Monday, May 31, 2010

Keeping veterans safe

As we pause on Memorial Day to remember those who have died fighting our wars, it seems fitting to recognize the strides that Veterans Health Administration (VHA) hospitals have made in patient safety, including prevention of healthcare associated infections. Over the nine years I was hospital epidemiologist at the Iowa City VAMC, I became convinced that most U.S. hospitals could learn a lot from the VA system (beginning with their early implementation of an electronic medical record that remains superior to the one we have implemented in our university hospital). While I can nitpick about the way certain directives came down, overall I think the VHA has been ahead of the curve, which may also be a commentary on progress in the rest of our fragmented healthcare system.

The VHA is the largest integrated healthcare system in the United States. It can and should serve as a model for healthcare-associated infection prevention.

Friday, May 28, 2010

Going negative

Those of you that have had to sit through one of my "Business Case" talks know that one of my favorite books to recommend is William Ury's, "The Power of the Positive No." I probably should post more on the subject at some later point, but the take home message of the book is that you should say "no" to unreasonable demands by saying "yes" to yourself and your infection control team.

While flying back from San Diego I had a chance to read through two articles with a negative theme. The first was a negative study by Kyle Popovich and collegues at Stroger Hospital in Chicago published in the May Intensive Care Medicine. The group studied the benefit of daily chlorhexidine baths in a surgical ICU in preventing CLABSI. The results: negative, meaning that there was no benefit of CHG baths with a CLABSI rate between soap-and-water and CHG bathing periods (3.81/1,000 central line days vs. 4.6/1,000 central line days; p = 0.57). What I really liked about this study was that a group so highly linked to the benefits of CHG put the effort into reporting this negative study; this effort should not be underestimated. Both the journal and the authors should be applauded.

A related and I think very important article by Isabelle Boutron was published in JAMA this week. The group looked at how authors report and discuss results of randomized clinical trials with statistically non-significant results. It was interesting to see how they quantified the "spin" and how the Discussion sections didn't often match the results. As a side note, the senior author on the paper, Douglas Altman, has been an author on many great epi and stats papers, just search his name and BMJ in PubMed; he has made and continues to make wonderful contributions to clinical research.

Thursday, May 27, 2010

17 states report CLABSI rates. Why only 17?

The CDC just released the First State-Specific Healthcare-Associated Infections Summary Data Report, which focuses on CLABSI. HHS press release is available here. Needless to say, we are all disappointed with the rates here in Maryland given how hard the State and hospitals have worked at preventing these infections. No one seems more disappointed than Peter Pronovost. No excuses.

And the winner is...

Ebbing Lautenbach, Tom Talbot, Eli Perencevich, Trish Perl

Last night we celebrated a successful ASM General Meeting for Division L by taking in a Cards-Padres game. We made it through 7 innings, 1:30am EDT (12:30 CDT for Tom). Wish we could have lasted until the exciting Friar win in the 13th - a Jerry Hairston Jr. home run, are you kidding me? Tom was getting ready for the Lacrosse Final Four this weekend; I hope to catch the semifinal games this Saturday in Baltimore.

Microbiologic myopia

Today's New York Times has an article on toxigenic E. coli strains that cause severe foodborne illness. While many people are familiar with the H7:O157 strain, there are six other similar strains that have been largely ignored and have escaped regulation. Kudos to the New York Times for putting this story above the fold on the front page. As I read this article, I couldn't help but think how closely this parallels the situation in hospital epidemiology, where laws continue to be passed to test patients for MRSA, while untreatable gram-negative infections are ignored. Cynically, I suspect that as soon as there's a rapid test for KPCs, there will be the sudden discovery of a crisis, and we'll have new laws to test all patients for these organisms.

Wednesday, May 26, 2010

ASM General Meeting

Eli's off speaking at the ASM General Meeting in San Diego....for those of you who'd rather stay home and catch a few highlights of that meeting online, check out the interview clips on USTREAM, here. The latest topics of discussion include persistence of microbes in the food chain, the role of gut flora in obesity, and the first synthetic genome.

