Olympic Crowds and Germs

Bio.Diaspora- Source Toronto Star

For Olympic goers, in addition to witnessing competition and national pride, one can run the risk of contagion. Here is an informative read in the Toronto Star, featuring my friend and colleague Dr. Kamran Khan.

Mass gatherings, particularly of populations from all points of the compass, can serve as epicenters for infectious diseases. An outbreak is only a plane flight away. The spread of infectious diseases can be tracked by way of the sale of airline tickets, epidemiologic data, biostatistics, geographic information systems, cartography, and mathematical modelling. Bio.Diaspora studies the spread of infectious diseases via travelers. 

I am currently in the Southern Cone of the world, in Cordoba, Argentina. Although far away from the Olympic Games, I am in the middle of winter, with cold temperatures and heightened influenza activity. Let's hope my Flu vaccine is protective.

Honduras Research 2012: Jaclyn Arquiette and Audrey Le

As I am in Argentina at the moment I was forced to experience the success of our VCU MIDPH and Honduras Research team vicariously. 

Jaclyn Arquiette

Congratulations to our two stellar medical students, Jaclyn Arquiette and Audrey Le. 

Both were standout Honduras 2012 medical team members, researchers and now, scholars. 

Ms. Arquiette studied the efficacy of our water filtration systems in La Hicaca and environs while Ms. Le surveyed the perceived impact of indoor air pollution in Honduran homes.

Audrey Le

Both demonstrated exceptional initiative, drive and organizational skills to complete the projects from start to finish in a relatively short time frame. 

Today each formally presented their work at Virginia Commonwealth University. 

Both have prepared abstracts, to be submitted for the American Society of Tropical Medicine and Hygiene 2012 annual meeting. 

For a day by day synopsis of the 2012 medical and research mission, including the works of Ms. Arquiette and Le, click here.

Dr.Michael Stevens and Audrey Le

Each is working on their respective manuscripts, to be submitted for publication later in the year.

Stay tuned.

Dr. Michael Stevens and Jaclyn Arquiette

HIV Testing Beyond the Clinic

HIV Testing at the DVV. Source- NY Times

About 30-40% of HIV infected people in the USA are unaware of their HIV positive status. This amount to roughly 250,000 infected individuals. This has public health implications as infected individuals will unknowingly transmit the virus to others.


Washington DC is a taking a novel approach to diagnosing HIV infection by making HIV testing accessible in unconventional settings such as grocery stores, street corners and even motor vehicle offices. Contact notification of partners of newly diagnosed HIV cases is being employed to heighten the diagnostic effort. Needle exchange programs for heroin users have also been implemented  with infections attributed to dirty needles reportedly plunging by 72 percent. With early diagnosis comes treatment and treatment is prevention.


This is sound public health policy.

Physical Inactivity- Impact on Global Health

Source: CDC.gov

The Lancet has a dedicated special issue to physical activity, just out and just in time for the Olympics. Being physically inactive is a major health burden on morbidity and mortality, as summarized here.


The impact of physical inactivity on global health is substantial. Based on this recent review, physical inactivity causes 6% (ranging from 3·2% in southeast Asia to 7·8% in the eastern Mediterranean region) of the burden of disease from coronary heart disease, 7% (3·9—9·6) of type 2 diabetes, 10% (5·6—14·1) of breast cancer, and 10% (5·7—13·8) of colon cancer. 
In addition, physical inactivity causes 9% (range 5·1—12·5) of premature mortality resulting in approximately 5·3 million of the 57 million deaths that occurred worldwide in 2008. If inactivity decreased by 10%- 25%,  between 533 000 and 1·3 million deaths could be averted every year. 


Check out physical activity for everyone. I am off for my morning jog now.

Truvada for the Prevention of HIV- Now FDA Approved

Many of you are likely aware that Truvada was FDA approved earlier this week for the prevention of HIV in high risk populations (men who have sex with men).


I wrote about this before, with focus on the iPrEx study that led to FDA approval.


On July 18, 2012, I was interviewed by WRIC 8 for a television news story about the new indication.The video can be seen here.

Occupational Exposures of Blood and Body Fluids by Healthcare Workers- Are They Reported?

Here is an important article in the Journal of Hospital infection on HCW reporting of blood and body fluid exposures. The major concern is exposure to potentially infectious body fluids with HIV and Hepatitis B and C viruses. The article highlights that only 58% of respondents (N=120) from a UK Dental Institute reported their needlestick injuries. Respondents felt that an electronic reporting system would facilitate reporting of injuries.


Surgeons in training are at particular risk for needlestick injuries and these frequently go unreported, as documented here (full -text) in the New England Journal of Medicine. The overall response rate was 95% (N=699) from 17 medical centers.  By the final year of training, 99% of residents had experienced a needlestick injury, for 53%, the injury involved a high risk patient. As many as 51% of all needlesticks were not reported to employee health. Most respondents cited "It takes too much time" as a reason for not reporting a needlestick injury. If the needlestick injury was witnessed by another person, such as a supervising surgeon, then the event was more likely reported. 


Safety in healthcare is not limited to patients. Systems must be in place to most best safety practices in the OR. This include systems based strategies, as recommended by the American College of Surgeons, that function to minimize percutaneous injury risk, such as the use of double gloves, blunt tip suture needles and hands free zones for the passing of sharp instruments.


Needlestick injuries can be a real threat. Despite excellent antiretrovirals to prevent infection with HIV, a failure of HIV postexposure prophylaxis was recently reported. Infection with HIV, Hepatitis B or Hepatitis C can be a career ending event, particularly for a surgeon, as infected healthcare workers with detectable serum viral loads are not allowed to perform invasive procedures. 


