Bed Bugs in the City Health Department

This news report has a hint of irony. A single bedbug was discovered at the NYC Department of Health and Mental Hygiene in Queens, forcing a temporary evacuation and fumigation of the facility. Per Health Department officials, this was not an infestation. It is, however, pesky and embarrassing. 

While this may be a figurative black eye on the face of the Health Department, the health consequences of  bedbugs are minimal as they are not known to be vectors of disease transmission. 

The anxiety, however, is real. I have blogged about this before.

Influenza Vaccines at the Airport and Taxi Drivers.

Source: Chicago Tribune

The CDC recommends yearly influenza vaccination for all people ages 6 months and older.Getting the public vaccinated is always a challenge.

Here is a novel approach: vaccinate taxi drivers, for free, at a major transit area, the airport. This is precisely what is being done in Chicago, as reported here by the Chicago Tribune. Taxi drivers are in contact with a wide variety of people, particularly air travelers, who cough, sniffle and sneeze in their cabs. A taxi driver's risk of influenza contagion is not inconsequential.

This is a clever vaccination campaign provided that a large fraction of Chicago's taxi cab drivers are vaccinated. 

Herpes Simplex Virus Infection Following Circumcisions that Included Direct Orogenital Suction

This report in the MMWR caught my eye. An outbreak of Herpes Simplex Virus (HSV) occurred in 11 newborns and resulted in 10 hospitalizations and 2 deaths. 

The cause was attributed to ritual circumcision that involved an ultra-Orthodox Jewish practice known as metzitzah b'peh, in which the circumciser (mohel) places his mouth directly on the newly circumcised penis and sucks blood away from the circumcision wound (direct orogenital suction). 

In the cases where typing was performed in the outbreak, the isolates were HSV-1 (oral herpes). Oral contact with a newborn's open wound risks transmission of HSV and other pathogens.

As circumcision is a surgical procedure and should be performed under sterile conditions. Orogenital suction should be avoided, for obvious reasons.

The Next Pandemic

It should be no surprise that a pandemic or epidemic is looming around the figurative corner, especially for those of us in infectious diseases. Here is a commentary recently published in the New York Times, on the coming plague and why zoonoses (infectious diseases transmitted from animals to humans) will plague us until the end of time. With the widespread access of air travel, the introduction of an infectious disease is only a flight away.

I am studying for my re-certification examination in infectious diseases and came across an interesting reference in my lecture notes on the Sixth Plague of Egypt, a plague of boils (Book of Exodus). This can be no other than our nemesis since time immemorial, Staphylococcus aureus.  

Infectious diseases will continue to vex us. Job security.

Ward Physicians, Hospitalists and the iPatient

There has been a change in the age mix of ward attending physicians.  Medical care is now subject to greater demands on supervision, documentation, efficiency, and, for residents, duty hour restrictions. As a result, supervising physicians now are younger, general internists or hospitalists, and more directly engaged in patient care. The focus is patient throughput. 

The days of subspecialty oversight, by older physicians, with an academic perspective are largely over. The old model allowed for greater resident autonomy in patient care, the new model favors supervision and efficiency.

Here is a commentary, by Robert Wachter and Abraham Verghese, published in JAMA. The authors call for a new balance between resident supervisions and autonomy, one that still allows for more traditional teaching of residents and students, particularly at the bedside.

At risk in the current model, is the loss meaningful and transformational human contact with the patient, in favor greater of efficiency and of managing the virtual patient in the electronic medical record, also dubbed the "iPatient".


Here are my thoughts.  I believe that greater supervision and work hour restriction of residents is likely a good thing although there are no robust data to suggest that this results in improved patient and educational outcomes. There is also no data to suggest that the new model is detrimental to patients and learners. As we are not likely to turn back the clock, the onus is on us to ensure that there is no erosion of the human touch in medicine. Academic, supervising physicians should learn to balance efficiency, work rounds with select bedside teaching rounds, perhaps to highlight and review interesting cases, patient stories and exam findings. 

The task is not simple and, at times, inconvenient, but medical training was never meant to be easy. 

Chronic Fatigue Syndrome- Not Caused by an Infectious Disease

Source: ProHealth.com

Here is a brief commentary in the NY Times on chronic fatigue syndrome. Recently, chronic fatigue syndrome has been linked to infection with xenotropic murine leukemia virus-related virus (XMRV). Many were skeptical. Over the years, the syndrome has been associated with other viruses such as EBV,CMV and HHV6, none of which has held up to scientific scrutiny.  

Journal mBio reported the results of a prospective, multicenter analysis of chronic fatigue and XMRV and found no evidence of XMRV infection. 

The etiology of chronic fatigue syndrome remains elusive. I am sympathetic for those who suffer from chronic fatigue. As a profession, we must not mislead patients by suggesting that the malady is an infectious disease or that a simple cure or treatment is at hand.

It is time to move on.

VCU Global Health Initiative on the new Department of Medicine Website

The Virginia Commonwealth University Department of Medicine has a new website. Dr. Stevens and I are represented on the homepage with a profile about our ongoing work in Honduras,

If you have a moment, check it out.

Cyberchondriacs

We have all heard about hypochondriacs. Now we are living in the era of cyberchondriacs, people who a compulsively search the Internet for information about real or imagined symptoms of illness.  The phenomenon is noteworthy.

Here is recent commentary in the Richmond Times Dispatch on cyberchondria. The quality of health information online is variable, many of it written by laypersons or advocacy groups and not subject to a rigorous peer review process. This can be dangerous, as unreliable information can result in increased anxiety and  unnecessary evaluations and treatments, as published here in the International Journal of Adolescent Medical Health.

