Thursday, August 17, 2017

Medical Literary Messenger Spring / Summer 2017- Published!

As Editor in Chief of the Medical Literary Messenger I am proud to announce that the Summer / Spring Edition has published. This edition includes our first ever photoessay, featuring the VCU Global Health and Health Disparities Program in Honduras. Kudos to all MLM associate editors and contributors.

The publication can be downloaded as a PDF (click here) or as an EPUB/MOBI (here).

All prior editions are available on the archives section of MLM website.

Tuesday, August 15, 2017

Amazing vs. Hired!

I was reading the highly academic Moderate Drummer magazine the other day and came across this referenced cartoon. There is a lot of truth in it.

Having great technique ( 'chops' in drumming parlance) is wonderful but is useless unless you can play consistently and keep time with a band. Drummers who can keep time are generally hired for the gig!

I have seen something similar play out in other spheres.  I have known many knowledgeable and book smart physicians who are less than adept at applying the knowledge at the bedside.  I have also known many footballers (soccer players) with great skill and technique who cannot play a 90 minute match with a team.

Skill, technique and knowledge are absolutely necessary, yet not sufficient.  Application is key. 

If you have both then you are the real deal.                   

Tuesday, August 8, 2017

Test Stewardship and C. difficile: Vexing to No End

Test stewardship is an evolving topic in the medical literature. I recently wrote about test stewardship with respect to urine cultures and CAUTI rates.

Now, as reported here, computerized clinical decision support tools in the EMR can assist in reducing inappropriate C. difficile. Given that nucleic acid amplification tests can be overly sensitive and that C. difficile is part of the normal bowel flora, we are still looking for the 'right test at the right time' to make the diagnosis. A magic 'diagnostic' bullet of sorts.

In the above referenced paper, C. difficile test stewardship decreased inappropriate C. difficile testing, specifically, not testing patients with diarrhea while on laxatives. No significant harm was reported.  This is not salvation but at least a step forward in not over diagnosing hospital onset C.difficile. So I say, press on with such interventions (which we are doing at VCU).

Clostridium difficile infections in the hospital continue to vex us, largely because the extent to which they are preventable is highly debatable, as explored here.  

With the current state of science, solving our C. difficile problem is much like solving world inequality.

Sunday, August 6, 2017

Sepsis Antibiotic Protocols: Potential Downstream Effects

Sir Alexander Fleming
"The thoughtless person playing with penicillin treatment is morally responsible for the death of the man who succumbs to infection with the penicillin-resistant organism."  Thus were the words of Sir. Alexander Fleming, the discoverer of penicillin.

We have a potential tragedy of the commons with antibiotics. The consequences extend beyond the growth of antibiotic resistance. The implementation of an electronic sepsis initiative to standardize and maximize antibiotic use for sepsis cases resulted in increased hospital onset C. difficile, as reported here in AJIC. Not surprisingly, the protocol resulted in increased broad spectrum antibiotic use.

Protocols and standardization generally improve patient safety (central line checklists, surgical times outs) but the process is not foolproof. 

We need to monitor and formally study unintended consequences so as to be nimble, pragmatic and modify our infection prevention strategies. 

I am now back from my native Argentina and back to the grind.