This needs to be taken seriously. Reporting of needlestick injuries must be vigorously encouraged and be made nearly effortless so that prompt post-exposure management is initiated. 

Big Pharma- Betrayal of Trust

Not too long ago I blogged about dodgy antimalarials as a public health risk. Here is a disturbing news report published in The Guardian about GlaxoSmithKline (GSK) pharmaceuticals. 


GSK was recently reprimanded for the promotion of anti-depressants for unapproved indications, concealing critical safety evidence from the FDA and offering lavish entertainment and incentives to doctors for endorsing their products. They were hit with a $3 billion fine, which in light of their massive profits, really will have little impact on their bottom line. 


This is Big Pharma at its worst.This is a betrayal of the public's trust in medicine and science.

Invasive Streptococcus- a Lethal Pathogen

Here is an New York Times newspaper article on the virulence and danger of invasive streptococcal disease. The newspaper article features a quote from VCU's own Dr. Michael Edmond.


The story is a strong reminder of the difficulty in making an early diagnosis as the clinical findings may be subtle. Sadly, as chronicled in the article, a delay in diagnosis and treatment can be fatal.

The Coffin-Maker as an HIV Benchmark

Source: NY Times

For those of you interested in the HIV epidemic, here is a good read in the Sunday New York Times. Improvements in HIV care and expanded access to retrovirals, particularly in resource poor settings, are having an adverse effect on the business of coffin-makers. This is a good thing.


Thanks to programs such as Pepfar, deaths from HIV/AIDS are decreasing significantly in Africa.


This is US Foreign aid put to excellent use. 

Vitamin D and Hospital Acquired Infections

I read an intriguing paper (full text online) on the vitamin D and its potential role in preventing hospital acquired infections.

The authors believe that vitamin D supplementation in vitamin D deficient, hospitalized patients could improve health outcomes. Vitamin D is inexpensive and supplementation is generally safe. They cite numerous publications on the immunomodulatory effects of vitamin D and its potential impact on both bacterial and viral infections. The paper references various associations (not causation) between low vitamin D levels and healthcare associated infections including pneumonia,Clostridium difficile and surgical site infections. 


Compelling, however, before we launch into mass vitamin D screening and supplementation of hospitalized patients, further data is needed to define target vitamin D levels for maximal immunologic benefit and optimal repletion strategies. Last, prospective clinical studies are needed to definitively confirm the infection prevention benefit of vitamin D. Until then, vitamin D supplementation to reduce the risk of hospital-acquired infections will likely not be the standard of care.  

At-Home HIV Tests- Likely a Good Thing

Source: NY Times

Last week the FDA approved an at-home HIV test, OraQuick. An informative read on the matter is found in the New York Times. The test is highly sensitive and positive results must be confirmed in a medical office.

As an infectious diseases specialist, I fully support at-home HIV testing. Alarmists have predicted a wave of suicides if home tests are made available. I think that these concerns may now be unfounded. Although there is still a stigma associated with HIV,  the disease can now be managed very well and is no longer a death sentence. 

Timely diagnosis is urgently needed. Diagnosis is treatment and treatment is prevention.

Clinical and Diagnostic Reasoning of Senior Medical Students

The public trusts the medical education system to graduate clinically competent physicians. The clinical reasoning skills of medical students are not systematically and uniformly examined during the clinical years of training. Traditional assessments such as ward evaluations, written examinations and even simulated patient encounters (using patient-actors) do not robustly measure clinical reasoning and diagnostic skills.  This was quite evident to me after nearly 7 years in charge of medical student training in internal medicine at the Virginia Commonwealth University School of Medicine.

Here is an article published in Academic Medicine exploring the diagnostic justification (DXJ) abilities (clinical reasoning) of senior medical students. All senior medical students in the classes of 2011 (n = 67) and 2012 (n = 70) at a Midwestern university were required to take and pass a 14-case, standardized patient examination prior to graduation. For nine cases, students were required to write a free-text response indicating how they used patient data to move from their differential to their final diagnosis. The DXJ scores were compared with traditional standardized patient examination (SCCX) scores.

Although using SCCX and DXJ scores led to the same pass-fail decision in the majority of cases, discrepancies occurred.  In discrepant cases, students would fail using the DXJ score but pass using the SCCX score, suggesting that deficiencies in diagnostic reasoning may go unnoticed. 

We are exploring the use of simulated technologies to simultaneously assess patient care and clinical management skills in a standardized, uniform fashion.  We are using newer simulation tools, e.g. high-fidelity mannequins (iSTAN), for the assessment of student diagnostic and management skills in real time based on response to changes in mannequin-patient clinical signs, data, and pathophysiologic state. Think of it as a flight simulator for medical trainees.

Stay tuned.

Medicare and Medical Education- Open Your Eyes

Every now and then I hear a medical resident grumble about government intrusion into medicine. To me, this is much a like a 'keep your government hands off my medicare' moment. 


Here is a letter published in Academic Medicine underscoring the importance of knowing that all ACGME clinical residency training programs are (and have been) funded by Medicare.  This important fact is frequently not known by residents (shocking) and by the public (not so shocking).


That is right. Medicare (i.e. the Federal Government) funds the training of doctors in the USA.  So, the next time you hear a doctor espouse outrage about government intrusion into health  care, keep in mind that his or her residency training was paid for by the US taxpayer.


Knowledge can be enlightening.