Monday, May 24, 2010

Lunch Break: How to be a good mentor or hospital epidemiologist

TED has posted a wonderful clip of a lecture given by legendary psychiatrist Viktor Frankl in 1972. There is a wonderful lesson contained within this short clip. Channeling Goethe - "if we take man as he really is, we make him worse, but if we overestimate him...we promote him to what he really can be. We have to be idealists." To me this is lesson one of being a good mentor and also the leap of faith we need to take to promote quality in our hospitals. It can be highly frustrating dealing with clinicians refusing to wash their hands; perhaps if we aim higher, we can achieve what is possible?

Great quote: "I know I am speaking in a marvelous accent without the slightest English"

Sunday, May 23, 2010

Practical Healthcare Epidemiology, 3rd Edition

In a moment of weakness, I agreed to review this textbook for JAMA. This required me to actually read it, something I probably should have considered before I said "yes" to the assignment.

I can’t paste my review here (I’ll link to it when it is published), but I can say that I truly liked this textbook: very readable, makes ample use of tables, figures, and bulleted lists, and the authors have (mostly) not succumbed to the temptation to drown the reader in exhaustive or excessive detail. So the book is, as advertised, very practical. I’m going to recommend it to our ID fellows, and keep a copy for the infection preventionists as well. There is an E-book version that is much cheaper than the hard copy, but my reading of the Adobe Digital Editions website leads me to believe that it is not viewable on either the Kindle or the iPad (which, if true, is a major limitation—Eli, do you know if you can read an Adobe Digital Edition E-book on iPad?).

The review got me thinking about how rarely I ever pull textbooks off my shelves or even access them online. I wonder if the days of the textbook, even the electronic text, are numbered. Not only are there many other sources to turn to for information, but the financial woes of most academic medicine departments no longer allow for professional activity that isn’t linked to some “revenue stream”. So everything except patient care, grant writing, funded research, or reimbursed service activity is de-emphasized. Writing a good book chapter can be a huge time-sink, and the reward for doing so is very small.

Saturday, May 22, 2010

So sorry

So I admit that I've also been starting sentences this way more often, both in written and verbal communication. So what? So far, no one has called me on it. So there!

PPIs: The Hospital Epidemiologist's New Challenge?

2 more studies (May 10 issue of the Archives of Internal Medicine- here and here) tie use of proton pump inhibitors (PPIs) to Clostridium difficile infection. These drugs have been linked to C. difficile in past reports, and have also been linked to hospital associated pneumonia. Although the risk is still generally small, these are among the top 3 most frequently prescribed classes of drugs in the US. I'm always amazed when I attend on Medicine how many people are on these drugs for unknown reasons. Some statistics reveal that 60-70% of people who take them don’t really need them. Maybe its time we expand our view of antibiotic stewardship in hospitals?

Friday, May 21, 2010

Why your friends spread influenza and you don't

There was a really interesting study by Nicholas Christakis and James Fowler in the May 15th Economist (here) and posted online (full manuscript here). The general thought behind the study was that people in the center of social networks, the ones with more friends or connections, would be more likely to be infected with influenza sooner. Thus, if you could identify people in the center they could serve as an early warning system for flu. The problem is, this would take a significant amount of effort. The insight into this problem comes in the form of what is called the friendship paradox. This 'paradox' suggests that your friends have more friends than you do.

To test this theory, Christakis and Fowler identified 319 students and then 425 of their friends. If friendship paradox would work in identifying influenza then the 425 should get flu earlier. So they followed the 744 students from September to December 2009 during the H1N1 epidemic and found that the friends, the 425 more likely to be in the center of the network, developed influenza (self-diagnosed and confirmed) around 2 weeks earlier. In fact, self-reported symptoms peaked 83 days earlier and visits to healthcare facilities peaked 46 days earlier in the connected group. Maybe this is a new method that could be added to other monitoring systems. Either way, come influenza season, stay away from your friends, especially the ones who are really friendly.

