Honduras 2013- Second Day / Segundo Día

I awoke early today to a strong cup of Honduran coffee. The team and the trucks are ready to head up the mountain. We have a busy clinic s schedule over the next six days.

We will be out of contact for most of the week as the mountains are without mobile coverage. More details on Saturday.

Me desperté bien temprano esta mañana para disfrutar de una auténtica y cargada tasa de café hondureño. Tanto el equipo como las camionetas están listos para escalar la montaña. Tenemos un horario de consultorio bastante programado para la semana que viene.

Vamos a estar fuera de contacto hasta el sábado. No hay cobertura celular en las montañas. Habrá más detalles el fin de semana que viene.

Cheers / Ciao-

Honduras 2013- First day / Primer día

Finally arrived in Olanchito after a long day and a long drive. Tonight we prepared medicines for the comic week. Stay tuned.

Hemos llegado tras un día largo y agotador. Esta noche preparamos los medicamentos para la semana que viene.
Manténgase al tanto del viaje a través de mi blog.

Honduras 2013- VCU Global Health and Health Disparities Set to Depart

The Blogger- in La Hicaca, Honduras
Photo credit: MP Stevens

It has been a grinding and long week on the infectious diseases consult service at VCU Medical Center. The volume of patient care has limited my ability to read and write. Drag.

A change of pace is in order. We are off to Honduras bright and early on the 26th of May for our 2013 VCU Global Health and Health Disparities relief trip. A busy week is planned.

For a detailed synopsis of the 2012 trip, click here. For a summary of the January 2013 planning trip, click here.

Stay tuned and check back over the following week for blog updates in country.

Think Outside the Box: Meningococcal Vaccination in Men Who Have Sex With Men

Every now and then, one has to think outside of the box and practice medicine

Source: NY Times

unconventionally.

Here is an article on Dr. Demetre Daskalakis, an infectious diseases specialist and gay rights advocate in New York City. Using meningococcal vaccine provided by the NYC Department of Health and Mental Hygiene, the Dr. Daskalakis is vaccinating men at risk for menigicoccal meningitis in unlikely places, gay night clubs.

The vaccine initiative is a a response to a cluster of cases in invasive meningococcal among men who have sex with men in NYC. Click here for the CDC-MMWR report on the outbreak.

Unusual medical circumstances at times require unconventional public health interventions.

Well done.

Childhood Poverty- The Shameful Truth

I am headed back to Honduras with VCU Global Health and Health Disparities Program in less than 10 days, where poverty and its related health and social consequences are unavoidable and seemingly ubiquitous.

Poverty is not exclusively an issue of developing countries. Here is an NY Times Blog on poverty as a childhood disease. The effect of poverty on children go beyond health matters and impact education and achievement.

The American Academy of Pediatrics has published a call to action on childhood poverty.

Childhood poverty in modern society should shame us into action.

Asymptomatic Clostridium difficile Carriage- Uncharted Waters

Here is a recent publication on C.difficile carriage authored by my colleague and SHEA Guidelines Committee collaborator, Dr. Surbhi Leekha.

The investigators assessed the first stool sample after admission from consenting patients and tested it for toxigenic C.difficile  using polymerase chain reaction. .

Of 320 participants, 31 (9.7%) were positive for toxigenic CD. Using multivariate logistic regression, independent predictors of C.difficile  colonization were recent hospitalization (odds ratio [OR], 2.45; 95% confidence interval [CI]: 1.02-5.84), chronic dialysis (OR, 8.12; 95% CI: 1.80-36.65), and corticosteroid use (OR, 3.09; 95% CI: 1.24-7.73). Screening patients with risk factors (48% participants) would identify 74% (95% CI: 55%-88%) of C.difficile  carriers.

These findings are important. So what happens next?

