New Website is Launched

It has taken me a bit of time to get the project completed. Finally, here it is. 

Please check out my new professional website.

www.drgonzalobearman.com

Probiotics for the Prevention of C.difficile

The prevention of C.difficile associated diarrhea is a growing area of interest, particularly for patient on antibiotic therapy. Here is a systematic review published in the Annals of Internal Medicine on the use of probiotics for the prevention of C.difficile associated diarrhea.

Twenty trials including 3818 participants met the eligibility criteria. Probiotics reduced the incidence of C.difficile associated diarrhea by 66% (pooled relative risk, 0.34 [95% CI, 0.24 to 0.49]; I² = 0%). Of probiotic-treated patients, 9.3% experienced adverse events, compared with 12.6% of control patients (relative risk, 0.82 [CI, 0.65 to 1.05];I² = 17%).

This is reasonable quality evidence to support the use of probiotics to reduce the risk of C.difficile associated diarrhea. The potential harm is minimal.

Who would best benefit from probiotics? This is not clearly defined, however, prescription of probiotics for those receiving prolonged antibiotics (> 2 weeks) or for those on antibiotics with a prior history of C.difficile associated diarrhea seems justifiable.

It may change my practice.

Thrive

Medical Muse- Fall 2012

For those of you with a literary curiosity, a short story I wrote, titled Thrive, was just published in the Fall 2012 edition of Medical Muse magazine.

You can download the Fall 2012 edition here.

The story starts on page 18.

The New 'Pet Scan' - Using Dogs to Sniff Out C.difficile

Here is an article published in the British Medical Journal on a novel 'pet scan', using trained dogs to sniff out C.difficile in stool samples and in hospitalized patients.

Dutch investigators assessed the sensitivity and specificity for detection of C difficile in stool samples and in patients by a trained, 2 year old beagle. 

The dog’s sensitivity and specificity for identifying C difficile in stool samples were both 100% (95% confidence interval 91% to 100%). During the detection rounds, the dog correctly identified 25 of the 30 cases (sensitivity 83%, 65% to 94%) and 265 of the 270 controls (specificity 98%, 95% to 99%)

Impressive, but how would this benefit hospital infection prevention efforts? Early diagnosis of C.difficile infection may lead to prompt isolation and treatment, however, this may not impact cross transmission within the hospital environment. Significant uncertainties such as these must be answered by clinical studies before dogs are routinely employed as an infection prevention strategy. 

At the very least, C.difficile sniffing dogs would give new meaning to the term Dogs on Call.

VCU Medical Students Audrey Le and Jackie Arquiette Recognized by School of Medicine

Congratulations to VCU Medical students Audrey Le and Jackie Arquiette who were recognized by the VCU School of Medicine and on the VCU News website for their work on our Honduras medical relief research program.

Well done ladies.

Jackie Arquiette

Audrey Le

Contact Precautions: Benefits Revisited

It seems like the topic of contact precautions is receiving ongoing attention in the hospital epidemiology literature. The current trend of articles tend to question the benefits of contact precautions and underscore its untoward consequences.

The latest study, published in Infection Control and Hospital Epidemiology, examines the effects of contact precautions on healthcare worker (HCW) activity in acute care hospitals. Using a prospective observational design, a total of 7,743 HCW visits were observed over 1,989 hours. Patients on contact precautions had 36.4% fewer hourly HCW visits than patients not on contact precautions as well as 17.7% less direct patient contact time with HCWs. In addition, patients on contact precautions tended to have fewer visitors 23.6% fewer. HCWs were more likely to perform hand hygiene on exiting the room of a patient on contact precautions (63.2% vs 47.4% in rooms of patients not on contact precautions).

Less than 10 years ago, active detection and isolation for MRSA was all the rage in hospital epidemiology. Times are changing as we learn the potential negative impact of isolation precautions.

An excellent related blog from my colleagues in Controversies in Hospital Infection Prevention can be found here.

We feel it is time to rethink contact precautions for the control of endemic pathogens. By using robust, horizontal infection prevention measures, endemic pathogens such as MRSA and VRE may be effectively controlled without employing contact precautions.

Stay tuned.

Global Burden of Disease Report: Obesity Rises to the Top

Source: The Lancet

The recent Global Burden of Disease compilation published in The Lancet is eye opening. This is the largest systematic study to describe the global distribution and causes of a wide array of major diseases, injuries, and health risk factors.

The good news: infectious diseases, maternal and child illness, and malnutrition now cause fewer deaths and less illness than 20 years ago.

The bad news: there has been a massive shift (pun intended) in obesity as a cause of morbidity and mortality. Over the last 20 years, there is an estimated 82% increase in obesity rates worldwide. The health consequences are increases in diabetes, stroke and heart disease.

Back in 1985, I watched the famous Live Aid concert to benefit the victims of starvation. 

Times have changed. 

The next such benefit concert, ObesityAid, will need to raise awareness and assistance for over-nutrition.

What Makes an Excellent Clinician?

What makes an excellent clinician, at least at an academic medical center? Explanations and theories abound. 

Here is an qualitative study on the above question published in Academic Medicine.

The  high performance of excellent clinicians is characterized by clinical skills, cognitive ability, people skills, engagement, and adaptability. These high achievers are driven by a core philosophy of high motivation, passion for patient care and are engaged in deliberate activities resulting in reflective clinical practice and scholarship.

