Medicine in Literature- Spring 2012

Just the other day I gave the orientation for my Medicine in Literature class. This year I have 22 very bright and thoughtful 4th year medical students enrolled in the class. As expected, their undergraduate coursework was heavily concentrated in science, chemistry, biochemistry, biology and physics. My college experience was not unlike theirs.


What value is there in a medicine and literature class? A scholarly review on the topic, published in the Annals of Internal Medicine, can be found here. 


To date, there is no longitudinal data to suggest that teaching humanism though literary texts results in a more caring, empathetic doctor. Of course, an elective in medicine in literature will self select motivated students interested in both literature and doctoring. Regardless, the point is to stimulate thought and reflection on the experience of patients and physicians through narrative and to put these reactions in writing, for discussion and feedback, via an on-line discussion board.


If this exercise serves to spark even the smallest interest in the human competencies of medicine, then the class will be well worth it.

MRSA Furuncles- Why Not to Try This Yourself

I learned of this video while getting a haircut over the weekend.


MRSA skin and soft tissue infections can be extremely serious and result in hospitalization. Most commonly, MRSA infections present as furuncles (boils).


Do not take matters into you own hands (pun intended), as demonstrated in this video:

In brief, if you suspect an MRSA boil, seek help from a qualified medical professional. These infections require proper incision and drainage along with antibiotics. Decolonization of the MRSA carrier state should also be attempted, especially after several episoded of skin and soft tissue infection. 


Clinical practice guidelines for MRSA infections, by the Infectious Diseases Society of America, can be found here.

Alcohol Hand-Rub: Concerns about Efficacy?

Don't write off hand hygiene!

Here is a short report in the Journal of Hospital Infection. Investigators performed a retrospective analysis of alcohol hand-rub use and its correlations with hospital acquired MRSA infections and ESBL enterobacteriacea infections.


Between 2005 and 2008, the use of alcohol hand rubs increased significantly by 8 L per 1000 patient-days of hospitalization per year. During the same period, adherence to hand hygiene increased significantly from 55.6% to 70.9% (P < 0.0001). Despite these improvements there was an increase in the incidence of ESBL-producing strains in the past three years and a marginally significant negative correlation (decrease) in MRSA infections. 
Figure 1 in the manuscript nicely summarizes the findings in pictorial fashion, to include it here, however, would be a gross violation of copyright. Sorry.


I would caution the conclusion that alcohol based hand rubs are ineffective for the control of drug resistant pathogens. Hand hygiene is only part of a multi-modal infection prevention effort. Infection prevention best practices include hand hygiene, central line checklists, ventilator associated pneumonia 'bundles', urinary catheter 'bundles', removal of unnecessary invasive devices, chlorhexidine bathing of patients, reducing antibiotic selective pressure (for ESBLs- limiting the use of 3rd generation cephalosporins  and fluoroquinolones), use of gowns and gloves and adherence with isolation precautions.


This was a small study, and failed to account for all of the above with the exception of alcohol hand rub use/hand hygiene.

Hand hygiene remains vitally important.

Cigarette Smoking: Effects on Bone and Wound Healing

This one is really nothing new.

It should be no surprise that I come across many smokers in my clinical practice, especially in Richmond, Virginia, headquarters for Altria/Phillip Morris. The city is an unofficial smoking capital of the world.


Of course, we all know that cigarette smoking is harmful and greatly increases the risk lung cancer, oral cancer, bladder cancer, heart disease and stroke, among other ailments. Like a broken record, I find myself counseling patients with severe bone, joint and wound infections to quit smoking. Most are seemingly unaware that smoking has a significant negative impact on wound and bone healing.


Two very nice reviews on the topic can be read here and here.


In these cases, smoking cessation may be both limb and life sparing.

Bare Below the Elbows and Neck Ties- Impact on Contagion

The doctor's tie: couture or contagion?

Well here is an interesting read, hot off the press from the Journal of Hospital Infection.