Thursday, May 20, 2010

S. epidermidis vs. S. aureus: Who's the winner?

Wow! There's a very exciting paper in this week's Nature. Investigators in Japan have found that some strains of Staph epidermidis secrete a protease that destroys S. aureus biofilm, including those biofilms produced by MRSA and VISA strains. They used multivariate analysis to demonstrate that persons naturally colonized with the protease producing S. epi strain were protected against S. aureus nasal colonization. But they took it a step further and showed that when this S. epi strain was inoculated into the nose of S. aureus carriers it eliminated colonization, whereas a mutant that lacked the protease gene did not. The implications of this work are potentially huge. We've always thought of S. epi as the wimpy cousin of the big, bad S. aureus. Now the story seems to be changing. Who'da thunk it?

Scientists create new bacteria out of nothing

Just reported in the journal Science, Craig Venter's group has created Mycoplasma mycoides out of nothing. Now if they could just create a new antibiotic!

Tuesday, May 18, 2010

Guidelines and conflict of interest

Annals of Internal Medicine has a new paper that caught my eye-- The Vexing Problem of Guidelines and Conflict of Interest: A Potential Solution. As you read it, think about how this applies to SHEA's Guideline for Preventing Nosocomial Transmission of MRSA and VRE.

Lunch Break: How not to wash your hands - "Händewaschen"

I hope many of you read this blog during your lunch. We know you do actually, we can tell. Thought you might enjoy this video while you scarf down your PBJ. (Video is not for the squeamish. However comments on YouTube may not be safe for work)

The limitations of technology

We've posted here often on the limitations of ADI in infection control. You can throw lots of money and technology at problems and see few benefits. Mike's posting from a few days ago was a perfect example of this - yes you can do ADI for MRSA but if you don't have adequate hand hygiene adherence, you're cooked. There was a recent article in the New Yorker which highlights this problem, which unfortunately now requires a subscription to read in its entirety, but even the available abstract is interesting.

The article discusses Saul Griffith, an inventor extraordinaire, who won a a MacArthur Fellowship (Genius grant) for an invention of a complicated, advanced device to rapidly custom-manufacture low-cost eyeglass lenses. His invention would save the world by making glasses available to all poor citizens. However, the problem wasn't that poor populations couldn't afford lens, those were available from China for pennies. The problem was that there weren't enough people trained to test people's eyesight! So after all of the effort, there was little to show for it.

Griffith has also spent a lot of time trying to develop new sources of renewable energy, creating flying wind turbines that float high in the air, where the wind speed is more reliable. During the process and looking at all of the data, he realized that current and likely immediate-future technology wouldn't be enough. The math just doesn't work. We would have to build wind turbines every second and nuclear power plants every week for years. It's just not going to happen. We have to actually cut individual consumption. So now, he is "selfishly" working to cut his own consumption; he estimated that he would have to cut his own energy use by two-thirds or more to have an impact. We all will. It will be difficult.

With infection control, we're in the same situation. Resistant bacteria are spreading everywhere. The easy answer is to hope science and expensive "easy" solutions will save us. We can just swab everyone's nose (and butt and throat and axilla and groin) pop it into a machine that will tell us what they are colonized with and boom - no more resistance!! Well, if history, and Saul Griffith's experience is any guide, it won't work. We are all faced with his "cheap-glasses conundrum: the inadequacy of addressing complex societal issues with technological ingenuity alone." I think we all need to realize, as Mike has written, that we are all individually responsible for the resistance problem. We can't wait for a technological savior. Like Saul Griffith, we need to look at ourselves and get others to look at themselves. And we need to get people to wash their hands.

Monday, May 17, 2010

Did someone get fired for using NHSN or NNIS definitions to count CLABSIs?

