Thursday, August 30, 2012

Why Don’t They Listen?- ID Consults and Recommendations

At times I am vexed after spending a fair amount of time on an infectious diseases consults only to have the recommendations either ignored or partially heeded by the primary team.

Here is an article (free full text) in Clinical Infectious Diseases on adherence to recommendations of infectious diseases consults.

The authors reviewed 465 consultations at 2 academic institutions. The overall adherence was 80%, with 85% adherence to crucial recommendations. Using multivariate analysis, adherence to ID recommendations was highest for therapeutic recommendations instead of diagnostic recommendations, when they related to a specific clinical question, and when recommendations were deemed crucial by the ID service. Not surprisingly,  adherence was greater if the primary service was medicine.

I have always felt that for a consult to be meaningful it must be focused, answer the clinical question(s) in a prioritized fashion, and, be succinct. In a busy hospital, no one has the time or inclination to read an overly verbose consult.

Brevity is key.

Wednesday, August 29, 2012

Final Day- 2012 Infectious Diseases Board Review Course

Today is the final day of the 2012 Infectious Diseases Board Review Course. 

Apart from (re)learning a lot, I had the pleasure of catching with with Drs. Johanna Brown and Kiren Mitruka, fellow infectious diseases trainees at Cornell University, 10 years ago!

The Blogger with Dr. Brown (L) and Dr. Mitruka (R)

It is hard to believe that 10 years have elapsed since our days of training together.

Tuesday, August 28, 2012

Pubic Lice- Infectious Diseases Factoid!

Source: Wikipedia
I am on day four of the 2012 Infectious Diseases Board review Course in Tyson's Corner, Virginia. This morning, the lectures covered sexually transmitted infections.

Today's interesting fact: one can get pubic lice in the eyebrows, particularly after oral sex.


Monday, August 27, 2012

Physician Specialty Re-Certification: Improvement in Patient Outcomes?

Zzzzzzzz.....sleeping at the ID Board Review Course
I am currently in Tyson's Corner, Virginia, at the 2012 Infectious Diseases Board Review course. I am due to re-certify in infectious diseases this October. The Board Review Course days are long with nearly 9 hours of lecture, a veritable test of attention span and mental fortitude.

The rational is that re-certification ensures an up-to-date physician. This is logical, but what is the evidence that re-certification results in better patient outcomes?

Here is a review exploring the association between specialty board certification and published in Academic Medicine

The bottom line: although it may be reasonable to require re-certification in specialty boards, there is no robust measure or association between (re)certification and improved patient outcomes.

Back to the books.

Friday, August 24, 2012

Noise Induced Hearing Loss at Rock Concerts

Scene of the crime: ringing in my ears after a Duran Duran concert
Portsmouth, Virginia, August 22, 2012
The other night I attended a rock concert. The next morning, while rounding on patients in the hospital, my ears were still ringing!

Here is an article in the Canadian Journal of Public Health on noise induced hearing loss in attendees of rock concerts. The survey respondents, concert goers at a Toronto rock and roll venue, reported tinnitus (ringing) and other hearing disturbances by 84.7% and 37.8%, respectively.

Okay, we had excellent seats and were only several rows from the stage, so it was worth it, but, I should have know better. I will carry ear plugs next time. 

Rock on!

Wednesday, August 22, 2012

Tropical Diseases Are Exclusively of Developing Countries: Think Again

Source: NY Times
Tropical diseases are associated with poverty and seen only in developing countries, or so the thinking goes. Here is contrary perspective written by Dr. Peter Hotez, the Dean of the National School of Tropical Medicine at Baylor College of Medicine.

Of note, tropical diseases disproportionately affect Americans living in poverty, and  thrive in the warm climate of the south. Contact with mosquitos and other insects, poor sanitation and lack of access to healthcare all heavily burden the poor.  

This is not exclusively a Third World phenomenon.

Monday, August 20, 2012

Communication of Risk to Patients: Context Matters

The internet can be tremendous resource and can minimize information asymmetry, particularly between doctor and patient. Unfortunately, there is a lot of medical misinformation out on the web as much of it is not subject to medical peer review and written by advocacy groups.  A challenge facing physicians is how to effectively communicate information and opinion about risk so that informed decision making between doctor and patient genuinely occurs.

