Thursday, February 28, 2013

VCU Global Health and Health Disparities Program- Make a Donation

Water Filter Distribution: 2012
Sustaining a medical relief effort in rural Honduras requires resources.

To make a fully tax free donation, via the MCV Foundation, click here.  On the drop down menu scroll down to ''Global Health and Disparities Program''.

No donation is too small. 

Twenty five dollars will provide potable water, via a water filtration system, for a household for two years.

To learn more about the VCU Global Health and Health Disparities program, click here. For a day by day account of our 2012 Honduras medical relief, click here

Thank you for the support.

Wednesday, February 27, 2013

The White Coat Redux?

Looking cool in a new ''white coat'
The White Coat Redux? Not really, think of it as the white coat reformatted.

Here is an excellent blog post by Mike Edmond titled "My new white coat is a cool black vest".

As of April first, we our new policy of no longer isolating patients for MRSA or VRE infection/colonization. This is an opportune time for us to remind staff about washing their hands, wiping down their instruments, and rolling up the sleeves.

Big changes are afoot at VCU Medical Center.

Monday, February 25, 2013

Dr. House- A Distortion of Reality

I must admit that I find Dr. House entertaining despite knowing that much of it is far fetched. I mean, who typically confirms an exotic diagnosis by means of an instantaneous invasive procedure or laboratory result over the course of minutes?

Here is a paper published in The American Journal of Medicine titled "Dr. House, TV and Reality..."  

French investigators analyzed 18 episodes of House.  Main patient characters were 12 men (66%) and 6 women (33%); the average age was 31 (22-38) years. There were 225 investigations or interventions reported, averaging 14 (9-15) per episode, representing one examination every 3.1 (2.9-4.8) minutes. The most frequently prescribed investigations were magnetic resonance imaging (MRI; 13; 72%), blood sample (11; 61%), and biopsy (10; 56%). The most frequent interventions were surgery, anti-infectious treatments, and steroid treatments (9 each; 50%). Two patients (11%) died. 


Medicine as practiced by Dr. House is a distortion of reality. The patient demographics are skewed (towards younger populations), the number and speed of diagnostic interventions are exaggerated, and the outcomes are overly optimistic.

Although entertaining, this program can be confusing to the public and result in unrealistic diagnostic and treatment expectations.

Friday, February 22, 2013

Addictive! The Science of Junk Food

Source: NY Times Magazine
My graduate seminar at Virginia Commonwealth University, Contemporary Issues and Controversies in Public Health is now in full swing. 

One of the topics covered in the class, by way of the books Fast Food Nation and Food Fight, is the ongoing obesity epidemic in the USA. 

Here is a detailed and well researched article in the New York Times Magazine focusing on the addictive nature of junk food and the manipulative, scientifically driven tactics employed by the food industry to increase consumption. The manipulative tactics to ''optimize'' the appeal of food through sugars, fats, salt and texture is akin to the practices employed by tobacco companies for the sale of cigarettes.  Food advertisement is aggressive and frequently aimed at children, minorities and the poor. Consumers are crassly labeled as ''users'' or ''heavy users'' of a food product.  

The goal is simple: maximize profit.

The obesity epidemic is real. Healthful eating is a challenge.

Wednesday, February 20, 2013

Global Spread of Healthcare Associated Multi-Drug Resistant Bacteria
In the era of modern travel, it should be of little surprise that the global spread of drug resistant, hospital acquired bacteria is a reality.

Here is an article on the global spread of drug resistant healthcare associated bacteria published in Clinical Infectious Diseases. 

The article highlights various trends in the travel of drug resistant pathogens. MRSA spread from the UK and North America across Europe and then Asia over more than a decade. VRE and KPC-producing Klebsiella pneumoniae followed a similar path some 20 years later. Recently, metallo-beta-lactamases originated in Asia.  Within a year,  almost every continent witnessed the appearance of metallo-beta-lactamase producing bacteria.  

Per the authors, global air travel likely facilitated rapid dissemination of the more recent drug resistant organisms. 

Microbial globalization.

Friday, February 15, 2013

Medico della Peste- Plague Doctor

Bongiorno from Firenze, Italia.

