Medical Literary Messenger Spring 2018: Published!

For those who are literary minded, check out the latest edition (Spring 2018) of the Medical Literary Messenger. Downloads are free, open access and in PDF or e-pub format.

All archived back issues can be accessed here.

Once again, I am deeply indebted to the entire editorial team and the contributors.

Without them, this project would neither exist nor thrive.

Trust the Process! Standardizing Care To Maximize Safety

Source: CNBC.com

Here is an interesting read in the Harvard Business Review highlighted that the biggest problem in U.S. healthcare is the lack of process.

I could not agree more.

The authors emphasize the importance of designing models and processes that result in quality and efficiency of care.  Technology is mentioned as a means to augment standardization.

All of that is spot on, however, one explicit point was conspicuously absent from the paper:  In the absence of hospital executive sponsorship and commitment to standardization, optionalism will reign.  Forget your focus groups, your root cause analyses, your quality improvement models etc, without executive oversight-vision, resources, mandates and accountability, this all adds up to nil.

Trust the process.

Contact Precautions in Nursing Homes: Not What You Might Expect!

I like it when studies challenge expectations.

It is generally believed that patients in contact precautions are visited less frequently by healthcare workers.  Not so, as reported in this recent paper on contact precautions and healthcare worker practice across nursing homes in the Veterans Affairs (VA) Healthcare System.  Increased patient contact may be be secondary to a greater need for clinical care by isolated patients.

Sadly, compliance with gowns and gloves for isolation was limited. This was not unexpected as was the global sub-optimal hand hygiene reported.

The clinical impact of contact precautions on endemic pathogens in VA Healthcare System nursing homes? Not reported in this study. To me, that is the million dollar question.

Back to watching the World Cup....

Antebrazos Descubiertos! Editorial Publicado en La Revista Latinoamericana de Infectología Pediátrica

Para los de solo habla inglés, disculpen, que este blog será en español.

He escrito mucho sobre el atuendo médico pero esto es la primera vez que publico un manuscrito basado en este tema en una revista latinoamericana- la Revista Latinoamericana de Infectología Pediátrica.

Así que les paso este link (manuscrito) con mucho orgullo, para que lean sobre el uso de uniforme con antebrazos descubiertos.

Polémico e interesante.

Congratulations VCU ID! A Proud Night for All.

Drs. Salma Abbas and Barry Rittmann

Dr. Mike Stevens recognizing VCU Global Health Pathway graduating residents

Congratulations to our infectious diseases fellows, Drs. Salma Abbas and Barry Rittmann on their graduation!

Dr. Salma Abbas has finished her  3rd year of training- with a dedicated year in hospital epidemiology and a Master of Public Health degree. Dr. Rittmann completed his clinical fellowship and will continue as a 3rd year hospital epidemiology fellow at VCU.

Special kudos to Dr. Mike Stevens, recognized for his leadership of the VCU Global Health Residency Pathway training and given an Excellence in Teaching award.

The ID Division was also recognized for our distinguished teaching, a testament to our education mission.

Last but not least, a special thank you to our fellowship directors, Drs. Jane Cecil and Jillian Raybould, our ID Associate Chair for Education, Dr. Sangeeta Sastry, and of course the entire ID faculty and staff, without you, our education accomplishments would not  come to fruition.

The VCU Department of Medicine Residency and Graduation Ceremony event was held at the Virginia Science Museum, a proud night for all.

Don't Expect Me To Be Productive. It's World Cup Time!

Argentine Compatriot: Lionel Messi

For anyone concerned about my productivity over the next 4 weeks, please have some understanding and compassion. It is World Cup time and I will be focused on the 64 live matches. I am a man and Argentine so resisting the football (soccer) craze is futile.

I am not the only one struggling with the World Cup vs. work dilemma, as summarized in this article. Work productivity and the World Cup do not mix!

There will be emotional ups and downs all tournament long.  I will have to catch up on work tasks post tournament. However, if my Argentine compatriots take the trophy back to Buenos Aires, it will all be worth it.

Olé, Olé, Olé, The Beautiful Game!

I Love Bundles and Checklists, Until They Do Not Work!

Source: National Health Council.org

Like most hospital epidemiologists, I absolutely love bundles and checklists that standardize risk reduction practices.  These mechanisms help to optimize practice and minimize optionalism.

Unfortunately, sometimes the bundles do not work, as reported in this recently published article.

Kudos to the authors for taking a hard look at ventilator associated pneumonia (VAP) bundle compliance and impact on ventilator associated events (VAE).  Bottom line, the current bundle does little to actually impact VAE. 

Not all VAE are VAP, admittedly. Regardless, we need better protocols that encompass all aspects of ventilator safety-including infections, minimizing pulmonary edema,sedation vacations, extubations etc.

The most eye opening result of the above study: the use of chlorhexidine oral care increased the risk of VAE, a proper challenge to the paradigm of bioburden reduction.

So, once again, I love bundles and checklists until they do not work.  

Time for us to rethink the current VAP/VAE reduction process. We should avoid clinging to failed practices and critically seek new VAE risk reduction mechanisms.

What is the Missing Piece of Global Antimicrobial Stewardship? The Environment!

Source: PBS.org

Environmental change is a looming threat and in this case it is not global warming.

In 2017, Lubbert et al published this manuscript describing environmental pollution from  mass drug manufacturing industries in India. Significant concentrations of well-known anti-infectives such as voriconazole, fluconazole and levofloxacin were recovered in the water surrounding these production facilities. Corresponding microbiological analyses revealed a significant concentration of extended-spectrum beta-lactamase and carbapenemase-producing Enterobacteriaceae and non-fermenter bacteria.

To what extent does environmental contamination of water and food supplies with antimicrobial agents drive global antimicrobial resistance?  The answer is not fully known but is neatly explored in this Lancet Infectious Diseases commentary.

Bottom line, as we attempt to get a grasp limiting antimicrobial resistance, our approach must be multi-dimensional. This includes antimicrobial use in both animal and human populations, clinical surveillance mechanisms to monitor resistance patterns, and environmental monitoring. In toto, these elements can better shape and define the policies and practices desperately needed to optimize global antimicrobial stewardship.

Can't Explain! Vexing (Unexplained) Medical Symptoms

Got a feeling inside (can't explain)

It's a certain kind (can't explain)

I feel hot and cold (can't explain)

Yeah, down in my soul, yeah (can't explain)

The Who certainly did not have unexplained medical symptoms in mind when composing their famous hit sing, Can't Explain.

I have been giving this some thought lately given the frequency with which chronic fatigue presents in the general infectious diseases clinic.

This article, published in the Journal of the Royal Society of Medicine (UK),  explores how physicians manage unexplained medical symptoms.  Thirty to fifty percent of symptoms cannot be well explained. Sadly, we are poorly trained to consistently approach these symptoms and engage patients in a meaningful, reassuring way. The result is an encounter which is unsatisfying for both doctor and patient.

All is not doom and gloom. There may be a partial solution, as published here. Targeted, focused teaching on the management of medically unexplained symptoms, over 2-3 hours per year, would be both well received and beneficial.

Can't explain should not mean that we can't reassure.