Scrutinizing Short Term Medical Relief Trips- Ethical Considerations

I have been preparing a summary presentation of our ongoing Honduras medical relief program with my colleague  Dr. Michael Stevens. This program is under the auspices of the VCU Global Health and Health Disparities Program.

The ethical aspects of medical relief work have particularly interested us. These concerns are concisely summarized in the following paper, published by the Hastings Center.

•Who really benefits? Is it the recipients or the participants?

  Do these relief trips simply serve to make us feel better about ourselves?

•Has the community been involved in the planning?

•Is the program culturally sensitive?

•Is the program sustainable and will it truly benefit the recipients?

•Are lasting collaborations in place?

•Is there a risk for harm?

The above issues have driven us to collaborate with community leaders and the local Ministry of Health to develop a sustainable clinical/public health program in a rural and mountainous area of Honduras. 

For last year's mission detail and for an informative interview with a collaborator, click here.

The Peer Review Process: Assessment of Quality and What Makes a Good Journal Reviewer?

Peer Review
Source: columbia.edu

Academics pride themselves in the peer review process but what measures exist to assess its quality?

Here is a study published in the American Journal of Infection Control that attempts to tackle the above question.The study utilized 2 online surveys, one for authors (n = 102) and one for Editorial Board members (n = 20) to assess their perspectives on the quality and timeliness of peer review. 

Authors of accepted manuscripts were significantly more likely to rate the review as the same or better than other peer reviews they had received when compared with authors of rejected manuscripts (93.3% vs 47.4%, respectively, P = .001).Board members were significantly more likely to rate reviewers as fair and unbiased (91.4% and 70%, respectively, P = .04). 

But what make a good reviewer? Well the data are sparse.Here is a perspective (free, fulltext) in JAMA on the assessment of a good journal reviewer. Surveys of reviewers of 420 manuscripts were completed by journal editors and authors.  Using logistic regression analysis, the only significant factor associated with higher-quality ratings by both editors and authors was reviewers trained in epidemiology or statistics and younger age (40-60 yrs).

I review a fair number of manuscripts, am trained in epidemiology and am young (between 40-60). Let's hope that the quality of my journal reviews do not disappoint.

Rethinking Contact Precautions for the Control of Endemic Drug Resistant Organisms

Should we relax contact precautions as currently practiced, particularly for the control of endemic hospital pathogens such as MRSA and VRE? 

We think so and recently published a manuscript in Current Infectious Diseases Reports arguing the above point.

Much of our argument is based on the premise of a horizontal infection control program, one in which all infections are targeted by multipotent, broad based infection prevention interventions. With this strategy, hospital acquired infections may be controlled, thus limiting the need for contact precautions, particularly for certain pathogens.

Change may be in the air.

Nurses as Barometers of Quality Patient Care

Source: Fisk.edu

Without doubt, nurses spend more time with patients than other healthcare workers so their opinions on patient safety should matter.

It now appears that nursing assessment of patient care is statistically associated with improved patient outcomes.

Investigators from the University of Pennsylvania assessed hospital quality by aggregating hospital nurses' responses to report on quality of care.  The results are published here. 

The result? A 10% increment in the proportion of nurses reporting excellent quality of care was associated with lower odds of mortality and failure to rescue; greater patient satisfaction; and higher composite process of care scores for acute myocardial infarction, pneumonia, and surgical patients. 

Ask the nurses about patient safety and quality of care, their opinions matter.

Hepatitis B: The Importance of Vaccination, Immunity and Transmission from Healthcare Worker to Patient

Source: ct.gov

I am back from the ID Week- Infectious Diseases Society of America Conference in San Diego. Thank you to those of you who followed the blog during the trip.

Here is an article that caught my eye this morning, on the transmission of Hepatitis B from an Orthopedic surgeon to several patients. The manuscript highlights several critical points, namely, the importance of universal Hepatitis B vaccination and of assessing response to the vaccine. More importantly, the article underscore the need to evaluate the clinical practice, with possible restrictions on the performance of invasive procedures, for healthcare workers infected with Hepatitis B virus.

Back to the grind.

ID Week 2012- Day 3

The last 3 days have been action packed. Dr. Edmond has been the star with three important presentations.

This afternoon we presented one of our studies on the surveillance of bloodstream and catheter associated urinary tract infections outside the ICU. It was well received.

Later in the day I caught up with Dr. Chiu-Bin Hsiao, a colleague of mine from the my spell at the University at Buffalo- Erie County Medical Center.

Heading back to Richmond tomorrow.

ID Week 2012 Day 2-Part Deux

The scientific program so far has been excellent. Drs. Stevens, Edmond and I paused in the poster hall for a photo opportunity.

Later in the day, I snapped a photo of the San Diego cityscape and of the day's end.

ID Week 2012- Day 2

We are off to a fine start here in San Diego.

Our very own Dr. Michael Edmond was masterful, in front of a large crowd, during the clinical controversies in infectious diseases session. He successfully argued in an eloquent debate that the current state of science cannot prevent all hospital acquired infections.

More to come so stay tuned.

En Route- Infectious Diseases Society of America Conference 2012

Drs Stevens, Edmond and I will soon be at the 2012 ID Week conference.

Stay tuned.

The Plague- Random Thoughts

Physician during the Great Plague

This morning I was perusing Daniel Defoe's Journal of Plague Year.  This book was published in 1722, well after the 1665 bubonic plague that ravaged London. Defoe's inspiration and source for much of the book was from English physician Dr. Nathaniel Hodge's (1629–1688) book on the  Great Plague- Loimologia, or, an historical Account of the Plague in London in 1665, With precautionary Directions against the like Contagion, published in 1672.