In my meanderings through the Old Boot, I came across a plague doctor's mask. As an infectious diseases physician I am naturally attracted to all things plague. I have previously blogged about the loimology, or the study of plague and pestilence.

I purchased one such plague doctor's mask for my home office.


I plan not to wear it in the hospital.

Wednesday, February 13, 2013

Increased Physical Activity - Transit Walking
We are all aware of the ongoing obesity epidemic in the USA. Coupled with a lack of exercise is an excess consumption of calories. Are there novel ways of meeting exercise requirements through everyday tasks? 

Here is an intriguing read from the American Journal of Public HealthThe investigators examined transit walk times using the National Household Travel Survey administered by the US Department of Transportation.

Not surprisingly, people are more likely to transit walk if they are from lower income households, are non-White, and live in large urban areas with access to rail systems.  Of note, however, transit walkers in large urban areas with a rail system were 72% more likely to transit walk 30 minutes or more per day than were those without a rail system.

 From 2001 to 2009, the estimated number of transit walkers rose from 7.5 million to 9.6 million (a 28% increase); those whose transit-associated walking time was 30 minutes or more increased from approximately 2.6 million to 3.4 million (a 31% increase). 

What does this mean? Transit walking may contribute to meeting physical activity recommendations. This study does not assess whether transit walking actually resulted in health benefits for the respondents. Reasonable and sustainable increases in physical activity should not be detrimental, however. 

Here is a prior post on tasks that may get us back to our lean, hunter-gatherer primal selves.

Get off the couch.

Monday, February 11, 2013

Efficacy of Alcohol Based Hand Sanitizers for Enteroviruses

There is no doubt that alcohol based hand sanitizers have revolutionized hand hygiene in the hospital. These products, however, have their limitations. 

Here is an article published in the Journal of Hospital Infection assessing the efficacy of alcohol based hand sanitizers againts Human enterovirus 71 (HEV71) infections.

A common alcohol-based hand disinfectant (0.5% chlorhexidine gluconate + 70% isopropanol) as well as different concentrations of isopropanol and ethanol were tested for virucidal activity against HEV71.

The findings? Widely used alcohol-based hand disinfectants based on 70% ethanol or isopropanol have poor effectiveness against HEV71. Even 95% ethanol did not fully inactivate HEV71. 

For cluster or outbreaks of enteroviral infections, hand hygiene with alcohol-based hand disinfectants is not sufficient to prevent transmission. 

In this setting, we are back to medicated soap and water  to physically remove viral particles from hands.

Friday, February 8, 2013

Stool Transplantation for Recurrent C.difficile Infection- The Evidence Amounts

Nasogastric tube- for infusion of donor feces solution
The evidence supporting stool (fecal microbiota) transplantation for the management of recurrent C.difficile diarrhea continues to flourish. I have previously blogged about this before, in reference to the stool transplantation donor.

Here is a randomized control trial of fecal microbiota transplantation published in the New England Journal of Medicine.

The randomized assignments were one of three therapies: an initial vancomycin regimen (500 mg orally four times per day for 4 days), followed by bowel lavage and subsequent infusion of a solution of donor feces through a nasoduodenal tube; a standard vancomycin regimen (500 mg orally four times per day for 14 days); or a standard vancomycin regimen with bowel lavage. The primary end point was the resolution of diarrhea associated with C. difficile infection without relapse after 10 weeks.

The study was stopped after an interim analysis. Of 16 patients in the infusion group, 13 (81%) had resolution of C. difficile–associated diarrhea after the first infusion. The 3 remaining patients received a second infusion with feces from a different donor, with resolution in 2 patients. Resolution of C. difficile infection occurred in 4 of 13 patients (31%) receiving vancomycin alone and in 3 of 13 patients (23%) receiving vancomycin with bowel lavage (P<0.001 for both comparisons with the infusion group).

Of note, there were  no significant adverse events reported. 

For recurrent C.difficile infection, stool transplantation may be the new standard of care.

Thursday, February 7, 2013

Effect of Daily Chlorhexidine Bathing on Hospital-Acquired Infection: Again

The data supporting chlorhexidine bathing of hospitalized patients continues to grow.

