GH2DP Road Scholars- Honduras Research

Gaby Halder at APHA Annual Conference

The VCU Global Health and Health Disparities Program (GH2DP) has formalized our student scholars program.

Click here to see the new website for GH2DP Student Scholars. The honor roll is extensive and includes Rachel Whitney, Brittany Morehouse, Kate Pearson, Gaby Halder, Áudrey Le and Jackie Arquiette.

Each year, we travel the dusty Honduran country roads to reach isolated communities where our student scholars perform valuable studies that support the clinical mission and advance public health.

Fallen Idols

Here is an interesting essay that caught my eye in the NY Times Book Review. The writer explores the disappointment of meeting a revered or admired author.The artist may not always be as likable as the art he produces. This is particularly true when a writer meets a particularly admired or celebrated author.

As an infectious diseases trainee at Cornell University, I was excited to meet a a certain physician-author at the institution. I had read and admired one of his books. When inquiring about him, the response from many faculty members was nearly universal, ''stay away from that jackass, he has a malignant personality.'' 

Perhaps it is best to separate the writer from his work or to appreciate them as almost separate entities. To quote a line from the above essay,  “Tolstoy I’m sure was an incredible jackass, but I still love him."

US Physicians and Views on Controlling Healthcare Costs

I rarely write about health policy as it is not remotely in my area of expertise. 

Here is a report (free, full text)  published in JAMA this month. A cross-sectional survey was mailed in 2012 to 3897 US physicians randomly selected from the AMA Masterfile.

A total of 2556 physicians responded (response rate = 65%). Most believed that trial lawyers (60%), health insurance companies (59%), hospitals and health systems (56%), pharmaceutical and device manufacturers (56%), and patients (52%) have a “major responsibility” for reducing health care costs, whereas only 36% reported that practicing physicians have “major responsibility.” Most were “very enthusiastic” for “promoting continuity of care” (75%), “expanding access to quality and safety data” (51%), and “limiting access to expensive treatments with little net benefit” (51%) as a means of reducing health care costs. Few expressed enthusiasm for “eliminating fee-for-service payment models” (7%). Most physicians reported being “aware of the costs of the tests/treatments [they] recommend” (76%), agreed they should adhere to clinical guidelines that discourage the use of marginally beneficial care (79%), and agreed that they “should be solely devoted to individual patients’ best interests, even if that is expensive” (78%) and that “doctors need to take a more prominent role in limiting use of unnecessary tests” (89%). Most (85%) disagreed that they “should sometimes deny beneficial but costly services to certain patients because resources should go to other patients that need them more.” 

These results are telling. Many physicians favor cost containment strategies that enhance high quality healthcare. Predictably, many were against payment reform that impacts fee for service work. This last point will be a huge barrier in healthcare cost containment.

One factor at play is the tension between meeting the medical needs of the individual patient while being sensitive to the allocation of resources for the collective good of the population. This is a tension that we will need to better navigate. Another is that universal access to healthcare will erode some physician autonomy and earning potential. 

The resources are not infinite and doing things 'as always' will not fly in the face of more equitable access to healthcare.

Honduras 2013 Review at VCU Infectious Diseases Case Conference

On July 22nd, in conjunction with my close friend Dr. Michael Stevens, I presented a summary of our 2013 VCU Global Health and Health Disparities Program Honduras trip at the VCU Infectious Diseases Case Conference.

A neat summary of the presentation and the program can be found here, on Dr. Stevens' blog.

For a PDF version of the slides click here.

The Missing Ink- Not Missed in Medicine

I recently finished a book titled The Missing Ink by Phillip Hensher. The book wittingly and nostalgically explores the lost art of handwriting in the modern era. For example, school children are no longer taught cursive, rather, they are instructed on keyboarding.  

Handwritten notes and prescriptions certainly will not be missed in medicine. Here is a recent scientific article on how poor handwriting results in significant medical errors. Written documentation errors occurred in 65 of 1,934 prescribed agents (3.5%). Common mistakes included prescribing errors (37%), transcription errors(53%), and administration documentation errors(10%). The handwriting readability was rated as good in 2%, moderate in 42%, bad in 52%, and unreadable in 4%. The handwriting readability was rated as good in 2%, moderate in 42%, bad in 52%, and unreadable in 4%.