Wow. I just read the second article that Mike posted Saturday out of the Chicago Tribune and I kinda wish I didn't. I'll paste the section that scared me a bit below, but it appears that someone might have been fired for "over-reporting HAIs", which is a bit scary to me. There is tremendous pressure to not call a BSI , a CLABSI, which I think is now part of the getting to zero culture. I wonder what percent of the way towards zero will be paved with these sorts of statements:

"Thorek's infection rate was the highest of all medical centers in Illinois. Frank Solare, Thorek's president and chief executive officer, said hospital officials have collected medical charts for the 22 infected patients and have "started an independent review … to try and understand this."

Asked why the Lakeview hospital didn't take action last year, Thorek's compliance officer Morgan Murphy said a former employee didn't alert senior management to the problem. "It wasn't making its way up the chain, unfortunately," he said.

Senior management also suspects that the employee may have counted central line infections incorrectly, inflating the hospital's numbers. "There may have been over-reporting," Murphy said."

Saturday, May 15, 2010

MRSA active surveillance: It just doesn't make sense

A study in the June issue of Infection Control and Hospital Epidemiology takes a look at staphylococcal colonization in healthcare workers. Over 250 HCWs were cultured and nearly half (44%) were colonized with S. aureus. MRSA colonization was found in 7% overall and was highest in nurses (10.5%). If the findings of this study are generalizable to other hospitals, this study has two important implications. First, given that nearly half of HCWs were colonized with S. aureus, hand hygiene practiced at very high levels of compliance is warranted. It seems that in the hysteria surrounding MRSA it's been forgotten that MSSA is also a pathogen. Second, why should hospitals engage in active detection and isolation (ADI) when non-patients are a significant reservoir for MRSA in the hospital setting? For those who continue to truly believe in ADI it seems that to me that their logic should dictate that MRSA colonized HCWs be removed from practice. And then there are visitors who may be colonized. The solution there could be to ban all visitors to the hospital. Of course, all of this assumes that the ADI zealots are driven by logic. Here's my recommendation: let's stop focusing on who has what organism (see Eli's posting from a few days ago), and just get everyone to wash their hands before and after every patient contact. The key word here is every. And maybe if that happened, we wouldn't need contact precautions any more. Now here's an interesting thought experiment: what could we do with all the money that's been spent on MRSA surveillance cultures over the last 5 years?

Public reporting of HAIs in Illinois

This morning's Chicago Tribune has an article on public reporting of healthcare associated infections. There's really nothing new that comes to light in the article. A second piece in the paper focuses on hospitals with high infection rates and hospitals elaborate on specific reasons for their performance, including poor data collection and surveillance methods. This newspaper has had a long-term interest in HAIs and was one of the first media outlets to investigate the issue, publishing an expose in 2002. Here's the link to the Illinois hospital report card that shows central line associated bloodstream infection data by hospital.

Thursday, May 13, 2010

What if all S. aureus was MRSA?

We spend so much time discussing MRSA. We debate, we mandate, and we worry. Frankly, I'm getting tired of it. I'm far more worried about MDR-Gram negatives and all that oil spilling into the Gulf. So, while I was at the Orioles game today with my son, my mind drifted into an absurd thought experiment. To be clear, I'm a big baseball fan and I was trying to pay attention, it was just really boring until the O's scored 5 runs in the 8th, including a grand slam, to win it 6-5.

So as my mind drifted like the (three!) dingers Millwood was allowing, I thought: What if I could magically turn all S. aureus into MRSA? Now, I could have easily dreamed that all S. aureus would become penicillin sensitive, but I prefer to dream possibilities. What would this counterfactual world look like and why would I have such a thought? Would the world end? No. I know MRSA is the SUPERBUG, but I suspect the world would look as it does, but with a few differences; some good and some bad.