Here is a multicenter, cluster-randomized, nonblinded crossover trial to evaluate the effect of daily bathing with chlorhexidine-impregnated washcloths on the acquisition of MDROs and the incidence of hospital-acquired bloodstream infections. The study was published just this week in the New England Journal of Medicine.

Nine intensive care and bone marrow transplantation units in six hospitals were randomly assigned to bathe patients either with no-rinse 2% chlorhexidine–impregnated washcloths or with nonantimicrobial washcloths for a 6-month period, exchanged for the alternate product during the subsequent 6 months. .

A total of 7727 patients were enrolled during the study. The overall rate of MDRO acquisition was 5.10 cases per 1000 patient-days with chlorhexidine bathing versus 6.60 cases per 1000 patient-days with nonantimicrobial washcloths (P=0.03), the equivalent of a 23% lower rate with chlorhexidine bathing. The overall rate of hospital-acquired bloodstream infections was 4.78 cases per 1000 patient-days with chlorhexidine bathing versus 6.60 cases per 1000 patient-days with nonantimicrobial washcloths (P=0.007), a 28% lower rate with chlorhexidine-impregnated washcloths. 

As with previous studies, no serious skin reactions were noted during either study period.

The data supporting chlorhexidine patient bathing, in adult populations, is now irrefutable. Failure to implement is a failure to practice evidence based infection prevention. 

Wednesday, February 6, 2013

Clostridium difficle in the Local News- Richmond, VA

Dr. Michael Edmond
Clostridium difficile is a hot topic in both the medical and evening news. 

Here is a link to a recent investigative report on Clostridium difficile by the Richmond NBC affiliate. The video clip features my colleagues Dr. Amy Pakyz and Dr. Michael Edmond.

Here is a television report on the fecal transplantations that we perform at VCU Medical Center.

Monday, February 4, 2013

Simulated Practical Exam in Internal Medicine- Congratulations Dr. Cheryl Bodamer

Dr. Cheryl Bodamer
Congratulations to Dr. Cheryl Bodamer for her successful presentation of our research on simulation in internal medicine. 

Although I am less involved now in medical education, I am proud to be a co-investigator in Cheryl's poster titled An Initial Validation of the Internal Medicine Simulated Practical Exam (IMSPE) for 3rd Year Medical Students. The research was presented at the International Meeting on Simulation in Healthcare, Orlando, Florida, January 26-30.

Using an online photo-quiz, the i-Stan simulator and the Harvey Cardiac Simulator, we have developed a standardized exam to assess clinical and knowledge competencies of third year medical students.

This is one additional assessment tool to confirm clinical competency in medical education.

Stay tuned, a manuscript is forthcoming. 

Friday, February 1, 2013

Blood and Body Fluid Exposure in the OR- Transmission of Hepatitis B from an Orthopedic Surgeon to Two Patients

Blood and body fluid exposures are typically associated with risk of bloodborne pathogen infection from patient to provider. Here is a recent report in Clinical Infectious Diseases on the transmission of Hepatitis B from an orthopedic surgeon to several patients.

During the evaluation of a needle-stick injury, an orthopedic surgeon was found to be unknowingly infected with hepatitis B virus (HBV) (viral load >17.9 million IU/mL). The surgeon had previously completed two 3-dose series of hepatitis B vaccine without achieving a protective level of surface antibody. 

The investigators performed a retrospective cohort study of all patients who underwent surgery by the surgeon.  A total of 232 (70.7%) of potentially exposed patients consented to testing of HBV by DNA sequencing; 2 were found to have acute infection and 6 had possible transmission (evidence of past exposure without risk factors). Genome sequence analysis of HBV DNA from the infected surgeon and patients with acute infection revealed genetically related virus (>99.9% nucleotide identity). 

 Here are several important points:
  • All healthcare workers must be vaccinated for Hepatitis B and adequate response to vaccination must be documented.
  • For those who fail to mount a response to the HBV vaccine, underlying infection with HBV must be excluded
  • For healthcare workers with HBV infection, restrictions on invasive procedures must be in place as guided by an institution's bloodborne pathogens committee

The risk of doctor-patient bloodborne pathogen exposure is real, and it goes both ways.

Safety first, always.