Friday, April 27, 2012

Sexual Education in US Secondary Schools- Eye Opening

Here is a report from the CDC on HIV, STD and pregnancy prevention in US secondary schools. As you you will note, sexual education varies considerably across states and is appallingly insufficient in some. 

Take a particular look at Table 3,  a state by state summary of condom related topics taught in grades 9-12. The numbers speak for themselves. 

As an infectious diseases physician who sees and treats many young people with sexually transmitted infections and newly acquired HIV infections, the reports above are deeply concerning.

Thursday, April 26, 2012

Periodontal Disease and Heart Disese

Here is a statement from the American Heart Association on the association between periodontal disease and coronary artery disease.

The mouth is teeming with bacteria and serious infections, such as endocarditis, are commonly from an odontogenic source.  The purported pathophysiology behind periodontal disease and coronary artery disease includes indirect mechanisms such as inflammation and mimicry and direct mechanisms such as bacterial invasion of atherosclerotic plaques.  

The data to date support an association between periodontal disease and heart disease independent of known confounders, they do not, however, support a causative relationship.Last, there is no convincing data to suggest that treatment of periodontal disease will impact, in the long term, cardiovascular disease.

Heart disease has also been associated with Chlaymydia pneumoniae and Helicobacter infections. Association does not mean causation and to date coronary artery disease is not treated with antibacterials.

Tuesday, April 24, 2012

Scientific Misconduct in Medicine: A Pox On Us!

Here are two disturbing reports published in the British Medical Journal about  the falsification of scientific data in medical research. One report is a survey of research misconduct among Dutch physicians while the other is on scientific misconduct in the UK.

I fortuitously came across the above reports after reading this thought provoking post by Eli Parencevich on the retraction rate of scientific articles, particularly in high impact journals.

The motives behinds scientific misconduct are multiple and include career advancement, recognition and the opportunity for larger, more prestigious grants. This is compounded by a peer-review process that is not sufficiently rigorous to uncover errors in methodology as described here in the Economist.

When the scientific method is corrupted by falsification, bias and conflict of interest, there is a betrayal of trust in science and medicine and a resultant compromise of the common good. 

Monday, April 23, 2012

Fecal Microbiota Transplantation- The Universal Donor

The blender- not just for smoothies! 
I spent much of the weekend updating a C.difficile lecture. I added new fecal microbiota transplantation references with particular emphasis on a paper reporting the use of a 'universal donor' for stool .

 A few points. Fecal transplantation is a reasonable and effective treatment for recurrent C.difficile colitis. The goal is to restore the normal microbiologic flora of the colon to prevent recurrences of C.difficile colitis. Here is a scholarly review on fecal bacteriotherapy for the treatment of recurrent C.difficile colitis.

Once stool donors are screened for HIV, Hepatitis B and C, donor stool can then be screened for pathogens such as salmonella, shigella, giardia, C.difficile, and cryptosporidium. A slurry is made with normal saline in a blender. The particles are removed via sieves and then concentrated via a centrifuge. The concentrated fecal solution can be administered  immediately  via nasogastric tube or by colonoscopy with enema, or, it can be frozen for future (transplantation) use.

We need to get past the yuck factor and make this therapy available for those who suffer from recurrent C.difficile colitis

Friday, April 20, 2012

SHEA Meeting and Evidence Based Infection Prevention Practice

Hand Hygiene. Source: World Health Organization
Here is a summary in Infection Control Today on evidence based infection prevention interventions advocated at the recent SHEA conference.

A couple of considerations. All infections are not preventable. Not all infection prevention interventions are easily implemented and not all are backed by high quality evidence.  Implementation takes administrative support, finances, trained infection preventionists and significant effort.

So where does a hospital infection prevention program start? The following list is worthy of universal application.
  • Improve hand hygiene among healthcare professionals
  • Use of appropriate isolation precautions for patients known to be colonized with dangerous or drug-resistant organisms like Clostridium difficile or MRSA
  • Ensure adequate cleaning of the environment and equipment
  • Remove catheters and other devices promptly
  • Educate healthcare professionals and patients

Wednesday, April 18, 2012

Care for the Patient, Not the Disease

Sir William Osler
The other day on the infectious diseases consult service I was reminded of the importance of understanding a patient's subjective experience of disease. 