Now we all "know" that MRSA is more virulent than MSSA and leads to higher rates of mortality. Do we? I was a co-author on a meta-analysis, one that you must be required to reference if you publish on MRSA, since it's been cited >500 times. We found that MRSA bacteremia was associated with twice the odds of death compared to MSSA. I don't believe it. Never did. It's not that I don't think it was a great study; it was and is. It's just that since (fortunately) you can't randomly infect patients with MRSA or MSSA, you can never really study the clinical impact of MRSA. Since MRSA patients are sicker at baseline, before they even get infected, and vancomycin is a poor antibiotic, it is likely that MRSA just appears more virulent. If you give patients with MSSA vancomycin, they would do as poorly as those who were infected with MRSA.

Another reason that I'm not worried about an all MRSA world is that we have plenty of treatment options for MRSA unlike MDR-GNR. More are likely in the pipeline. The one downside I think of an all MRSA world is that it would be more expensive to treat infections since many of the treatment options would be more expensive. We would also have new abbreviations to learn: LRSA or DRSA (linezolid or daptomycin), etc. Yes, I know VRSA.

So far, I suspect I've put you to sleep, much like I was during the first seven innings of today's game. But here's my point. There would be a very important upside to this all methicillin resistant, Staphylococcus aureus world. It would mean that hospital epidemiologists and clinicians, patients and societies and legislators and journalists and everybody...could stop worrying about MRSA and start worrying about plain old S. aureus. What? Yes! We could isolate, treat, worry about, write about, legislate and actually deal with all patients with Staph aureus the same way. Since all S. aureus would be "the same" - which it really is, we've just forgotten that MSSA and PCN-sensitive SA are so deadly.

So there you have it. We could look to prevent ALL Staph infections, not just MRSA ones, since they would all be MRSA in this new world. And since MRSA is likely not worse than MSSA, no one would be worse off and I suspect many would be better off because we could target for prevention the 99% or 70% or 50% of infections caused by S. aureus that we currently ignore. And better yet, we could do this now. We don't have to wait for this 100% MRSA world. We could stop this MRSA insanity and actually target all S. aureus infections, or dare I dream, all hospital pathogens: resistant or sensitive, Gram-positive or Gram-negative (or C. diff). Alas...

Go Orioles. (Who says a guy can't dream...)

Monday, May 10, 2010

What in the world?

Could the UK come up with any more crazy infection control rules? They've banned Christmas decorations, aquariums, fresh flowers, and sitting on the hospital bed. Now a major hospital in Scotland is limiting visiting hours to three and a half hours daily to reduce infections. That's a half hour less than the old rule, but apparently the old rule wasn't enforced. I won't even try to guess what's next....

Hurry up, CDC

It has been a while since we blogged about the ridiculously stupid mask fiasco, mainly because the 2009 H1N1 virus is off the radar in most parts of the country and world.

This hasn’t stopped California OSHA from citing UCSF for not requiring N95 masks for the care of patients with suspected or confirmed 2009 H1N1. A post from the EIN this morning details the citation, which includes a fine and a requirement to rectify the situation by June 6, 2010. Here is a short excerpt from that EIN post:
I am…concerned about the short time window which we have been given to rectify the situation. Given the availability of 2009 H1N1 vaccine and increasing evidence in the literature that N95 masks are not superior to surgical masks, we plan to appeal before making a change in our practice; however, it is unlikely that OSHA will be willing to consider such an appeal without a formal change in the CDC guidance. I have heard that the CDC will soon be providing updated guidance on infection control practices for 2009 H1N1 - does anyone know the status of these guidelines and when they will be available?

Given that the “2009 H1N1” is going to be with us as a seasonal strain now, the CDC has only two options that make any logical sense: either back off the mistaken N95 recommendation, or begin requiring N95 use for all suspected or confirmed seasonal flu.

It would be nice if CDC acted quickly, and if OSHA held its fire until new guidance is issued.

