Monday, April 29, 2013

US Healthcare System- Falling Behind

If you think that the US healthcare system is a model to emulate, think again. Here is an eye opening report recently published by the Institute of Medicine

US males and females in almost all age groups (up to age 75 years) have shorter life expectancies than their counterparts in 16 other wealthy, developed nations: Australia, Austria, Canada, Denmark, Finland, France, Germany, Italy, Japan, Norway, Portugal, Spain, Sweden, Switzerland, the Netherlands, and the United Kingdom. The scope of the US health disadvantage is pervasive and involves more than life expectancy: the United States ranks at or near the bottom in both prevalence and mortality for multiple diseases, risk factors, and injuries.

Our healthcare system is very good at providing high priced care, ordering expensive diagnostic tests, and performing costly elective procedures and surgeries. We are poor at preventing and managing diseases and chronic illnesses. Great disparities exist across US populations with respect to healthcare access, quality and outcomes.  

Sadly, I see this often during an average day's work.

The reasons for our healthcare shortcomings are multiple, as outlined in this viewpoint, and likely are the result of a myriad of factors including:
  • Lack of universal healthcare
  • Socioeconomic inequalities in the USA which include disparities in income and significant pockets of poverty
  • Excessive calorie consumption and rampant obesity 
  • High levels of drug abuse
  • High ownership of firearms with resultant gun violence, gun related accidents and suicides
  • Lower prevalence of safe sex in adolescents, lack of comprehensive sexual education
  • Cultural views about the government and personal autonomy/responsibility
  • Weaker public investment in early childhood education and safety net programs
Those who feel that our healthcare is superior to all are misinformed.   

Saturday, April 27, 2013

VCU Global Health Symposium 2013: Our Stellar Research Team

Today was the inaugural VCU Global Health Symposium. The purpose of the symposium was to engage the VCU community on collaborative global health outreach projects. 

During the scientific poster sessions, our Honduras medical relief research team was reunited.

Kudos to our stellar students.

L-R: Kate Pearson, Jackie Arquiette, Gaby Halder, Audrey Le, Dr. Michael Stevens

Friday, April 26, 2013

The Environment and Infection Control- Making Progress Yet Questions Remain

The may issue of Infection Control and Hospital Epidemiology explores the role of the environment in infection prevention. The exact impact of the environment as source or cause of a hospital acquired infection remains debatable. It is estimated that 20% of all hospital acquired infection may be environmental in origin while 40%-60% are from a patient's endogenous flora, 20%-40% are from cross infection via HCW hands and 20%-25% are from antibiotic driven changes in flora.

Here is an interesting article in this issue exploring the impact of copper textile surfaces on hospital acquired infections.  The investigators determined whether placement of copper alloy-surfaced objects in an intensive care unit (ICU) reduced the risk of hospital acquired infection (HAI) across the ICUs of three hospitals. Patients were randomly placed in available rooms with or without copper alloy surfaces, and the rates of incident HAI and/or colonization with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) in each type of room were compared.

The rate of HAI and/or MRSA or VRE colonization in ICU rooms with copper alloy surfaces was significantly lower than that in standard ICU rooms (0.071 vs 0.123; P=0.02).  Patients cared for in ICU rooms with copper alloy surfaces had a significantly lower rate of incident HAI and/or colonization with MRSA or VRE than did patients treated in standard rooms.

These findings are tantalizing. A significant study weakness is that hand hygiene and disinfection practices were not monitored closely. These are significant confounders. In addition, it is neither cheap nor easy to widely install copper impregnated surfaces across the hospital environment.

How incrementally beneficial are technologies, such as copper impregnated surfaces, atop other infection prevention strategies and how should this technology be best employed, particularly given the cost? This is the million dollar question.

We have made progress but have yet to define the optimal strategy for textiles in infection prevention. 

Wednesday, April 24, 2013

Sprinting Toward the End- A Psychologically 'Good Death'?

Source: NY Times
Here is an article titled Sprinting Toward the End, published in the New York Times.

The article explores the idea that it has become obligatory for some people with terminal illnesses to work like dogs during their final months or years. For these patients, this may be their definition of a 'good death', perhaps with psychological benefits.

I am by no means an expert on the psychology of death and dying, however, I have witnessed this phenomenon in at least one terminally ill patient, who never let go of the trade and practice that made his life meaningful and rewarding. In the end, his work eased his suffering. I have given a lot of thought to this patient and have written a reflective essay which will likely publish in the Fall edition of the Medical Literary Messenger

We can learn a lot from our patients.

Monday, April 22, 2013

Antiretrovirals Before Sex for Adolescents and Young Adults at Risk for HIV Infection

I have previously blogged about the the use of antiretrovirals before sex, so called pre-exposure prophylaxis. Here is a recent article that explores the concept of HIV pre-exposure prophylaxis for adolescents and young adults who have sex with men.

