Friday, February 26, 2016

Images from Charleston, SC: APM 2016 Winter Meeting, Final Day

I wrapped up my final day in Charleston at some excellent lectures one on the future of academic internal medicine at the APM Winter Meeting. As I only have 2 years under my belt as the Chief of Infectious Diseases at Virginia Commonwealth University, I learned valuable pearls of wisdom at this medical leadership conference.

My favorite quote from one of the presentations, one on the value and importance of simply listening:
Don't Speak unless you can improve on silence.
The scientific program ended at 2 pm so I killed the last several hours strolling the city. I purchased some records at The Vinyl Countdown, strolled past the College of Charleston, and came across the Argentine ice creamery Freddo.  With a dulce de leche ice cream it was almost like being back in Argentina.

In my walk I observed that the MUSC Pathology Symposia had a marquis welcome at the Riviera Theater. Cool.

After a coffee at a rather bohemian coffee house, it was off to the airport.

I am off to India in 48 hours, to the International Congress on Infectious Diseases

Stay tuned.

Thursday, February 25, 2016

Images from Charleston, SC: APM 2016 Winter Meeting

I am currently at the APM 2016 Winter Meeting in Charleston, SC. This is a medical leadership conference and the content has been excellent.

Here are some images from a later afternoon stroll in Charleston. I forgot to pack my camera so my iPhone would just have to suffice.

Tuesday, February 23, 2016

Public Understanding of Hospital Acquired Infection Rates

The purpose of publicly reported hospital quality data is to improve patient care and better inform cases. Let's not touch the first objective at this time. Does public reporting better inform patients and allow for better choices with respect to healthcare?

Check out this telling paper published by my friend and  colleague Dr. Dan Morgan. 

The researchers selected 110 randomized, hospitalized patients and assessed their interpretability of hospital acquired infection (HAI) data as presented on the Centers for Medicareand Medicaid Services Hospital Compare website. 

The participants (N=110) correctly identified the better of 2 hospitals when given written descriptions of the HAI measure in 72% of the responses . When no written HAI measure description was provided and hospitals differed by denominator for infection rate, 38% answered correctly (31%-45%). Understanding of HAI data was variable in this cohort. 

Of note, on 5 % of the respondents had ever used the Hospital Compare website and only 36% stated that the Hospital Compare information would help their decision to receive care in their current hospital. This last point is important. It is highly debatable how much choice is truly available to patients. In the USA, many are still uninsured and have no real choice in provider or hospital. Of those with insurance, many must choose an 'in-network' provider or healthcare system. Last, for life threatening emergencies, I doubt that patients are instructing ambulances to take them to their preferred hospital or ER.

Those who feel that medicine is a simple commodity, impacted by Consumer Reports like product assessments, are deluding themselves.

Monday, February 22, 2016

Touchless Technologies for Room Disinfection

I spent most of last weekend reviewing papers and preparing my slides on an invited lecture on new technologies for room disinfection. I will be giving this lecture in early March at the 17th International Congress on Infectious Diseases, Hyderabad, India.

In 2015, along with several colleagues, I co-authored this review of touchless technologies for room disinfection. Touchless technologies, specifically, the use hydrogen peroxide vapor (HPV) or ultraviolet violet-C emitting devices are a potential boon to infection prevention efforts.

In updating my slides, I am once again struck by the lack of high quality data on the use of either hydrogen peroxide vapor or UV-light on improved clinical outcomes. Without doubt, these technologies further reduce bioburden following a standard, manual, terminal clean of a hospital room but this may not always translate into decreased infection rates.  Also, implementation of touchless disinfection technologies, beyond the research realm and to scale across a large healthcare system is costly. To date, no formal cost benefit analysis on this front has been published.

Technologies are exciting and we are always looking for the infection prevention magic bullet but many unanswered questions remain.

At present we should be cautious about the incremental benefit of these disinfection technologies.

