Non Potable Water in the Toilets and Urinals

Just yesterday I paid a visit to the men's room in the new VCU School of Medicine Education Building.

The School prides itself on green technologies such as using rainwater for the flushing of toilets and urinals. I am a fan.

Above the urinal, the following was conspicuously visible:

Really? Who drinks the water from the toilets and urinals anyway?

Typhoid Mary Revisited

Mary Mallon, better known as Typhoid Mary, is revisited in this brief article published in the New York Times.

Typhoid Mary, a food worker in the early 1900s, is known for asymptomatic, long term biliary carriage of Salmonella typhi.  By not properly washing her hands, Typhoid Mary contaminated prepared food and was responsible for salmonella outbreaks in New York City.

A recent scientific publication highlights the newly discovered biochemical and immunologic mechanisms that allow for long term, asymptomatic carriage of Salmonella typhi.

Typhoid Mary, gone but not forgotten.

Hand Hygiene Before Putting on Nonsterile Gloves: A Waste of Time?

Here is a very intriguing article on the utility of hand hygiene prior to donning examination gloves.

The study was a prospective, randomized, controlled trial of health care workers entering contact isolation rooms in intensive care units. Baseline finger and palm prints were made from dominant hands onto agar plates. Health care workers were then randomized to directly don nonsterile gloves or perform hand hygiene and then don nonsterile gloves. Postgloving finger and palm prints were then made from the gloved hands. Plates were incubated and colony-forming units (CFU) of bacteria were counted.

Total bacterial colony counts of gloved hands did not differ between the 2 groups (6.9 vs 8.1 CFU, respectively, P = .52). Staphylococcus aureus was identified from gloves (once in "hand hygiene prior to gloving" group, twice in "direct gloving" group). All other organisms were expected commensal flora.

These data sugest that hand hygiene prior to donning nonsterile gloves does not decrease the already low bacterial counts on gloves and questions the utility of this practice.

So are we ready to stop washing out hands prior to putting on examination gloves?

Admittedly, slipping a still damp hand into an examination glove can be a hassle and yes hand hygiene is time consuming, but one study does not eliminate the time honored tradition of hand hygiene prior to patient care. 

Before suspending hand hygiene prior to examination glove use (while still encouraging hand hygiene following glove removal), prospective studies should assess the impact of this practice change on infection rates.

Until then, I am washing my hands.

Chaperones in Clinical Care

The other day I was asked about the use of chaperones during clinical examinations. Common sense dictates that chaperones should be used when performing intimate examinations (breast exams, pelvic exams), particularly by male providers. 

Should chaperones be present for an intimate examination of a male patient by a male provider? 

Here is a link to the NHS guidance statement on the use of chaperones in the clinical setting.  As summarized by the Medical Protection Society in the UK, although there are no concrete rules about when to use a chaperone, the following should be considered:

• Being the same sex as the patient does not negate the need for a chaperone;
• Age is not a factor, the elderly and young children can be just as uncomfortable with the situation as a teenager;
• Consider the patient’s religious/cultural beliefs; and
• Follow your gut feeling: if you feel uneasy or the patient seems unwilling to be examined, either arrange for a third party to be present or advise them to see another physician

These are all important considerations. Liberal use of chaperones may be hampered by one practical factor, the availability of a nurse in the clinic to serve as a third party, as summarized in this research article.

Common sense plus nurse availability are likely to remain the driving and limiting factor in the use of chaperones during clinical examinations.

Final Call for Submissions- Medical Literary Messenger

Calling all students, residents, physicians, nurses, patients and the general public, the Medical Literary Messenger is still accepting submission (poetry, prose and photography) for the Fall 2013 edition.

Submissions will close at the end of August.

All original work can be submitted at www.med-lit.vcu.edu

Probiotics for the Prevention of Diarrhea

I have previously blogged about probiotics and antibiotic associated diarrhea. New data however has emerged challenging previous conclusions. I now stand corrected.

Are probiotics really useful for the prevention of antibiotic associated diarrhea and C.difficile infection? Here is an article published in The Lancet that suggests otherwise.

The most recent study was multicenter randomized, double-blind, placebo-controlled trial of inpatients aged 65 years and older and exposed to one or more oral or parenteral antibiotics. Participants were randomized to receive either a multistrain preparation of lactobacilli and bifidobacteria, with a total of 6 × 1010 organisms, one per day for 21 days, or an identical placebo. Patients, study staff, and specimen and data analysts were masked to assignment. The primary outcomes were occurrence of antibiotic associated diarrhea (AAD) within 8 weeks and C difficile diarrhoea (CDD) within 12 weeks.

Of  the 17,420 patients screened, 1493 were randomly assigned to the microbial preparation group and 1488 to the placebo group. 1470 and 1471, respectively, were included in the analyses of the primary endpoints. AAD (including CDD) occurred in 159 (10·8%) participants in the microbial preparation group and 153 (10·4%) participants in the placebo group (relative risk [RR] 1·04; 95% CI 0·84-1·28; p=0·71). 

Probiotics were not efffective in preventing either antibiotic associated diarrhea or C.difficile infection. 

We still have much to learn about the pathophysiology and prevention of antibiotic associated diarrhea.

Dr. Feelgood- The Story of Dr. Max Jacobsob

Here is a gripping read about Dr. Max Jacobson, the book is titled Dr. Feelgood.

The book chronicles the history of Dr. Max Jacobson, a German born, New York City based physician who was a doctor to the stars, including JFK. Dr. Feelgood was known for his special injections of ''energy formula'', a secret mix of vitamins and hormones. Through detailed research, the authors expose the principal ingredient of the energy mix, methamphetamine.

Throughout the book's pages, stories unravel about Dr. Feelgood's widespread and addictive influence on figures such as JFK, Marilyn Monroe, Frank Sinatra, Elvis Presley and Mickey Mantle. 