The other day, when the electronic prescription system was down, I reached for a prescription pad and hand wrote several scripts. My penmanship is certainly not beautiful, so I doubt anyone would clamor for future written prescriptions from me.

Phillip Hensher may be right about the relevance of handwriting. Although we will never give up the convenience and clarity of typed print, handwriting ''... involves us in a relationship with the written word which is sensuous, immediate and individual.''

Perhaps this is why writing the prescriptions by hand, albeit slow and possibly illegible, just felt cool.

Dr. Jeff Wang: First Graduate of VCU’s Global Health & Health Disparities Program (GH2DP) Residency Track

Belated congratulations to Dr. Jeff Wang, our first Internal Medicine graduate of the VCU’s Global Health & Health Disparities Program (GH2DP) residency track (June 2013).

Jeff was a standout member of the 2013 team and actively participated in a both clinical care and research while in Honduras. To read more about his Honduran experienced, as highlighted in the VCU School of Medicine website, click here.

Jeff will pursue a career in infectious diseases.

That is a plan I enthusiastically endorse.

Antibiotics for the Treatment of Chronic Lower Back Pain: A Paradigm Shift?

Here is an article in the European Spine Journal that at first seems a bit ridiculous. Antibiotics for the management of lower back pain (LBP). Really?

The investigators tested the efficacy of antibiotic treatment in patients with chronic LBP  (>6 months) and Modic type 1 changes (bone edema).

The study was a double-blind randomized controlled trial with 162 patients whose chronic LBP of greater than 6 months duration occurring after a previous disc herniation and who also had bone edema demonstrated (Modic type 1) changes in the vertebrae adjacent to the previous herniation. Patients were randomized to either 100 days of antibiotic treatment (amoxicillin-clavulanate 500 mg tid x 90 days) or placebo and were blindly evaluated at baseline, end of treatment and at 1-year follow-up.

The antibiotic group improved highly statistically significantly on all outcome measures and improvement continued from 100 days follow-up until 1-year follow-up. These included presence of constant back pain, disturbed sleep due to pain, and pain during flexion and extension of the spine.  

Here are some important facts to consider before dismissing the results as a mere placebo effect.

• First, the study design was rigorous- randomized, prospective, double blind  
• Second, there are data to suggest that the purported pathogens (P.acnes, staphylococci, corynebacteria) are not present in other spinal disorders, suggesting that these bacteria are not mere colonizers or innocent bystanders
• Third, P.acnes, secretes proprionic acid, which is capable of dissolving fatty bone marrow and bone, suggesting that biologic plausibility exists for a bacterial cause of back pain 
• Last, many antibiotics have anti-inflammatory effects, however, amoxicillin-clavulanate, the antibiotic used in this study, typically does not

By no means should all patients with chronic bone receive antibiotics. Further studies are needed to replicate these results. If these findings are valid, a 90 day course of antibiotics for chronic LBP patients with disc herniation and bone edema in the adjacent vertebrae may be warranted.

Sorry about the long blog entry today. 

Infectious Diseases versus Oncology- Dark, Humorous, Telling

Here is a video satirizing infectious diseases versus oncology

Dark, humorous, telling.

Pneumonia- Life Altering

Here is an intriguing read published in the American Journal of Medicine on hospitalization for pneumonia.  In the modern era, pneumonia is highly curable. Nevertheless, even with successful treatment, there are long term health consequences.

The investigators analyzed data from a prospective cohort of 1434 adults aged more than 50 years who survived 1711 hospitalizations for pneumonia, myocardial infarction, or stroke drawn from the Health and Retirement Study (1998-2010).  The outcomes of interest included the number of Activities and Instrumental Activities of Daily Living  requiring assistance and the presence of cognitive impairment and substantial depressive symptoms.

Hospitalization for pneumonia was associated with moderate-to-severe cognitive impairment (odds ratio, 2.46; 95% CI, 1.60-3.79) and substantial depressive symptoms (odds ratio, 1.63; 95% CI, 1.06-2.51).

This is an important finding. Although curable as an infectious disease, pneumonia in elderly patients results in long term cognitive and psychological consequences that are potentially life altering.

What does this mean? Future studies are needed to better understand this phenomenon. Prevention of pneumonia is equally important. Preventive measures such as smoking cessation and maximizing the vaccination of older adults for pneumococcus and influenza may limit the incidence and consequences of pneumonia.