Wednesday, February 17, 2016

Contact Precautions: Is the Pendulum Swinging?

In 2012, I co-authored a paper with Dr. Michael Stevens on a framework for discontinuing contact
precautions for endemic MRSA and VRE. 

I highly doubt that anyone read it. 

We then pressed on and successfully discontinued contact precautions at VCU Medical Center and published our results here.

With a group of collaborators from the Society of Healthcare Epidemiology of America, we published an extensive review of contact precautions for the control of endemic MRSA and VRE, once again suggesting that contact precautions may have little benefit as an infection prevention strategy in this situation.

As of late, there has been a relative surge of interest on the topic of contact precautions with this recent publication in Infection Control and Hospital Epidemiology once again calling for robust studies to support the use of contact precautions for MRSA and VRE. This is a huge departure from the 2003 SHEA Guidelines for the control of MRSA and VRE  in which contact precautions was the law of the land.

Before we make something the standard of care and mandatory in infection prevention, we must back it by quality evidence. 

Anything less is subject to dogma and bias and this is not science.

Friday, February 12, 2016

Dengue- Thinking Outside the Box

There is plenty of dengue, a mosquito borne viral illness, in Honduras, where we have our VCU Global Health and Health Disparities program clinical and public health project. To date, there is neither a vaccine nor an antiviral to treat dengue. For the treatment of dengue, some have thought outside the box. Check out this article- one in which lovastatin ( a cholesterol lowering agent) is used to treat dengue in a randomized, double-blind, placebo -controlled trial.

Dengue results in an inflammatory processes that affects vascular endothelium. Statins such as lovastatin decrease inflammation and improve endothelial function yet are not directly anti-viral. In this study lovastatin was safe and well tolerated but no benefit was observed on any of the clinical manifestations or on dengue viremia. 

Lovastatin is not salvation for the management of dengue. The study may not have been adequately powered  to detect a difference between lovastatin and a placebo. 

Regardless, the concept was cool, treatment with lovastatin caused no observable harm and it was subjected to empirical assessment.


Monday, February 8, 2016

The 80/20 Principle

Every now and then I go back to my bookshelf and dust off the book The 80/20 Principle- The Secret to Achieving More With Less Effort, by Richard Koch.

A free PDF copy is available here.

Based on an economic observation known as the Pareto Principle, the 80/20 Principle is an observation that 20% of inputs results in 80% of outputs or that 20% of your effort achieves 80% of your results. 

In more practical terms, much of the day is wasted and if you look around attentively, examples abound.  Much of what  we do during the workday has little meaning or real purpose- pointless meetings, shuffling papers, etc. Much of the issues that I deal with as an infectious diseases physician can be broken down in the 80/20 perspective: 80% of the infection prevention problems are caused by 20% of the units in the hospital.

By only recently recognizing this trend, I have learned to maximize my focus and productivity. Most importantly, I have learned to comfortably say 'no' to many unimportant requests. In doing so, things are clearer, more manageable and less stressful.  

This is achieved with personal awareness and self-discipline, there are no shortcuts.

Friday, February 5, 2016

The Annual Health Examination (Or Annual Check Up): Waste of Time and Money?

The time honored annual 'check-up' is traditionally viewed as sacrosanct in medical practice but what evidence exists to support it?

As it turns out, the evidence to support the periodic health examination is far less than robust and these visits are generally not recommended for asymptomatic adult patients. This does not mean that age and gender specific screening such as mammography and colon cancer screening should not be performed, rather, that an an annual 'check-up' is not necessary to achieve these targets.

For a very recent article on the matter, published in Annals of Internal Medicine, click here

New Perspectives on old paradigms, I love it.

Back on the VCU ID Consult Service tomorrow... 

Wednesday, February 3, 2016

Back in Honduras- February 2016: Random Images

Below are some random images from the last several days, many of them from my meanderings across the Catracho countryside.

Próxima parada...EEUU...bittersweet.