Social Determinants of Health: Homelessness and Tuberculosis

This article in the American Journal of Public Health caught my eye.

Most clinicians know that poverty and homelessness is associated with tuberculosis infection and disease. Here is a unique article that attempts to quantify the risk and incidence of tuberculosis in a cohort of homeless persons in Houston, Texas. 

What emerged was rather lopsided incidence of tuberculosis in homeless people. The average incidence per 100 000 was 411 among homeless and 9.5 among housed persons. The homeless were more likely than the housed to be US-born, clustered, and in a larger-sized cluster.  Using multivariable analysis, independent risk factors for TB rates were social determinants and not comorbidities. 

Homelessness is urban blight.

Hand Hygiene- Missed Opportunities

I recently attended an excellent lecture titled "Hand Hygiene: Thinking Outside the Box" by Dr. Michael Edmond.  One message in the lecture is that hand hygiene opportunities are nearly innumerable during the course of patient care at the bedside. 

Why? Even after hand hygiene, re-contamination of the hands is common by touching the inanimate environment (bedside table, stethoscope, reflex hammer, pen, computer keyboard, bedside monitor, IV pole etc) at the point of care. 

Here is an article in the Journal of Hospital Infection on common hand hygiene (missed) opportunities.

Fifty-eight 90 min sessions of unobtrusive observation were made in open bays and isolation rooms.  Hand-hygiene audits were conducted using the World Health Organization ‘five moments for hand hygiene’ observational tool.

In critical care, the majority of activity occurred within the bed space. The bedside computer and equipment trolley were the surfaces most commonly touched, often immediately after patient contact. In the general ward, movement between bed spaces was more common and observed hand hygiene ranged from 25% to 33%. Regardless of ward type, observed hand-hygiene compliance when touching the patient immediately on entering an isolation room was less than 30%.

Contamination of the hands after direct contact with the inanimate environment is perceived as low risk. Hand hygiene must be meticulous at the point of care, even after touching the inanimate environment.

Flushing the Toilet- A Potential Health Hazard

I am by no means the most senior or experienced physician at Virginia Commonwealth University but I have been at it long enough to meaningfully say that I have never heard of research on this one before: toilet flushing aerosols as an infectious diseases risk. Here is an article published on the matter in the American Journal of Infection Control.

The authors searched the  peer-reviewed scientific literature to identify articles related to aerosol production during toilet flushing, as well as epidemiologic studies examining the potential role of toilets in infectious disease outbreaks.

The findings are intriguing and suggest that potentially infectious aerosols may be produced in  during flushing. Aerosolization can continue through multiple flushes thereby. Some of the aerosols desiccate to become droplet nuclei and remain adrift in the air currents. 

Of note, however, no studies demonstrated or refuted toilet plume-related disease transmission.

The aerosols generated by flushing a toilet could represent a risk for transmission although the significance remains unknown. I still prefer a flushing toilet over a non-flushing latrine however!

As always, after flushing the toilet, wash your hands and perhaps hold your breath.

Congratulations Kate Pearson- 2013 CUGH Conference

Once again, kudos to VCU medical student Kate Pearson.

This time Kate was at the Consortium of Universities for Global Health Conference, March 14-16, in Washington, DC.

The focus of her work was a pilot survey of satisfaction with the healthcare provided by the VCU Global Health and Health Disparities Honduras medical relief program.

Read more about her research project here.

Kate will join us in June 2013 for the next medical relief mission. In addition to clinical care, Kate will continue her research on patient satisfaction and perceptions of the quality of care delivered by our team.


Upwards and onwards.

Bacterial Contamination of Cell Phones- Revisited

Here is a recent article in Journal of Hospital Medicine on bacterial contamination of smartphones. I have previously written about bacterial contamination of mobile phones on this blog both here and here. 

One hundred fifteen (56.7%) participants used smart phones, and 88 (43.3%) used non-smart phones. Bacteria with pathogenic potential were isolated from 58 (28.6%) mobile phones, more often from smart phones than from non-smart phones (34.8% vs 20.5%, P=0.03). Using multivariaable analysis, smart phones (vs non-smart phones) were a significant risk factor for contamination by bacteria of pathogenic potential (adjusted odds ratio [OR], 4.02; 95% confidence interval [CI], 1.43-11.31). 