After a patient with AIDS was admitted to the medical service with an acute gastrointestinal bleed, he repeatedly expressed his disapproval for the delay in receiving a medicated cream to treat his mild case of seborrheic dermatitisWhen I suggested that he should worry more about taking the HIV medications and addressing the current GI bleed, he put things in perspective for me. 

"Doc, I may be a bit vain about my face, but when I am broken out" he said in a low voice, "people be asking me if I have that disease (HIV)."

The biopsychosocial impact of illness is undeniable. In this instance, I had failed to recognize his fear of stigma from even a mild case of seborrhea. I was properly humbled.

To quote Sir William Osler: Care more particularly for the individual patient than for the special features of the disease (address to the students of Albany Medical College, 1899).

Monday, April 16, 2012

The New MCAT- Behavioral and Social Sciences

The new MCAT: more than just science
The Medical College Admission Test (MCAT) traditionally focuses on the biological and physical sciences but scientific knowledge and technical savvy do not always make a good doctor.

Effective 2015, the new MCAT will also test the social sciences by requiring students to analyze passages in areas such as ethics, humanism and cross-cultural studies. At hand is a multiple choice test that will theoretically screen for the right mix of a scientist, humanist and future doctor. 

Will it work? Maybe.

Here is an informative read on the matter, in the NY Times' Education Life magazine, and an argument in favor of the new MCAT published in the New England Journal of Medicine.

Friday, April 13, 2012

Beach Sand as a Health Hazard- Revisited

Paradise or public health hazard?
Here is a brief report on the potential health risks of beach sand in Infection Control Today.

In 2009, I did a radio interview with WRVA Newsradio 1140 AM on the findings related to this paper, published in the American Journal of Epidemiology. Digging in the sand and being being buried in the sand was associated with gastrointestinal illness and diarrhea. 

Beach sand can concentrate enteric pathogens. Be sure to wash your hands before putting your hands in your mouth or eating your picnic at the beach. 

Don't forget the sunblock either.

Wednesday, April 11, 2012

Can We Expect Patients to Question Health Care Workers’ Hand Hygiene Compliance?

Source: Daily Mail UK
Empowering patients to speak with their doctor about hand washing has been suggested as a potential means for improving hand hygiene compliance. Here is a brief study published in Infection Control and Hospital Epidemiology (apologies that there is no abstract).

During a 4 week study, an educational brochure on hand hygiene was given to patients and an interview prior to hospital discharge was performed.  Patients felt it proper to speak up and request that a physician or nurse wash their hands. Few patients, however were willing to do so. Only 43% of respondents claimed that they would ask a doctor to wash his hands while 67% would do so for nurses, especially if the nurse were both female and junior.

I feel that patients should be empowered to demand hand hygiene, however, this will not be sufficient. We should not put the burden of practice change on patients. That is our problem to tackle and enforce. With respect to patient temerity on asking the doctor to perform hand hygiene, perhaps there is some truth in the following: 

The doctor is often more to be feared than the disease.  ~French Proverb

Tuesday, April 10, 2012

Science and Yoga

Source: NY Times
Last weekend I plowed through The Science of Yoga by New York Times science writer, William J Broad. I do not practice yoga yet find myself intrigued by its purported health and fitness benefits.

Here is a comprehensive review of comparative medical studies on the health benefits of yoga.

Overall, the studies comparing the effects of yoga and exercise suggest that yoga may be as effective or better than exercise at improving a variety of health-related outcomes. These include heart rate variability, blood glucose, blood lipids, cortisol level, and oxidative stress. Yoga is inferior to regular aerobic exercise for aerobic fitness as measure by VO2 max.Yoga also appears to improve subjective measures of fatigue, pain, and sleep in both sick and well populations. 

This is all very encouraging, but as I learned, there are risks associated with yoga too, reports include musculoskeletal injuries, neck injuries and even strokes from thrombosis (clotting) of the vertebral arteries from neck contortions. To read how yoga can wreck your body, click here.

An additional caveat is that the practice of yoga, as a healing art, is not regulated like medicine, physical therapy and dentistry. No national standard exists for training, certification and licensing. Hence, guidance, supervision and quality of outcome and risk of injury can vary tremendously.

Monday, April 9, 2012

Bleach Baths- Revisited

Last week the issue of MRSA decolonization arose again.