The study was a prospective, controlled investigation of the effect of shirt sleeves and ties on the transmission of bacteria from doctors to patients.  Four clothing combinations were tested: long sleeve shirt with unsecured tie, long sleeve without tie, short sleeve with tie, and short sleeve without tie. The ties and sleeves were innoculated with Micrococcus luteus. Each of the four clothing combinations was worn by a physician while he examined five simulated patients in each combination group. The simulated patients were mannequins dressed in hospital gowns lying in hospital beds in a simulation center. Cultures were obtained from the mannequin’s cheek, right hand, and abdomen before and after a standardized 2.5-min history and physical examination


The findings? Wearing an unsecured tie results in greater transmission , 60% of contaminated mannequins when wearing a unsecured tie vs. 10% of contaminated mannequins when not wearing a tie (P=0.036). Sleeve length did not affect transmission rate. 


Here is a letter to the editor, in the Journal of Hospital infection, summarizing a randomized comparison study of bare below the elbows and quality of hand washing. A bare below the elbows approach did not impact the quality of handwashing but did improve the quality of washing at the wrist. The impact that cleaner wrists may have on infection prevention is not known.


Regardless, a bare below the elbows, no necktie recommendation for inpatient care, as recommended by the Infection Control Committee in my hospital is an easy ,safe, and cheap intervention, with the potential benefits far outweighing the harm.

Hypervirulent Klebsiella- From the Hospital to the Community

Klebsiella growing on an agar plate: Source CDC

Well I am finally back from The Winter Course, in Snowmass, Colorado. I managed to successfully give my 3 lectures and to a avoid visiting the orthopedist despite daily runs on the ski slopes.

We have witnessed a trend of bacterial pathogens emerging as disease agents not only in the hospital but also in the community. Examples include community associated MRSA and Clostridium difficile. Most recently, in the last 10-15 years, a new variant of Klebsiella pneumoniae is causing serious, community-acquired infections in young, healthy adults. These bacteria have the potential to become antibiotic-resistant. 

My colleague and former mentor from the University at Buffalo, Thomas Russo, recently published on a new variant of Klebsiella pneumoniae in Plos One. An informative article related to his work in Infection Control Today can be found here.

With the emergence and persistence of drug resistant pathogens, infection prevention is bound to remain both challenging and relevant......a form of job security, of sorts.

Back to the grind.

Presenteeism- When Sick Healthcare Workers go to Work

Source: NY Times

I am currently in Snowmass, Colorado at the 38th  Winter Course, giving several lectures, and, more importantly, listening and learning a lot from my peers. There was a fine presentation yesterday  by Dr. Dan Diekema from the University of Iowa, on managing hospital exposures to infectious agents such as pertussis, TB, varicella (Chicken pox) and tuberculosis. 


A topic raised during the presentation was "presenteeism'', or rather, healthcare workers coming to work while ill. I  refer you to this manuscript on presenteeism in the healthcare setting and its impact on infection prevention.


Despite prescribing 'sick leave' for their patients, when similarly ill, many physicians will still work.The motivation may be to serve their patients, but in doing so, they neither serve the patients nor themselves. To boot, ill healthcare workers serve as disease vectors to others in the workplace. 


Sick healthcare personnel in the workplace are a public health hazard. If you are ill, stay home, especially if you provide direct patient care.


Back to the Remington Course......

Going for a Total Joint Replacement? Get decolonized of Staphylococcus aureus!

Nasal Screening for MRSA Carriage

It is well known that when one suffers a post-operative or hospital acquired infection with S. aureus (or MRSA), it is frequently from one's endogenous (own) strain. In a study recently published in Infection Control and Hospital Epidemiology, investigators evaluated the cost effectiveness of preventing staphylococcal infections in prosthetic joints by decolonization, prior to surgery, with intranasal mupirocin.

The verdict? Empirical treatment with mupirocin ointment or use of a screen-and-treat strategy before prosthetic joint implantation is a simple, safe, and cost-effective intervention that can reduce the risk of surgical site infection. 

At VCU Medical Center, we do not screen all admissions for MRSA. We do, however, screen patients for elective surgeries such as prosthetic joint implantations. If the patient is MRSA positive, then she is decolonized with mupirocin (intranasal, twice daily for 5 days) and with chlorhexidine bathing the night before and the day of the surgery. The results have been excellent.

I am off to Colorado today where I will give several lectures, over the week, at the 38th annual Winter Course.

I will be blogging, light.