Like much of the inanimate environment, (smart)phones are colonized with bacteria. The impact on cross transmission of hospital acquired pathogens is not known. 

This get us back to the basics. Our hands are constantly in touch with the animate and inanimate environment. Handwashing prior to patient care remains the key risk reduction factor and must be practiced religiously.

The Importance of Bedside Nurses for the Reduction of Urinary Catheter Use

This week I am giving the VCUHS Forum Grand Rounds on infection prevention and safety. A topic of discussion is the prevention of urinary catheter associated infections.  Unfortunately, urinary catheters are overused, frequently without appropriate indications thereby predisposing patients to urinary tract infections.

Here is a timely article in the American Journal of Infection Control on the importance of the bedside nurse for the evaluation of urinary catheter necessity. The study reports the effect of 3 interventions over 5 years: a nurse-driven multidisciplinary effort for early urinary catheter removal, an intervention in an emergency department to promote appropriate placement, and twice-weekly assessment of urinary catheter prevalence with periodic feedback on performance.

The investigators assessed the views of bedside nurses, case managers, and nurse managers with respect to appropriate catheter use, how often need is assessed, and who they consider responsible for the evaluation of urinary catheter need.

The outcome: a significant reduction in urinary catheter use from 17.3%-12.7% during the 5-year period (linear regression with time as independent variable, R2, 0.61; P < .0001) was documented. Of bedside nurses, 222 of 227 (97.8%) identified themselves as responsible or as sharing the responsibility for catheter necessity evaluation, 223 of 229 (97.4%) were confident in their knowledge, and 166 of 222 (74.8%) viewed physicians as receptive to their requests for catheter removal >70% of the time.

Nurses are critically important front line providers and their opinions matter. Sustained reductions in urinary catheter use is impossible without their enthusiasm and collaboration.

The Value of a Formal Infectious Diseases Consult

Those who work closely with me know that I prefer to convert curbside consultations to formal consultations. Why? Well, since I am not a fee-for-service private doctor, finances are not a consideration. Rather, I have always felt that curbside or telephone consults are performed with inadequate clinical information to result in meaningful diagnostic and management recommendations.

Here is a paper recently published in Clinical Infectious Diseases that highlights the clinical value of a formal infectious diseases consultation compared to a telephone consultation for the management of S.aureus bacteremia.

The investigators retrospectively studied 342 S.aureus bacteremia (SAB) episodes with 90-day follow-up. Patients were grouped according to bedside, telephone, or no infectious diseases service (IDS) consultation within the first week. 

Seventy-two percent of patients received bedside, 18% telephone, and 10% no IDS consultation. Patients with bedside consultation were less often treated in an intensive care unit during the first 3 days compared to those with telephone consultation (odds ratio [OR], 0.53; 95% confidence interval [CI], .29-.97; P = .037; 21% vs 34%), with no other initial differences between these groups. Patients with bedside consultation more often had deep infection foci localized as compared to patients with telephone consultation (OR, 3.11; 95% CI, 1.74-5.57; P < .0001; 78% vs 53%). Patients with bedside consultation had lower mortality than patients with telephone consultation at 7 days (OR, 0.09; 95% CI, .02-.49; P = .001; 1% vs 8%), at 28 days (OR, 0.27; 95% CI, .11-.65; P = .002; 5% vs 16%) and at 90 days (OR, 0.25; 95% CI, .13-.51; P < .0001; 9% vs 29%). Considering all prognostic markers, 90-day mortality for telephone-consultation patients was higher (OR, 2.31; CI, 95% 1.22-4.38; P = .01) as compared to bedside consultation.

The bottom line, in cases of SAB infectious diseases consultation was associated with decreased mortality. Patients with a formal infectious diseases consult likely underwent more thorough assessment, including additional diagnostic testing and more appropriate duration of antibiotic treatment. 

If available, a former infectious diseases consult is better than an over the telephone or curbside consult.