Patients may not fully share the blame for their cyberchondriac ways. Much of the search for answers  may stem from our short office visit times, where answers to symptoms and concerns are not addressed.

Below are clinical pearls for managing cyberchondriacs, as published in the Primary Care Companion-Journal of Clinical Psychiatry.

Source:  Primary Care Companion-Journal of Clinical Psychiatry. 

To borrow a phrase from one author, anxiety is more contagious than the flu.

West Nile Virus- Media Interview, Prevention of Disease

Source: Richmond Times Dispatch

Sadly, there was a recent death due to West Nile Virus here in Virginia. I was interviewed by the local newspaper, the Richmond Times Dispatch, on West Nile Virus infections.The short article be accessed here.

As there is no cure or antiviral therapy for West Nile Virus, the best intervention, as stressed in my interview, is prevention. By that, I mean being mindful about avoiding mosquito contact as much as possible.  This includes, limiting outdoor activity at dawn and dusk, using mosquito repellents on skin and clothing, wear long sleeves and long pants when feasible, repair or install window screens, and eliminate standing water where mosquitos breed (water in buckets, flower pots, tires etc). Last,  mosquito control programs are important. An informative presentation on mosquito control by Dr. David Gaines, the state entomologist for the Virginia Department of Health, can be found here.

Eating Organic: Is it Safer and More Nutritious?

One need to live in a cave to not be aware of the organic food craze in the USA. A reasonable question to ask is whether the consumption of organic foods is actually safer and more nutritious than the alternative. Admittedly, this a tough question to answer as there are no randomized, prospective randomized trials of people eating 'organic' vs 'non-organic'.

Regardless, here is a systematic review of  organic foods and potential health outcomes published in the Annals of Internal Medicine. The outcomes of interest was whether organic foods were more nutritious and resulted in fewer exposures to pesticides or bacteria of pathogenic concern.

There was no significant difference in nutrient contents between organic and conventional foods. The risk for contamination with detectable pesticide residues was lower among organic than conventional produce (risk difference, 30% [CI, −37% to −23%]), but differences in risk for exceeding maximum allowed limits were small. E. coli contamination risk did not differ between organic and conventional produce. Bacterial contamination of retail chicken and pork was commonly documented. Of note, the risk for isolating bacteria resistant to 3 or more antibiotics was higher in conventional than in organic chicken and pork (risk difference, 33% [CI, 21% to 45%]). Whether this is clinically significant is unclear.

The bottom line- the current body of literature is sparse, at best, and the findings are by no means conclusive. The published, peer reviewed literature lacks strong evidence that organic foods are significantly more nutritious than conventional foods. Consumption of organic foods, however, may reduce exposure to pesticide residues and antibiotic-resistant bacteria. 

Time for my breakfast bowl of organic granola....

Claims Data and Non-Payment for Hospital Acquired Urinary Tract Infections

Fighting CAUTIs
Source: AllenHospital.org

As many of us are aware, since 2008, claims data are used to deny payment for certain hospital-acquired conditions, including catheter-associated urinary tract infections (CAUTIs). Is this an effective strategy?

Here is an article in the Annals of Internal Medicine on billing claims data and hospital acquired urinary tract  infections.

From the study, hospital rates of CAUTI were very low:
2007: 0.09% (CI, 0.06% to 0.12%) 
2009: 0.14% (CI, 0.11% to 0.17%))

In addition, hospitals frequently requested payment for non-CAUTIs as secondary diagnoses: 2007: 10.0% (95% CI, 9.5% to 10.5%) 
2009: 10.3% (CI, 9.8% to 10.9%).

The implication? In this study, the threat of nonpayment for hospital-acquired CAUTIs reduced payment for 25 of 781,343 (0.003%) hospitalizations in 2009. Minuscule.

Although CAUTIs are the most common hospital acquire infections (and also the least severe), determining  CAUTI rates by claims appears inaccurate and discordant.  The financial impact of non-payment for CAUTIs also appears wimpy. 

CAUTIs are simply not captured by for billing purposes. We need another strategy.

Celebrity Power and Hand Hygiene

Here is a novel approach to promote hand hygiene by a US Healthcare system. Michael Jordan is now a champion of hand hygiene and patient safety. Most hospitals are not likely to have eye catching celebrities on posters to remind staff about hand hygiene, nevertheless, their general approach may be useful to other hospitals.

This is part of a coordinated campaign by Novant Healthare dubbed Washing Hands Saves Lives (downloadable hand hygiene program materials on the website). 

Getting people to wash their hands is an ongoing challenge. Strategies for hand hygiene improvement are typically multi-modal and require education, reminders, ease of access, surveillance, feedback and accountability.

Back to work...

Two Kinds of Intelligence- Listening, Reflecting and Narrative Medicine

Source: Wellsphere.com

Here is a perspective (free, full access) on narrative medicine titled Two Kinds of Intelligence, published in Academic Medicine. 

In its most simplified forms, the first type of knowledge is borne from study, books and classrooms. The second is more nuanced and comes from within, from the cultivation of emotional experience, reflection and discussion of transformative events.

These narrative are epiphanies, confessions and expressions of stories of self and stories of others.

Every patient has a story. Listening is not an easy skill to develop and maintain, yet it is critically necessary. Of importance, however, is that these stories be shared, either in writing or in conversation, allowing for reflection, transformation and a better understanding of the human condition. 

As we become more technically savvy in medicine and are increasingly pressed for time, the power of narrative may be our saving grace.