Here is an article, on explaining risks to patients, that was brought to my attention by my colleague Dr. Michael Stevens. Two important points I would like to mention:

First, the authors suggest that using information about relative risk without reference to absolute risk should be avoided. Here is an example:
  • Treatment X can reduce the risk of Outcome Y by 50% (this is a relative risk reduction) when compared to no treatment. However the absolute risk (risk without treatment) of Outcome Y is 1 in 1,000,000.  Thus, the relative risk reduction with Treatment X is from 1 to 0.5 per 1,000,000.  The overall impact of the Treatment X is very small given the already very low risk of the Outcome Y. Framing the discussion exclusively in terms of relative risk reduction (50% in this example) is misleading.
Second, the authors suggest that visual representations of risk may be effective for informing patients. As an infectious diseases physician, I am vexed when patients refuse vaccination on the grounds that thimerosol (a mercury containing preservative) will cause them toxicity and harm. These fears abound despite no convincing evidence of harm caused by low doses of thimerosol in vaccines. So here is a visual aid for those who fear thimerosol, many of whom, however, eat fish because of presumed health benefits.

A picture is worth a thousand words.

Friday, August 17, 2012

Chlorhexidine for Infection Prevention- A Systematic Review

Washing with chlorinated lime solution
Here is a systematic review on the topical antiseptic Chlorhexinine, published in the Journal of Hospital Infection. 

Sixteen published studies and four conference abstracts were included int he systematic review. Nine studies reported the impact of CHG on incidence of central-line-associated bloodstream infection (CLABSI); the incidence rate ratio (IRR) was 0.43 [95% confidence interval (CI): 0.26–0.71]. Five studies assessed the impact of CHG washcloths on incidence of surgical site infection (SSI); the RR was 0.29 (95% CI: 0.17–0.49). Four studies reported the impact on vancomycin-resistant enterococci (VRE) colonization; the IRR was 0.43 (95% CI: 0.32–0.59). Three studies reported the impact on meticillin-resistant Staphylococcus aureus (MRSA) colonization rate; the IRR was 0.48 (95% CI: 0.24–0.95). No impact was seen on MRSA, VRE, or acinetobacter infection rates.

By no means is chlorhexidine an in infection control panacea. However, if used regularly as an infection prevention measure for patient surgical/procedure skin preparation, patient bathing and for healthcare worker hand preparation, the impact infection is beneficial. Specifically,  non-rinse CHG application significantly reduces the risk of hospital (central line) associated bloodstream infection, surgical site infections and and colonization with VRE or MRSA.

Chlorhexidine certainly is an advancement over the antiseptic of the 19th century, chlorinated lime solution.

Thursday, August 16, 2012

Audience Response Systems in Lecture- What is the Benefit?
Today (8/15/12) I gave a lecture to the new, 1st year class of medical students at the Virginia Commonwealth University. The topic was measures of disease frequency in the M1 Population Medicine course.

No doubt, the students were all attentive and eager to learn. The students are only in their 1st week of medical school so what else could I expect? Regardless, I employed an audience response system (ARS), to enhance student participation. Is there any evidence that this improves the educational experience?

By engaging students in class, one study demonstrated that ARS can increase student awareness of knowledge relevant to their peers. Another publication suggested that ARS improved student performance on case based discussions. Last, a prospective, randomized controlled trial that included 17 obstetrics and gynecology residents suggested that ARS had a positive impact on knowledge retention. Residents who received ARS interactive lectures demonstrated a 21% improvement between pretest and posttest scores; residents who received the standard lecture demonstrated a 2% improvement (P = .018).

Although not a huge body of literature, the data suggests that ARS can positively impact the educational experience. The optimal balance of ARS, traditional lecture, and small group discussion has not been defined. The impact of an ARS based curriculum on pre-clinical medical student Step 1 USMLE score is also unknown.

At the very least, an interactive lecture format should stave off boredom and sleeping in class.

Tuesday, August 14, 2012

The Nocebo Effect

Many are aware of the placebo effect, but what about the nocebo effect? When notifying patients about the potential side effects of a medication or treatment, the risk of actually experiencing those side effects can increase. Here is an article on the nocebo effect published in the NY Times Sunday Review.

A medical review article recently published on the nocebo effect can be found here.

What is a medical practitioner to do? Not informing a patient of potential side effects is an ethical dilemma.