The modern era of methamphetamine addiction is initiated.

Medicinal Leeching- Making a Comeback

Source: BBC News

This week has been a grind on the infectious diseases consult service and it is just Thursday! Nevertheless, there is always time for a perusal of the headlines.

Who would have thought that medicinal leeching was making a comeback? Here is a report from the BBC on medicinal leeching.

The article is interesting as it frames the concept of bloodletting and leeching in historical perspectives. Simple bloodletting was considered more mundane while medicinal leeching was historically more elitist. 

In modern medicine, leeching does have a limited application, as summarized in this review.

Now back to the daily grind.

Hospital Humor: Cardiac Arrest

I am back on the infectious diseases consult service. Above is a poster spotted on the door of a hospital employee lounge.

Enough said.

How Doctors Think- Recognizing Cognitive Biases

This weekend I read an excellent article in Clinical Infectious Diseases on recognizing cognitive biases in clinical reasoning.

Studies suggest that diagnostic errors occur in 15% of cases across all medical disciplines. Common diagnostic errors include anchoring (locking onto a diagnosis without considering alternatives), availability (labeling diagnoses based what has been recently seen), heuristics (mental short cuts or "rules of thumb''), overconfidence bias, premature closure and outcome bias. 

The solution lies in metacognition- increasing physician awareness of their own thought processes or "thinking about thinking.''

As suggested by Groopman and Hartzband, three simple questions should be employed at the bedside.

• What else could this be? Give consideration to alternative diagnoses to avoid premature closure.
• Is there something that does not fit? Make sure that the clinical data truly fits with the presumed diagnosis.
• Is there more than one diagnosis?

Formal instruction on clinical reasoning and cognitive bias should be mandatory in undergraduate and graduate medical training programs 

Obesity and Hospital Acquired Infections

I am back to blogging about infectious diseases.

It is commonly accepted that obesity is associated with an increased risk of hospital acquired and surgical site infections.

Here is a state of the art review article on obesity and hospital acquired infections published in the Journal of Hospital Infection. 

The exact mechanism by which obesity increases the risk of hospital acquired infection is not known but may be due to several potential and inter-related factors. These include co-morbid conditions like vascular disease and diabetes mellitus, immunological changes, altered pharmacokinetics of antimicrobials, challenges in skin disinfection prior to invasive procedures, changes in gut microbiota and adverse effects on pulmonary function.

The obesity-infection association is most clear in cardiac, vascular, orthopaedic and gastrointestinal surgery. Unfortunately, a  clear BMI cut-off for increased infection risk cannot be determined. Also, obesity is frequently associated with underdosing of antimicrobials in both prophylaxis and treatment of hospital acquired infections. 

I am not entirely clear on the best preventive measures apart from systematically addressing the obesity crisis in the USA. On a more immediate level, we need to better optimize antimicrobial dosing and antisepsis for obese patients. This last point is pressing.

Given the habitus of the average North American, obesity will continue to vex infection prevention efforts.  

Medical Tourism and Orthopedics- Priced Out

Medical tourism is commonly associated with cosmetic procedures such as plastic surgery and botox injections. Medical tourism also exists for those seeking organ transplantation.The ethical concerns associated with organ transplantation and  medical tourism are nicely summarized in this publication.

Here is a recent article in The New York Times with a slightly different perspective on medical tourism. The focus is on the exorbitant price of orthopedic joint implants in the USA and how some Americans have gone to Europe for more affordable prosthetic joints. The price of prosthetic joints in the USA is astronomical compared to that of Western European countries. This is driven by various factors, many of which are not so righteous. 

The above is not surprising. I am not a healthcare economist, yet as a practicing physician I have a firsthand perspective of the excesses that drive our spiraling healthcare costs. 

We pay too much for our healthcare, as summarized here in this PBS Newshour report. Unfortunately, our outcomes are not always great.  

We don't get what we pay for.

One in Four: HIV Care Continuum Video

In the USA, only one in four HIV positive patients achieve fully integrated HIV care, that is, complete access to treatment resulting in a sustained, undetectable, viral load.

The reasons for this are multiple. This video provides a nice summary on the topic.

Albeit oversimplified, the video is timely and highly relevant. 

Continued Non-Compliance in the Operating Room

Here is a recent article we published in Surgical Infections. We explored non-compliance with the American College of Surgeons (ACS) Statement on Sharps Safety recommends the use of double gloving (DG), hands-free zone (HFZ), and blunt-tip suture needles (BTSN) in the operating room to decrease needlestick injuries. 

We used a voluntary convenience sample survey of surgical staff members in which queries related to understanding of the ACS recommendations were posed. A total of 107 of the 324 surveys were completed and returned, for a response rate of 33%. Most respondents were residents (64%) or attending surgeons (29%).

The findings were less than encouraging.

Respondents were most familiar with recommendations for DG (58% of residents and 68% of attendings) and HFZ (61% for both groups) but less so for BTSN (48% of residents and 52% of attendings). More than 50% of the staff believed that DG decreased the risk of needlesticks, yet fewer than half used DG more than 75% of the time. Half believed that HFZ protected from sticks, yet fewer than 10% used it at least 75% of the time. Fewer than 50% believed that BTSN minimizes the risk of injury, with fewer than 10% of respondents using them at least 75% of the time. Reasons for non-compliance included decreased tactile sensation with DG, lack of training with HFZ, and lack of availability of BTSN.

We have a long way to go in order to  improve compliance with the ACS safety recommendations in the operating room. Our surgical colleagues must be made aware of the guidelines and must be convinced that these are beneficial to their safety. Last, undergloves, indicator gloves, and blunt tip suture needles must be readily available. 

Change does not come easy.