Here is an informative video on the use of bleach baths for chronic skin conditions, including the treatment of staphylococcal colonization.

Here is medical paper on bleach baths recycled from a previous posting.

Back on the ID inpatient consult service today, back to the grind.

Friday, April 6, 2012

Household Staphylococcus aureus Decolonization- Effective or Not?

Community-associated Staphylococcus aureus continues to vex as a cause of skin and soft tissue infections. 

A study published in Clinical Infectious Diseases tackles the problem of patient  S. aureus decolonizationThe investigators compared 2 approaches to S. aureus eradication: decolonizing the entire household versus decolonizing the index case alone.

Among 126 cases completing 12-months of follow-up, S. aureus was eradicated from 54% of the index group versus 66% of the household group (P = .28). Over 12 months, recurrent skin and soft tissue infections (SSTI)  by index cases were self reported in 72% of cases in the index group and 52% in the household group (P = .02). Also, SSTI incidence in household contacts was significantly lower in the household versus index group during the first 6 months; this trend continued at 12 months.

Household decolonization was not more successful than individual decolonization in eradicating S. aureus from carriers. Decolonization of the households, however, resulted in fewer recurrent infection in both the index case and in household members.

This is an interesting study and the findings are by no means definitive. The infected cases were children, so this strategy may not apply fully to adults. Neverthless, for patients with recurrent staphylococcal skin infections, screening and decolonization of household members may be a reasonable next step.

Wednesday, April 4, 2012

Rapid Influenza Diagnostic Tests- Not So Accurate

So the flu season is nearly over in the Northern hemisphere. Regardless, this is still of relevance.

If one has a bad cold, and suspects influenza, I cannot argue with seeking medical advice. However, if one is subjected to a rapid influenza diagnostic test (RIDTs) on a nasopharyngeal sample, the result may not be accurate. 

This review and meta-anlaysis of 159 studies on RIDTs is revealing.  The pooled sensitivity and specificity for RIDTs were 62.3% (95% CI, 57.9% to 66.6%) and 98.2% (CI, 97.5% to 98.7%), respectively. In other words, a positive RIDT rules in influenza but a negative RIDT does not exclude the diagnosis. 

RIDTs are of variable utility. That is why we no longer use them in my hospital. The gold standard for influenza detection is viral culture or PCR, both are time consuming, taking at least 24 hours for a result.

The treatment of influenza, at least initially, remains largely a decision based on local influenza disease activity, patient risk factors and physician clinical acumen. 

Tuesday, April 3, 2012

Honduras 2011- Reunited on the VCU Internal Medicine Ward

The A Team- L to R: Baby Farfour, Hannah, Jean, Izabela and Mike

Today I received an email with photo from my colleague Dr. Michael Stevens. He reunited with our stellar nurses from the Honduras 2011 Medical team on the VCU Internal Medicine Floor. I must have missed the memo and hence the reunion, but no worries, I have the above photo to share.

The A team, joined by Hannah Farfour's newborn baby.

Stay tuned, VCU Honduras 2012 is around the corner.

Monday, April 2, 2012

Chocolate Consumption and Body Mass Index

Source: Reuters
Here is a a news report on the association with with frequency of chocolate consumption and Body Mass Index (BMI).

The manuscript, published in the Archives of Internal Medicine can be accessed here.

1017 subjects responded to the question "How many times a week do you consume chocolate?" Body mass index was determined for 972 subjects (95.6%), who had both weight and height recorded at the screening visit.

The mean age of the subjects was 57years and 68% were male. The average BMI was 28. Subjects ate chocolate a mean 2.0 times/wk and exercised 3.6 times/wk. Greater chocolate consumption frequency was linked to lower BMI, even after adjusting for confounders.

The findings of this study are interesting but by no means conclusive. Diet composition and calorie count influence BMI. The underlying hypothesis is that modest-frequent chocolate consumption might result in reduced fat deposition, likely offsetting the added calories. It is known that chocolate is rich in antioxidants which can modify metabolism and BMI in laboratory animals. Perhaps these mechanisms may exist in humans too.

I would not recommend consuming chocolate with reckless abandon. A prospective, randomized trial of chocolate consumption for metabolic benefits is needed in humans. If such a study is funded by the chocolate industry, and, if the results are favorable, be skeptical.