The answer may lie in communication, with a focus on tolerability. In this sense, information about the frequency of adverse events can be formulated positively ('the great majority of patients tolerate this treatment very well'). An example of 'positive framing' of potential side effects resulting in increased tolerability of influenza vaccination can be found here.

The words matter.

Monday, August 13, 2012

Medicine and the Cheesecake Factory- An Evolving Model of Medical Care?

Source: The New Yorker
Healthcare is an incredibly complicated system with many moving parts. Coordination of care is increasingly more challenging.

Physician practice has traditionally allowed for near complete autonomy. The result? Significant variation in practice and little standardization of care. This can result in costly care with a high risk of error and adverse events.When clinical pathways, safety checklists or other standardized practices are suggested, there is frequent push back from practitioners.

Medicine is nuanced and all patients are not the same, yet, there is a role for standardization of care. By using clinical pathways, safety checklists and comprehensive unit safety programs (CUSP), medical care can be made more appropriate, better coordinated, efficient, less costly and safer.  Even with greater standardization, medicine will undoubtedly remain an art, as providers will still need to recognize and respond to nuances in patient condition and deviate, accordingly, from routine care.

Here is an article by Atul Gawande, published in the New Yorker, exploring the Cheesecake Factory model of medical care.

The argument is persuasive and the model proposed may represent the future of medical practice. 

Friday, August 10, 2012

Copper for the Prevention of Hospital Acquired Infections

Copper- source: ECOTEXTILES
There is always much excitement about new technology in medicine, particularly when infections are potentially preventable by scientific breakthroughs. Here is a state of the art review article on the use of copper impregnated textiles to limit hospital acquired infections.

It is now well established that copper has antimicrobial effects in vitro. Clinical trials support the claim that copper impregnated surfaces can decrease bacterial counts, including MRSA and VRE.

Clinical trials are now ongoing to assess the impact of copper impregnated surfaces and textiles on the rate of hospital acquired infections. I am very excited to learn the results.

Several key elements need to be defined.

  • What is the minimum standard of copper impregnation on a surface/textile that would render it effective in a clinical setting?
  • Which surfaces in a hospital should be optimally targeted for copper impregnation?
  • What impact will copper surfaces have on spore forming organisms such as C.difficile?
  • Superimposed on infection prevention best practices, what would be the incremental impact of copper impregnated surfaces and textiles on hospital infections and is it cost beneficial?
These are all critical questions that must be answered before universal adoption of copper impregnated technologies for infection prevention. 

Thursday, August 9, 2012

HIV Testing in the ER- A Good Start

I have blogged before about the need for aggressive HIV testing to identify the 200,000+ Americans who are infected yet unaware of the diagnosis.

The University of Alabama Birmingham is putting theory into practice. Here is an article in Infection Control Today reporting on the UAB experience on HIV testing in the ER. Over the last year, their ER has performed 20,000 HIV tests and has diagnosed 31 new HIV infections. A novel twist in the story is that that ER utilized new HIV testing methodology which allowed for diagnosis of chronic infection (antibody test) AND acute infection ( HIV antigen), by the  ARCHITECT HIV Ag/Ab Combo test. It is believed that about 10% of  HIV infections can be missed in high risk populations if only antibody testing is employed.

Per the American College of Physicians practice guidelines, HIV testing should be offered to all patients so testing in emergency rooms, an area of high patient volume, gets us one step closer towards identifying previously undiagnosed and untreated HIV infection.

With early diagnosis comes treatment and treatment is prevention.

Wednesday, August 8, 2012

Reduced Chlorhexidine Susceptibility- Implication for Infection Prevention?

Chlorhexidine is a chemical antiseptic widely use in the hospital. It is effective in killing a wide range of pathogens, is safe and used as a primary agent of skin antisepsis.  Here is a recent report, published in the Journal of Hospital Infection in drug resistant isolates of Klebsiella pneumonia. 

We have observed the emergence of extremely-drug-resistant (XDR) strains of Klebsiella pneumoniae. The author's hypothesized that reduced susceptibility to chlorhexidine may contribute to the endemic nature of this strain.

The minimum inhibitory concentration (MIC) of chlorhexidine was determined in 126 XDR K. pneumoniae clinical isolates using agar dilution.