I still cannot get excited about pre-exposure prophylaxis as a HIV transmission strategy. The hurdles are many and include cost (this may not be covered by insurance), side effects, the emergence of viral resistance and the fact that retrovirals have no impact on the prevention of other sexually transmitted infections such as syphilis, gonorrhea, chlamydia, gential warts and herpes.

In my opinion, pre-exposure prophylaxis is an inferior HIV prevention strategy when compared to comprehensive sexual education and the aggressive promotion of condoms

Call me old fashioned.

Friday, April 19, 2013

The Medical Literary Messenger Has Launched!

It has launched! As the Editor in Chief, I am very excited about it!

The editorial board of Medical Literary Messenger invites you to submit original prose, poetry or photography concerning the healing arts for the fall 2013 debut of our online literary magazine. Our journal is dedicated to the art of medicine and creative expression. We believe in the unifying power of sharing our experience with health and health care, therefore our call for submissions is open to everyone.

Submissions will be accepted electronically from now through July. 

Please visit our website for more information:

Virginia Society of Health-System Pharmacists

I was in Roanoke, VA this morning with colleagues Drs. Kim Lee and Michael Stevens, at the Virginia Society of Health-System Pharmacists annual meeting.

My lecture was on Clostridium difficile infections while Drs. Lee and Stevens covered antimicrobial stewardship.

Successful morning.

Wednesday, April 17, 2013

Getting Beyond MRSA- Controlling MSSA Infections

Over the last several decades we have focused more on infections caused by methicillin resistant Staphylococcus aureus (MRSA) than methicillin susceptible Staphylococcus aureus.  The prevalence of MSSA at hospital admission is greater than MRSA. The risk of infection is higher in MRSA carriers versus MSSA. Regardless, MSSA infections are of consequence and epidemiologocally important.

Here is a thought provoking review article in the Journal of Hospital Infection on controlling MSSA infections. The paper neatly summarizes the current knowledge on staphylococcal carriage, microbiological strategies for screening, and the impact of MSSA decolonization on staphylococcal hospital acquired infections.

Recent studies suggest that MSSA decolonization reduces S.aureus surgical site infections.
Questions remain about the optimal screening strategy and the added value of throat and skin decolonization atop nasal mupirocin use. 

Where I work, our strategy is to MRSA screen patients undergoing elective surgeries in cardiothoracic, neurosurgery and orthopedic prosthetic joint implantation.  Patients who are MRSA colonized are decolonized with chlorehexidine and intranasal mupriocin and vancomycin is the perioperative antibiotic of choice. 

Although both are uncommon, MSSA infections exceed MRSA infections at my hospital.

Perhaps we should rethink this approach and add MSSA to the decolonization protocol.  

Monday, April 15, 2013

How to Stay Healthy: Hang Out with People Who Are Healthier Than You

Dr. Mike Merrill- Source: Buffalo News
Physicians have views on health and wellness. 

Here is a quote from Dr. Michael Merrill, a colleague and classmate of mine from SUNY at Buffalo School of Medicine and Biomedical Sciences.

On advice for people who want to stay healthy: “Hang out with people who are healthier than you."

Read more on his medical perspective in this article published in The Buffalo News.

Staying fit and healthy is a challenge given ''...the downside of the great luxury we have in the world. You don’t have to get off the couch.''

Saturday, April 13, 2013

The Frozen Blogger on the Streets of Montreal

I am spending a Spring weekend in snowy Montreal. 

Despite the chill, the city is charming.

Idleness is delightful.

Thursday, April 11, 2013

The Busy Trap- Learn to Embrace Idleness

I am going to tread away from my comfort zone today. 

I re-read an essay titled The 'Busy' Trap in the New York Times wherein author Tim Kreider explores the ''so busy'' or the ''crazy busy'' self perception, a boast disguised as a complaint.

But need we really be that busy? The essay suggests that most busyness is purely self-imposed: work and obligations . The purpose of busyness may be to make us feel reassured, meaningful and save us from loneliness.

We need not be busy all time. With periodic idleness, solitude or lazy time, we can actually be more effective and efficient when time sensitive tasks and work obligations are due. Mindfulness is an effective skill that focuses the mind, eases stress and allows for 'down time.'

Here is a scholarly review article on the health and wellness benefits of mindfulness.

Embrace idleness. 

Wednesday, April 10, 2013

Hand Hygiene from the Patient's Perspective

Can the participation of patients in a hand hygiene program increase hand washing?  if so, what motivates patients to do so? 

Here is an article on hand hygiene from the patient's perspective. The study was performed over a  2-week period utilizing an anonymous, voluntary cross-sectional survey of hospitalized patients and their family members.