Patient care, reflection, reading and writing. This is time consuming and there are no short cuts.

Nostalgic Professionalism- Be Gone!

The concept of professionalism is changing in medicine, particularly in the era of duty hour restrictions. Here is a viewpoint on professionalism recently published in JAMA.

Marcus Welby, MD: Nostalgic Professional

The implementation of duty hour restrictions for physicians in training has raised the concern about a potential erosion in professionalism. Old school physicians (old school includes me and is defined by anyone who was trained prior to duty hour restrictions) cling on to the now 'antiquated' notion of 'nostalgic professionalism.' This form of professionalism is defined as consistently placing the patient's needs or the profession's needs above one's own personal needs. 

These values conflict with the current model of training. The newly proposed model of professionalism emphasizes the recognition of physician limits as humans, emphasizing the importance of physicians' health and alertness. I have certainly heard much about 'work-life balance' from residents and students at the university hospital where I work. When one is in training, there really is no substitute for direct patient care. Learning the practice and art of medicine requires long hours.

The solution? Per the authors, the new professionalism paradigm would be best served by a residency training system that fully adopted a team based model of patient care, one in which patient ownership was not delegated to a single resident/physician, but shared among a group of team members.

I am not necessarily opposed to the new paradigm of professionalism. However, I am not fully sold on the concept either. My concern is that, across a team, not all team members will really know the patient in full. I find it difficult to comprehend how a team will truly understand a patient, as an individual physician does through a history, a physical examination and careful reading of the patient's disease and personal narrative. That is how the doctor-patient relationship is built, enriched and sustained.

If we rely on the new paradigm of professionalism, one grounded in the 'team-patient' relationship, we may fall short of our goals of genuine patient ownership and responsibility. 

Those close to me know that I am not a conservative guy, but on this point, call me old fashioned.

Killer Bugs- We Need New Antibiotics

Killer Bugss- Source NY Times

Although it may ring a bit alarmist, this article,  published in the New York Times, is worth a read. 

Although we have learned much about infection prevention over the last several decades, difficult to treat, or multi-drug resistant organisms exist.

Now, more than ever, we need novel antibiotics.

8th Annual RCFC Copa Navidad- Benefitting the Fan Free Clinic

It is December 9th and time for the Richmond City FC Copa Navidad.  The charity match was held to benefit the Fan Free Clinic.

Once again, we partook in an epic clash of the Richmond City FC Blues vs the Richmond City FC Maroons. The most historic comeback in Copa Navidad history unfolded as the Maroons edged the Blues 10-9 in the waning minutes of the match. Thankfully, there were no bruised egos.  

A special thank you is in order to Tim Krout and SCOR-Sports Center of Richmond for generously donating the use of the indoor soccer field and to Scott Zawadzki, the CVSRA referee who lent his officiating services pro bono to the event.

Happy Holidays.

RCFC Blues

RCFC Maroons

RCFC at the Copa Navidad

RCFC: 40 +....the old guys

The Photographer- Doctors Without Borders/Médecins Sans Frontières (MSF)

For those of you interested in medical relief work, here is a fascinating book titled The Photographer. 

This highly creative, graphic and pictorial book chronicles the covert medical mission of Doctors Without Borders/Médecins Sans Frontières (MSF) into war torn Afghanistan of the 1980s.

What unfolds throughout the book's pages is a glimpse of  rugged, back country medicine, in its grittiest and most elemental form, with a true human focus.  Well worth the read.

I highly recommend it. 

Syphilis, Sex, Drugs and the Internet

Source: UMKC.com

The incidence of syphilis is on the rise, particularly in men who have sex with men (MSM).  I am seeing this far too frequently in the HIV clinic.

Here is an article published in the American Journal of Public Health on the dangerous mix of drugs, in particular methamphetamies, and the use of the internet to meet sexual partners in a cohort of MSM with syphilis.

Using multivariable analysis, methamphetamine use and searching for sexual partners on the internet was significantly associated with an increased number of sexual encounters. Not unexpected.

This underscores the need for comprehensive sexual education, as reviewed here in Sexuality Research and Social Policy. Common sense interventions such as sexual education and the promotion of condom use can have positive public health benefits.  

Hospital Privacy Curtains: Vectors of Contagion?

Well it has been an exceedingly busy week in the hospital on the infectious diseases consult service, keeping me away from many things, including blogging and reading.

Here is an article from the American Journal of Infection Control that caught my eye this morning. Neither the methodology nor the outcome is anything novel. Regardless, the results are worth mentioning.

In the above study, 92% of privacy curtains sampled during the study showed contamination. Forty-one of 43 curtains (95%) demonstrated contamination on at least 1 occasion, including 21% with MRSA and 42% with VRE. Eight curtains yielded VRE at multiple time points: 3 with persistence of a single pulse field gel isolate type and 5 with different types, suggesting frequent recontamination.

Here is a CBS News article related to hospital curtain bacterial contamination study mentioned above.

Privacy curtains between patients in rooms, like much of the hospital's inanimate environment, are teeming with potential pathogens. The relative contribution of curtains to the development of hospital acquired infection is not known.

Perhaps newer technologies, such as antimicrobial textiles, may help limit the bioburden on hospital curtains. Hand hygiene immediately prior to touching a patient is likely of greater benefit.

Wash those hands.