The MIC of chlorhexidine was higher for K. pneumoniae ST258 (N = 70) than other K. pneumoniae sequence types (N = 56); 99% of ST258 isolates had MICs >32 μg/mL, compared with 52% of other K. pneumoniae sequence types (P < 0.0001).  Also, chlorhexidine-resistant subpopulations were observed independent of the bacterial sequence type or the MIC.

The suggestion? Reduced susceptibility to chlorhexidine may contribute to the success of XDR K. pneumoniae as a hospital acquired pathogen. This is a small study  and definitely not conclusive. However, further surveillance of chlorhexidine  susceptibility is definitely warranted to track its clinical significance.

Monday, August 6, 2012

Evidence Based Control of Multi-Drug Resistant Enterobacteriaceae Needed

Source: CDC
Here is a publication on the need for evidence based policies to limit and control multi-drug resistant enterobacteriaceae (MDE) in hospitals. Much of our strategies to currently control MDE is ad hoc and not fully driven by high quality evidence or formal guidelines. 

Noteworthy points include:

  • The degree of transmissibility of MDE is unclear, hence further work is required to better understand where, when and how transmission occurs
  • The optimal screening frequency has yet to be determined.
  • There is no consensus on how long patients may carry MDE, thus the freqency of re-screening is unknown
  • Although oral gentamicin for decolonization of MDE has been reported, optimal strategies for decolonization of MDE do not exist
  • Environmental decontamination strategies and antibiotic stewardship (restriction of extended spectrum cephalosporins in particular) may also be effective interventions to limit the spread and appearance of MDE.

As we gather more experience on the control of MDE, attention must be given to both the positive and negative consequences of our infection prevention interventions.  The example MRSA active surveillance and its pros/cons is insightful and underscores a look before you leap approach.   

Friday, August 3, 2012

CUSP and Surgical Site Infections

A Comprehensive Unit Safety Program (CUSP) in the OR can result in positive outcomes as published recently in the Journal of the American College of Surgeons.

One year of pre- and post-CUSP intervention SSI rates were collected using the high-risk pilot module of the American College of Surgeons National Surgical Quality Improvement Program. Surgical Care Improvement Project process measure compliance was monitored using standardized methods. 

The surgical best practices intervention were as follows:

  • standardization of skin preparation
  • administration of preoperative chlorhexidine showers
  • selective elimination of mechanical bowel preparation
  • warming of patients in the preanesthesia area
  • adoption of enhanced sterile techniques for skin and fascial closure
  • addressing previously unrecognized lapses in antibiotic prophylaxis. 

The results? Not surprisingly, the SSI rate improved. The mean baslinee SSI rate was 27.3% (76 of 278 patients). Following the intervention the the rate was 18.2% (59 of 324 patients)-a 33.3% decrease (95% CI, 9-58%; p < 0.05).  There was no difference in surgical process measure compliance as measured by the Surgical Care Improvement Project during the same time period, suggesting that this was not a coonfounding variable.

One paper does not define science, however, this quasi-experimental study suggests that evidence based interventions can help reduce the rate of SSIs. The challenge is to implement and sustain the interventions. The CUSP model is a viable implementation strategy, even in the OR.

Thursday, August 2, 2012

Letra de Medico and Narrative Medicine

I returned today from my native Cordoba, Argentina. Not surprisingly, I spent much of my free time lying about the house and reading books.Not idle time at all! I even managed to write and submit another essay. Keep your fingers crossed on its acceptance for publication.

I fortuitously came across a title, Letra de Medico, by Argentine physician Carlos Presman. The book is a collection of essays and reflections on medicine and on doctoring. Presman is by no means the first physician to turn to narrative and written reflection as means of understanding either the human condition or the doctor-patient relationship. Many of the stories are rich and full of humor, underscoring the beauty and importance of humor as a healing art.

Most importantly, Presman reminds us that each patient is more than a mere clinical encounter. Every patient is a biography and a unique personal narrative, where the physician's role is to astutely read, understand, comprehend an take part in the 'story',  so as to better appreciate the experience of illness and to employ healing as an art and not merely a science.

I fully believe in the importance of narrative medicine as a model for medical practice. A insightful article on narrative (free and online) was published in 2001 in Journal of the American Medical Association (JAMA). I highly recommend it.