Honduran Sessions- The How and Why

It is not uncommon that we are asked why we go on medical relief trips to Honduras? Of course, we could launch into platitudes about doing good deeds for the sake of humanity, but that would give an oversimplified and false sense of purpose.

Of course, there is an element of medical and humanistic goodwill that drives our collaborative effort with local Honduran medical officials. Treating patients who live in extreme poverty for common illnesses that are easily addressed by primary care doctors and urgent care centers in the USA is gratifying. Providing clean water filtration systems, mass de-worming of rural populations and offering rudimentary dental care in areas devoid of both lasting health services and basic sanitation add to the mission’s humanistic appeal.  The opportunity to expose medical students and residents to medical relief work and its inherent rewards and challenges is stimulating and serves to train future leaders in global health. Last, our Honduran trips are accurately characterized as humid, dirty and uncomfortable. Perhaps that is part of the attraction, that is, it challenges us to display some fortitude, away from our comfortable stateside lives. All are noble goals.

Most importantly, during an intense 10 days in June, our yearly ‘Honduran Sessions’, lead us to an exploration and reaffirmation of what it means to be human, to witness suffering and need alongside survival and resilience. In doing so, we are inspired to collaborate and help, albeit on a limited scale, and are forced to reflect, individually, on what is truly meaningful in a world of growing disparity, tremendous wealth and immense potential.

Gonzalo Bearman

Michael Stevens

  

Vox Medica on Facebook

The blog is now on Facebook, if that is more convenient to followers, check it out.  

Handwashing and Masks Limit Household Influenza

The transmission of influenza can be halted, within a household, without antivirals such as Tamiflu. Here is a very recent publication on the role of hand washing and masks for limiting influenza transmission in households.

The investigators studied households with an influenza positive index case. Study groups were wearing a facemask and practicing intensified hand hygiene (MH group), wearing facemasks only (M group) and none of the two (control group). Main outcome measure was laboratory confirmed influenza infection in a household contact.


When the hand washing and masks were introduced early in households, there was a significant reduction in the odds of transmission in the household (adjusted odds ratio 0.16, 95% CI, 0.03-0.92).


In the event of high influenza activity, promotion of hand hygiene and household mask use may be of benefit, especially when begun within 36 hours of symptom onset on the index (first) household case.  

Public Health "Shock Adds" - The Full Frontal Truth

This is you brain on Drugs: 1987.
Source: NY Times

Here is a nice article exploring the controversy of using 'shock adds' as public health messages. The adds may be displeasing to some. The effectiveness of this tactic is certainly up for debate. In New York City, an aggressive anti-smoking campaign is partly credited with an all time low smoking prevalence of 14%.


Perhaps there is no single best way to display a public health message. There is no credible evidence, however, that aggressive public health 'shock adds' actually increase high risk behavior.


Below is an anti-smoking commercial. Until a negative health effect is established, press on.

VCU Global Health and Health Disparities

VCU students and medical residents- Honduras 2011

The Virginia Commonwealth University's Global Health and Health Disparities training program is taking shape. 


The budding program is in many ways the brainchild of my friend, colleague and collaborator Dr. Michael Stevens. With it, the dream of training students and physicians at VCU in global health is becoming a reality. I am proud to be part of the programs core faculty.


Please visit our new website, to learn of more about the program, its purpose, goals and manifesto. 

Bleach Baths to Control MRSA and S.aureus

Recently I saw a young, healthy woman in the clinic with recurrent MRSA boils.  Here is a paper on bleach baths to eradicate S.aureus colonization.


In a prospective trial, participants were randomized to receive no therapeutic intervention (control subjects) or one of three 5-day regimens: 2% mupirocin ointment applied to the nares twice daily, intranasal mupirocin plus daily 4% chlorhexidine body washes, or intranasal mupirocin plus daily dilute bleach water baths.

Decolonization was successful in 48% of the control group, 56% of the mupirocin only group, 54% in the mupirocin-chlorhexidine group, and 71% in the mupirocin-bleach group. 

An simple regimen of dilute bleach baths, intranasal mupirocin, and hygiene education effectively eradicated S. aureus.


It may be worth a try.

Antimicrobial Textiles in Medicine- Radio Interview

For those of you interested in my most recent publication on antimicrobial scrubs, here is my radio interview on WCVE-NPR. 


Thankfully, the radio interview is brief.