such as syphilis, gonorrhea and chlamydia, are by no means a vestige of the past. Chlamydia and syphilis are on the rise.

For an informative pictorial summary of the major sexually transmitted infections in the USA click here.

PS: the abstinence only sexual education strategy does not appear to be working.

Friday, March 9, 2012

Organizational Culture and Infection Prevention

The other day, during the course of a lecture at VCU Medical Center, I explored the impact of organizational culture on infection prevention efforts. Organizational culture, or, the attitudes and customs defining the 'way things are done' in a given organization can have a tremendous impact, either positive or negative, on an infection prevention program.

Here is a paper recently published in the American Journal of Infection Control that explored the impact of organizational program on an MRSA control program. Not surprisingly, the authors identified 3 organizational culture elements, namely, 'feeling overwhelmed', 'staff engagement' and 'hospital leadership' as having significant impact on infection prevention knowledge, attitudes and self reported practices regarding MRSA prevention.

I have always felt that a key component of any infection prevention effort, apart from education, surveillance and staff 'buy in', is hospital leadership. Quite simply, if hospital leadership does not support and champion an initiative, and, if leadership does not demand accountability, then many initiatives are doomed for partial implementation and weak results.

Wednesday, March 7, 2012

Safety Checklists and the Brown M&Ms

On Thursday, March 8th, I will be giving Anesthesia Service Grand Rounds at VCU Medical Center. The topic, not surprisingly, will be infection prevention and safety in the operating room.

Part of the presentation will focus on the the importance of safety checklists. Now, many have heard of the central line checklist and of the surgical time out checklist, but did you ever imagine that David Lee Roth and Van Halen were champions for safety in the workplace?

Learn more about the "Brown M&Ms" checklist below.

Tuesday, March 6, 2012

Certification in Infection Control and Improved Outcomes

Certification- The Gold Stadard
Does certification in infection control result in improved outcomes?  A study published in the American Journal of Infection Control would suggest that it does.

The investigators utilized a  2010 survey of California infection control departments. One hundred eighty hospitals provided data (response rate, 54%). Targeted MRSA screening upon admission was reported by the majority of hospitals (87%). The majority of hospitals implemented contact precautions for confirmed drug resistant organisms and C difficile patients; presumptive isolation/contact precautions for patients with pending screens were less frequently implemented. Few infection control policies were associated with lower drug resistant organism rates. Hospitals with a certified infection control director had significantly lower rates of MRSA bloodstream infections (P < .05).
Certification should, in theory, result in higher standards and evidence based practice, with resultant improvements in outcomes. More studies, with larger cohorts, are needed to replicate and confirm the findings. 
More interesting, in my humble opinion, was that neither MRSA active screening nor participation in IHI (Institute for Healthcare Improvement) was uniformly effective in reducing MRSA across all statistical models reported. Intriguing.

Monday, March 5, 2012

The Best Part About Global Warming- Reduction in Influenza?

Sneezing and aerosolization of viral particles
Source: Guardian UK
Factors affecting the transmission of influenza viruses are multiple. Important considerations for viral transmission include particle size, distance, humidity and temperature. An excellent review on the topic, one that I referenced in a recent lecture, can be found here.

In Sunday's New York Times,  I came across this article on global warming, and its potential impact on influenza. With rising mean temperatures and warmer winters, an unexpected benefit may be at hand: a reduction in influenza. Viral transmission is less robust with warmer temperature.

I still recommend a flu vaccine, despite the mild winter.

Friday, March 2, 2012

Prescription Drug Abuse in Real Time

I am well out of my area of expertise now so I will be brief. 

I was home in my home office relaxing, surfing the internet, trying to avoid responsibility and watching television. Here is Dr. Drew Pinsky on Bill Maher's Real Time. His comments on prescription drug abuse were spot on.

Thursday, March 1, 2012

(Hand) Hygiene: A Look From Both Sides

Source: WHO
Although knowledge and implementation gaps exists, the body of evidence suggests that hygiene can have massive public health benefits. A comprehensive review from the The Lancet Infectious Diseases can be found here.

The impact of improved sanitation, potable water and handwashing is greatest in resource poor settings. Challenges exist for promoting hygiene as a large scale public health intervention. This would require both political will and preferential financial allocation. Further research is required to better define the outcomes and efficacy of hygiene interventions.

A nuanced perspective on hygiene, with a focus on hand hygiene in developed countries and modern hospitals, suggests that the law of diminishing returns may be at play.  Aggressive promotion of hand hygiene in modern hospitals is the norm, however, improvements in hand hygiene may not result in infection prevention salvation. Meticulous hand hygiene may impact many yet not all healthcare associated infections. Infection prevention in the hospital requires hand hygiene, proper antibiotic use, safety checklists and best practices 'bundles', proper sterilization and disinfection of instruments and surfaces along with adherence to isolation precautions. 

Here is a blog entry on the above paper by my colleague Dr. Michael Edmond.

Hand hygiene may not be the definitive infection control intervention but we are by no means ready to write it off.