Of the 859 respondents, 89% considered hand hygiene important, and 75% would take hand hygiene practices into consideration when they choose a hospital. Most respondents (78.4%) would like more information on hand hygiene, particularly persons who have had experience with health care–associated infection (odds ratio, 2.48; 95% confidence interval, 1.57-3.89; P < .001). Respondents would be more willing to ask a doctor or nurse to wash his or her hands if they knew that the doctor or nurse would appreciate the reminder (doctor: from 48.9% to 74.6% [P < .001]; nurse: from 50.8% to 76.3% [P < .001]).

It seems obvious that having had a prior hospital acquired infection would motivate a patient to remind the doctors to wash their hands. How about the rest of the patients? How could they be mobilized as agents of hand hygiene? Despite understanding the importance of hand hygiene, patients balk at reminding doctors to wash their hands. This will be an ongoing challenge.

In the end, there is no single, best way to improve and sustain hand hygiene, as I have previously blogged. 

Monday, April 8, 2013

Patient Narratives and Surgical Site Infection

Those close to me know that I believe in the value of narrative as a means for better understanding illness and the human condition.

A greater understanding of patients' experiences within healthcare is helpful to improve clinical care. Here is a recent article on the value and potential use of patient narratives of surgical site infections. 

Narrative interviews were performed on 17 patients with surgical site infections [SSIs (four deep, 12 organ space and one superficial)] from three hospitals in the UK.

The results are telling. Patients lacked overall awareness, concern and understanding of SSIs. Seven patients did not know that they had SSIs. 

In my opinion, it is important for patients to have a clear understanding of their medical care. This would allow for more realistic expectations, improved outcomes and may ease suffering.  In this study, SSIs had a low profile and understanding among patients. If post surgical care were better understood by patients, SSI detection and prevention could be enhanced. 

Narrative medicine matters, even in surgical patients.

Wednesday, April 3, 2013

Sexually Transmitted Infections and Adult Film Stars: Occupational Hazard

Adult film performers are at an occupational risk for sexually transmitted infections (STIs). Here is manuscript published in Sexually Transmitted Diseases on STI testing of adult film performers in California. Keep in mind, working in adult films is legal and workers should be subject to the same workplace safety standards seen in other industries. As such, the results are truly concerning.

During the 4-month study period, the performers were offered oropharyngeal, rectal, and urogenital testing for Gonorrhea, and rectal and urogenital testing for Chlamydia. A total of 168 participants were enrolled: 112 (67%) were female and 56 (33%) were male. Of the 47 (28%) who tested positive for Gonorrhea and/or Chlamydia, 11 (23%) cases would not have been detected through urogenital testing alone. Gonorrhea was the most common STI (42/168; 25%) and the oropharynx the most common site of infection (37/47; 79%).  More importantly, thirty-five (95%) oropharyngeal and 21 (91%) rectal infections were asymptomatic. Not surprisingly,  few participants reported using condoms consistently while performing or with their personal sex partners.

The Adult Industry Medical Health Care Foundation was founded to provide HIV testing and urinary chlamydia and gonorrhea testing of adult film performers. As the tests are voluntary and as chlamydia/gonorrhea testing is on urinary samples only, many sub-clinical infections are missed.  

Like Nevada brothel workers, condoms should be required by law for all sex acts and STD testing, at all anatomic sites, should be mandatory and regular. 

Safety first, every day.

Monday, April 1, 2013

Simone's Maxims: Understanding Academic Medical Centers

The Ivory Tower
Recently a colleague tipped me off on a 1999 paper titled Understanding Academic Medical Centers: Simone's Maxims. I recommend anyone associated with an academic medical center to read, study and learn the truths in this manuscript. Of the many relevant and seemingly timeless points, here are a few:

Institutions Don’t Love You Back. True. And, on further thought, it is the relationships with people, staff and select colleagues at an institution that make the experience memorable and meaningful, not the institution itself.
For Academic Leaders, the Last 10% of Job Accomplishment May Take as Much Time as the First 90% and May Not Be Worth the Effort. Absolutely. Know when to leave the party, preferably while the party's still full.
Faculty Fired for Incompetence Will Almost Always Land a Better Job at Higher Pay. Eyeopening.
With Rare Exceptions, the Appropriate Maximum Term for an Academic Leader/Administrator Is 10 Years, Plus or Minus 3 Years. This must be why, subconsciously, I bowed out of the Internal Medicine Clerkship Directorship at 7 years.
Leaders Are Often Chosen Primarily for Characteristics That Have Little or No Correlation with a Successful Tenure as Leader. Being a good clinician or researcher does not always translate into a successful leader or team manager.
Academic Battles Are Recurring and Continuous, and No One Can Win Them All. Definitely, pick your battles wisely. No one can go undefeated in either life or sport.
Last,  Academic Medicine Is a Noble Calling. Yes! I could not agree more.

I would encourage you to read the full manuscript. It is most enlightening.