The implications are unclear. I hope that we do not get carried away as we did with active detection and isolation of MRSA, a strategy which is falling out of favor in some healthcare settings.  In other words, I hope that we do not begin widespread active detection and isolation for C.difficile carriage anytime soon. Rather, infection prevention measures such as hand hygiene (with soap and water, to physically remove spores from the hands), robust terminal disinfection of patient rooms with sporicidal agents and judicious antibiotic use with oversight from an antibiotic stewardship program should be vigorously promoted across all populations to control endemic C.difficile infection. This is all part of a horizontal infection control strategy.

The asymptomatic carriage of C.difficile needs to be studied further.

An Infectious Diseases Raconteur- The Doctoring of Mother Theresa

Dr. George Lombardi, an infectious diseases specialist, recounts his personal story of a young doctor who is whisked halfway across the globe to care for an ailing international religious icon, namely Mother Theresa.

The story can be heard here (then click on segment 1) on The Moth Radio Hour.

Dr. Lombardi's services were required as infectious diseases doctors ''know a lot about very weird things."

The story is earnest, comical, vivid and touching. It also underscores the methodical and careful approach to patient care, the primacy of patient advocacy and the need, when unusual circumstances arise, to push beyond one's medical comfort zone.

At the story's end, Dr. Lombardi is regarded as a "Rock Star" in the Convent.

Rock on.

Nurse-Patient Ratio! A Matter of Safety.

This week is National Nurses Week and the event has been well celebrated at VCU Medical Center.

In honor of National Nurses Week, I would like to highlight this article on nurse-patient ratios published in the Annals of Internal Medicine.

The bottom line: higher nurse staffing decreases mortality, very much in a dose-response fashion. We need adequate numbers of nurses to provide safe, reliable care.  

There are no shortcuts.

Nurses, thank you for all that you do for our patients

Update in Infectious Diseases 2012: Less is More

Part of the allure of infectious diseases, in addition to the pleasurably long hours, is the dynamic nature of the specialty. The infectious diseases literature is replete with new revelations and paradigm shifts in diagnosis and management.

Here is an excellent update from the American College of Physicians on clinical infectious diseases. 

The topics include, sinusitis, azithromycin drug toxicity, and the management of asymptomatic bacteriuria in women with recurrent urinary tract infections.

The underlying theme: stop prescribing so many antibiotics as outcomes are not improved (sinusitis and asymptomatic bacteriuria) and as there is a risk of harm (increased risk of cardiac death with azithromycin for patients with underlying cardiac disease).

For the conditions above, changing clinical practice may be tough. For many, the urge to reach for the prescription pad is strong and difficult to contain. Patients expect an antibiotic for many common, non-life threatening infections, despite the absence of proven benefit. This is a dangerous mix.

Less is more. Exciting times!

Patient Empowerment and Hand Hygiene

It has been a long two weeks on the internal medicine ward service. I am now free, for a bit at least, and back to blogging.

Achieving 100 percent hand hygiene compliance is an illusory dream. There is no single effective method for permanently improving hand hygiene. Strategies include surveillance and feedback, electronic prompts and monitoring, educational campaigns, strategic reminder posters and patient empowerment. An excellent review article on hand hygiene can be found here.

Here is an article summarizing patient empowerment and hand hygiene. The paper reviews the current literature on patient willingness to be empowered, barriers to empowerment, and hand hygiene programs that include patient empowerment and hand hygiene improvement. 

Several studies suggests that patients are willing to be empowered, however, there is variation in the actual number of patients that practice empowerment for hand hygiene, ranging from 5% to 80%. Patient empowerment can be enhanced when a patient is given explicit permission by a healthcare worker. 

To me it is not clear if patient empowerment can be sustained for meaningful impact on hand hygiene.  This is because of an asymmetry of power between doctor and patient. As a result, patients still balk at asking their doctors to wash their hands. I have explored hand hygiene from the patient's perspective before.

I am still unsure of how to effectively and consistently employ patient empowerment in a multi-modal hand hygiene program. 

Midwives!

The other evening, after a long, grinding day on the medicals wards, I came across this bumper sticker in the hospital parking lot:

 

You learn something new every day in this line of work.