To quote Benjamin Franklin, an ounce of prevention is worth a pound of cure.

HIV Self Testing- Potential Benefits

Source: FDA.gov

Depending on the setting, 30-60% of HIV positive individuals are unaware of their diagnosis. This is a huge obstacle for the diagnosis, treatment and prevention of HIV.

The US Preventive Services Task Force now recommends routine, voluntary HIV testing  for all people ages 15-65. A new era of prevention is on the horizon. The time is now to reassess the role of HIV self-testing.

Here is a review (free, full text) on HIV self testing published in Clinical Infectious Diseases. Proponents of HIV self testing argue that self diagnosis will increase the knowledge of HIV status, is convenient, and has the potential to remove the stigma surrounding HIV. Counterarguments include the potential for inaccurate results and the psychological danger when decoupling testing from pre/post result counseling.

The potential psychological danger of HIV self testing is not trivial. The article neatly summarizes the limited data on this concern, suggesting that evidence of harm is scant and that HIV self testing regret was minimal. This is encouraging.

If HIV self testing is reliable, actively promoted, and available, and if individuals testing positive are linked to counseling and care, this could significantly impact the HIV epidemic.

HIV testing leads to diagnosis, diagnosis leads to treatment, treatment is lifesaving and treatment is prevention. 

Universal MRSA Decolonization for Surgical Site Infection Reduction

This week has been ludicrously busy on the infectious diseases consult service, throwing me off of my blogging routine.

Here is an article that caught my eye in the American Journal of Infection Control. The subject is universal MRSA decolonization with a 5 day course of intranasal mupirocin and chlorhexidine bathing (2% CHG Cloths) in non-general surgical patients. The result was a 72% reduction in MRSA surgical site infections over two years. 

This is an important finding. However, I am more interested in the impact of this decolonization strategy on ALL infections, surgical site or otherwise, by ALL pathogens. These data are not reported in the paper.

Universal patient decolonization with mupirocin and chlorhexidine prior to elective surgeries is of greater value if it results in a sustained, horizontal infection risk reduction on similarly transmitted pathogens. That would be really exciting.

HARLOT plc: Medicine and Prostitution

Satire is a powerful literary device, just think of works by authors such as Jonathan Swift and Kurt Vonnegut.

Medicine is not immune to exposure by satire. 

Here is a satirical essay published in BMJ titled Harlot PLC: an amalgamation of the world's two oldest professions.  The authors cleverly expose the dark side  of medicine as a business by way of creating a fictitious medical company, HARLOT plc, that will ''maximize the profits of dodgy drugs and devices.''

Why is this important? Because in the development of drugs and technologies, financial motives and greed result in study designs, statistical methods and hidden conflicts of interest that require strategies for How to Achieve positive Results without actually Lying to Overcome the Truth (HARLOT). 

Insightful and worth reading.

The Physical Exam- A Fading and Irrelevant Art?

Here is an NPR article on the fading art of the physical examination. 

I still believe in the value of the physical examination. Sure, the history is frequently much more revealing than the physical exam. But, with some examination skills and clinical acumen, important clues can be deciphered, leading to the diagnosis. This is particularly relevant when technologies and laboratory testing is not readily available, such as on our Honduran medical relief trips.

The physical examination can also be a transformative experience, one that enhances the doctor patient relationship, as explored here.

The art of medicine is neither irrelevant nor dead.

The July Effect- New Interns and Medical Errors

I am back from a few days off and fully ready for July 1st!

July 1st marks the beginning of a new academic year in university hospitals. On this day, freshly minted doctors (interns) begin their post-graduate medical training.

Here is an article published in the Journal of General Internal Medicine that reports the  possible impact of new residents on medical errors.

The investigators examined all U.S. death certificates, 1979-2006 (n = 62,338,584), focusing on medication errors (n = 244,388). The July Effect in was compared between counties with and without teaching hospitals.

Inside medical institutions, in counties containing teaching hospitals, fatal medication errors spiked by 10% in July and in no other month [JR = 1.10 (1.06-1.14)]. In contrast, there was no July spike in counties without teaching hospitals. The greater the concentration of teaching hospitals in a region, the greater the July spike (r = .80; P = .005). These findings held only for medication errors, not for other causes of death.

The conclusion: July mortality spike results at least partly from changes associated with the arrival of new medical residents. 

If at all possible, avoid hospitalization in a university hospital in July.