Of note is the now very antiquated medical term Loimologia (loimology), the study of pestilential diseases and plagues.

In a few hours I am off the the Infectious Diseases Society of America/Society for Healthcare Epidemiology of America Conference in San Diego, where, without doubt, loimology will not be on the agenda.

Stay tuned for updates.

The Future of Medical Publications

Source: wisdom.blogs.com

For those of you interested in medical publications and scientific journals, here is a recent perspective on interactive journals and the future of medical publishing, printed in the American Journal of Medicine.

In academics, a coveted accomplishment is the peer reviewed paper. In this process, manuscripts are received by journals, reviewed by editors, and then distributed for peer review. If deemed suitable, the manuscript is then published. This time honored practice allows for quality and scientific rigor. Critics point out that reviewers and editors may have their preferences and biases that affect manuscript publication.

Over the years, individual medical blogs (like this one) have flourished.  Many medical journals have not fully embraced novel technologies afforded by the internet. Of the 588 journals reviewed in the above perspective, 9% had a journal based blogs, 8% allowed for direct web based commenting on an article, and 90% utilized social media/email sharing.

In the information age, the paucity of journal based blogs and direct commenting on medical articles by readers is lamentable. Allowing readers to more fully participate, interact and comment on scientific publications will result in wider dissemination of ideas, enhance perspectives and promote further inquiry. 

The tools for this are available, the time is now.

Chocolate Consumption, Cognitive Function and Nobel Laureates

It has been a long and hard week. Yesterday, I took the Infectious Diseases Board Examination for re-certification. This is a requirement every 10 years. Effective immediately, I am back to more pleasant distractions, like blogging.

Here is an article worth a perusal, recently published in the New England Journal of Medicine. In brief, the study concludes that chocolate consumption enhances cognitive function and closely correlates with the number of Nobel laureates in each country. This study describes a correlation and by no means assesses individual chocolate consumption, by Nobel Laureates or otherwise, in a dose response fashion. The data are intriguing yet by no means definitive. 

Regardless, I could have used some chocolate yesterday during the Board Examination.

Inviting Patients to Read Their Doctors' Notes

Electronic medical records have many purported benefits. Now, access by patients to their medical record may be added to the list.  He is an article published in the Annals of Internal Medicine (free, full text) of a year long trial that provided patients with electronic links to their doctors' notes.

11,797 of 13,564 patients with visit notes available opened at least 1 note. 5391 patients completed a post-intervention survey. The majority of the survey respondents (87%) reported that open notes helped them feel more in control of their care; 60% to 78% of those taking medications reported increased medication adherence; 26% to 36% had privacy concerns and 1% to 8% reported that the notes caused confusion, worry, or offense. 

On the provider end, few doctors reported longer visits (0% to 5%) or more time addressing patients' questions outside of visits (0% to 8%).

At the study's end, 99% of patients wanted open notes to continue and no doctor elected to stop.The majority of the patients reported an increased sense of control, a greater understanding of their medical issues, improved understanding of their plan of care, and greater likelihood to take their medications as prescribed. 

This is all very positive initial data but it falls short of answering the coveted final question; will it actually result in sustained improvements in patient outcome? In other words, by opening the medical record to patients, will they be sufficiently motivated to take medications as prescribed, undergo diagnostic and screening testing, lose weight, quit smoking etc?

My hope is that as we open up the medical record to patients, that we attempt to measure improvements in care and outcome.

Revisited: Eating Organic, is it Safer and More Nutritious?

Several weeks ago I blogged about a paper about organic food published in the Annals of Internal Medicine. In brief, the study's authors concluded that the published, peer reviewed literature lacks strong evidence that organic foods are significantly more nutritious than conventional foods.

This study has received much attention and criticism, as best summarized by Mark Bittman's (NY Times Food Columnist) recent opinion article. Many feel that the study is misguided and that its conclusions are misleading.  This counterpoint is worth a read and has valuable hyperlinks.

My morning bowl of granola is calling me.......

(Chronic) Lyme Disease Made Political.

Source: Slate.com

(Chronic) Lyme Disease made political, and in Virginia too.

Check out this related posting by Dr. Dan Diekema (of the University of Iowa). An insightful article on the matter was recently published in Slate.

Conspiracy over medical science and for political gain too. Disturbing.

 

Smoking Cessation Quitlines- Use Them!

Source: VDH.gov

Those who know me are well aware of my anti-smoking stance. I am always a bit perplexed when my patients are seemingly über-concerned about their cholesterol, the HIV management parameters, such as the CD4 and viral load counts, getting their influenza vaccine on time, etc, yet, continue to smoke with reckless abandon. Apart from the HIV medications, quitting smoking is the single most important healthy choice that they can make.

Lately, I have been handing out the Quit Now Virginia smokers quitline pamphlet to all of my patients who smoke. 

What evidence exists to suggests that quitlines are effective smoking cessation interventions?

Here is a scholarly (and open access) publication on smoking cessation quitlines. Bottom line,  smoking cessation quitlines are of varied structure yet most employ counseling with follow up calls to assist, encourage and promote smoking cessation. The efficacy of quitlines for smoking cessation is supported by various studies.

From my perspective, quitlines represent a convenient, evidence-based referral resource for physicians advocating smoking cessation but who cannot themselves provide the intensive intervention and follow up needed.

I am a big proponent of smoking cessation quitlines.