Addendum: Rather than spending its time and resources doing post-hoc punishment of hospitals that responded appropriately to 2009 H1N1, California OSHA should be doing more to reduce the real threat of HIV transmission in the porn industry. So far, Cal OSHA has taken the bold step of “setting up an advisory committee to study the issue”.

Saturday, May 8, 2010

Another benefit of hand hygiene!

We are always looking for ways to improve hand hygiene. Researcher Spike Lee at the University of Michigan has just published a creative study in the journal Science. In the study, subjects were asked to make a difficult decision. The subjects who washed their hands after making the decision, had lower cognitive dissonance; they were more at ease with their tough decisions. You can hear more about the study on this weeks Science Friday on NPR (here). Now if we could get our clinicians to round in the room (as some used to) and make decisions in the room, we could really increase our exit compliance. As it is, we could at least improve our entry compliance if we made the study results more available. Feel good about yourself: wash your hands!

Thursday, May 6, 2010

No MRSA here (part 2)

I'm in Charlottesville to participate in a debate at UVA with Dennis Maki on whether impregnated central venous catheters should be used in the critical care setting. I was assigned to argue the "no" side of the debate. Now I must have been temporarily insane when I accepted that invitation since no one in the world knows more about this topic than Dennis Maki. But I think it should be fun.

Now to the topic of this post. I've blogged before about the progress we have made at our hospital on reducing MRSA infections in our ICUs. We recently were able to sustain a period of no MRSA infections for over 6 months, and in the last 9 months we have had only 1 device-related MRSA infection (a VAP) in our 8 ICUs. Critics have argued (and rightly so) that just because our ICUs are doing well, it may not be so in the rest of the hospital. Our hospital leadership supported us in recruiting a new infection preventionist to take on the task of doing surveillance for device associated infections outside of our ICUs. And this morning before I traveled to Charlottesville, I finished an analysis of the first quarter data. Drum roll please!!!...For the first three months of 2010, we had zero nosocomial MRSA bloodstream infections associated with either peripheral IV lines or central lines across the hospital (ICU and wards, 820 beds). What's the significance of this? It's yet another finding that dispels the widely propagated myth that the only way to control MRSA in the hospital is by active detection and isolation. The only unit in our entire hospital where we obtain surveillance cultures for MRSA is our NICU (a unit that accounts for only 5% of our beds). And it validates our horizontal strategic approach to infection prevention--a focus on interventions that prevent all infections (e.g., hand hygiene, chlorhexidine bathing in ICU patients, the central line bundle, and lots of feedback to frontline providers).

Now I better get back to sharpening my arguments for the debate!

Wednesday, May 5, 2010

T. whipplei in toddler gastroenteritis

There's a new report from Marseille, France out in the May EID that identifies Tropheryma whipplei (the agent associated with Whipple's disease) in children ages 2-4 years old with a diarrheal illness. T. whipplei was present in 36 of 241 (15%) of those with gastroenteritis and none of 47 controls. In one third (13/36) of the T. whipplei positive kids, another pathogen was present. Since the organism can spread via the fecal-oral route, perhaps this will be an infection control issue now that it has been associated with a common clinical entity.

Tuesday, May 4, 2010

Should a hospital epidemiologist buy an iPad?

Perhaps some of you have already purchased an iPad. I suspect many of you think that getting another device is completely ridiculous since you already have a BlackBerry or iPhone, laptop and a desktop computer. If that is the case, you should check out Dropbox, which allows you to keep all of your documents synced across all devices and safely backed-up. If you are still on the fence, you may have been searching the interwebs for advice only to be faced with >1,000,000 google hits for "should I buy and iPad" with various humorously handy decision trees. None, I suspect, were actually helpful to you, the daring hospital epidemiologist or fearless infection preventionist. That's why CHIP exists, to serve our loyal readers.