VCU Health System Forum Grand Rounds: Infection Prevention Update- The State of the Art

For those of you from VCU Health System who have an interest in hospital infection prevention, I will be the lecturer at next week's Forum Grand Rounds. I will overview the state of the art in infection prevention with special emphasis on the upcoming changes in contact isolation precautions  at VCU Medical Center.        

Here is the official VCUHS Bulletin:

This Forum Grand Rounds will feature Gonzalo Bearman MD, MPH, of the Internal Medicine and Infectious Diseases Service at VCU Medical Center. Dr. Bearman will speak on Infection Prevention Update:  The State of the Art.

There will be two offerings of this Grand Rounds:  One on March 12th, 2013 (7:30 AM) and the second on March 13th, 2013 (1 PM). 

No advance registration required -- just bring your ID badge!

Grade Inflation in the Internal Medicine Clerkship- The Lake Wobegon Effect

During my tenure as the Internal Medicine Clerkship Director at Virginia Commonwealth University, we developed a grading process that mitigated grade inflation.  

For an honors or high pass grade, students had to meet certain standards across various metrics including ward evaluations, observed structured clinical examinations (OSCEs), team-based learning exams (TBL) and the written examination. In the end, an honors student was globally excellent across all performance metrics. 

The result: the proportion of Honors students went from 50% to 15%-20%. Despite the criticisms, our students fared exceptionally well in the national residency match program. 

Here is an article recently published on grade inflation in the internal medicine clerkships across the USA. A majority of clerkship directors reported that grade inflation still exists. More concerning, howoever, many noted students who passed despite the clerkship director believing they should have failed.

Here is a corresponding article in the New York Times that explores how failing medical students do not receive failing grades.

Call it the Lake Wobegon Effect of medical school, where every medical student is above average. 

Smoking and HIV Don't Mix!

Source: drugfree.org

I am always bewildered by my HIV positive patients who are exceedingly concerned about their HIV viral loads, CD4 counts, dietary supplements, cholesterol profiles and healthy lifestyles, yet continue to smoke. 

Here is an article from Clinical Infectious Diseases on the attributable mortality of smoking in HIV positive patients.

A total of 2921 HIV patients and 10,642 controls were followed for 14 281 and 45 122 person-years, respectively. All-cause and non-AIDS-related mortality was substantially increased among smoking compared to nonsmoking HIV patients. A 35-year-old HIV patient had a median life expectancy of 62.6 years (95% CI, 59.9-64.6) for smokers and 78.4 years (95% CI, 70.8-84.0) for nonsmokers; the numbers of life-years lost in association with smoking and HIV were 12.3 (95% CI, 8.1-16.4) and 5.1 (95% CI, 1.6-8.5). The population-attributable risk of death associated with smoking was 61.5% among HIV patients and 34.2% among controls. 

Even when HIV care is well organized and antiretroviral therapy is free and accessible, HIV-infected smokers lose more life-years to smoking than to HIV.

The bottom line: among HIV infected smokers the rate of non-AIDS related death was raised >5 fold and the majority of these deaths were from cardiovascular (heart) disease and cancers.

If you are concerned about your health, quit smoking.

Destiny of the Republic

Here is a fascinating read titled Destiny of the Republic by Candice Millard. The assassination of President James Garfield is examined from a different perspective: how his doctors mismanaged a non-fatal bullet wound, ultimately leading to his death. Despite well known medical advances such as surgical antisepsis by Dr. Joseph Lister and the germ theory of disease by Dr. Louis Pasteur, many American physicians, including those treating James Garfield, openly opposed these advances and refused to modify their practices. The result for James Garfield was tragic.

Even in the era of modern medicine, we still have physicians, surgeons and nurses who resist infection prevention practice change even when driven by sound science. This is not simply my personal observation, the phenomenon has been described in an article titled How Active Resistors and Organizational Constipators Affect Health-Care Acquired Infection Prevention Efforts.

In the end, evidence based medicine trumps anecdotes and a "this is just the way we do things around here'' mentality.

Quite simply,  you can't stop progress.