First and foremost, I don't think you should purchase iPads for tracking hand hygiene compliance and various other in-hospital surveillance activities. There are several reasons for this including cost, size (Hawthorne effect people!) and you aren't supposed to clean the screen with solvents since they can damage the oleophobic-coated screen, oh, and the cost. As Dan has stated, there are Apps for that, but stick with an iPhone or iPod Touch.

Beyond that, I think there are 3 basic types of hospital epidemiologists and IPs, each with different needs and lives. I'm sure I will leave some or most of you out, but perhaps reading between the lines will get you the answers you need. If you still have questions, we offer open comment posting and we will try to answer your questions.

1) I attend SHEA/APIC: This one's the easiest. If you want to travel lightly, and as of now TSA allows iPads to be kept in your bag when passing through security, then the iPad is for you. The key benefits of the iPad are light weight, long battery life - I used it for 11 hours Sunday and still had 25% battery life left - and access to any content you want to read. That includes .doc, .ppt and .pdf files. There is a 99 cent app called GoodReader that will meet 99% of your needs. You can use it to read almost any document, download any file, grab any email attachment from the iPad Safari web browser, save most webpages for later viewing, AND wireless sync with your laptop even if wifi is not available. That last one is cool, and more information on how to do that is available (here) on the GoodReader site. If you get a 3G iPad, you can surf, check email and even control your home or work computer all without paying crazy hotel wifi fees. Apple charges $15 or $30/month but you can cancel anytime. Thus, only pay when you attend SHEA/APIC.

The iPad is the best email device I've used and will get better when the 4.0 OS comes out in the fall when it will allow a single in-box for your half-dozen email addresses. Even now it's fantastic and typing is more than adequate. Enter your passwords once and never have to log-in again. It works with gmail, yahoo, mobileme, aol and outlook along with others. You can also probably log into your VPN and check labs and other hospital-specific data unless you work at the VA. Either way, you should check with your IT support staff if your require that type of access.

2) I submit abstracts to SHEA/APIC: Above, I described some reasons why I think the iPad is the single best media consumption (documents, email) device there is. It is also wonderful for PubMed searches and other web-based searches including uploading your abstracts. Creating abstracts is a bit tougher. They can be started or edited using Apple's Pages (for .doc) and Keynote (for .ppt) but these applications have their limitations, which hopefully will be remedied in a future update. First, you must email the documents to yourself to get them on/off the device (or sync with iTunes). Second, track changes is not available and all previous changes are accepted once the document reaches the iPad. Third, some formatting is lost. It is likely that none of the abstract, poster or slide presentations will need to be completed while you're traveling, however. Hopefully.

3) I submit manuscripts to ICHE/AJIC.
This is a bit more complicated. I would still say the iPad is for you, but the reasons are more subtle. You can create a draft document in Pages while you travel, but you can't really do track changes, insert endnotes etc. There is a PDF work-around since you can modify PDF documents using iAnnotate, but I suspect that is too much for most. However, the iPad is the single best PDF reader. Reading on a laptop or computer is sub-optimal since you can never get the screen set to the proper distance or are forced to read at a desk or table. With iPad, you can read PDFs as you would a book or magazine. No more printing and carrying PDFs! That will save your back and your eyes. This is why I purchased the iPad (the work reason, I also stream MLB games). It is fantastic to have all of your PDFs and MS Word files via Dropbox and GoodReader in one device that you can place next to your laptop when writing a paper or take to your reading chair when you finally make it home.

Final note: I also recommend Papers if you own a Mac/iPad/iPhone. This software is great for organizing the 1000's of PDFs you have scattered around devices. It pulls them all together and allows searching using metadata like you can in iTunes - search by author, title, date, journal. You can also dump PDFs in a folder and then create an Endnote library.

Final, final note: You don't need to get the expensive 64GB model if you have easy access to wifi, or get the 3G iPad, since you can always access your files in the cloud with services such as Dropbox and MobileMe. If you want to have 20 movies available as you fly back and forth from the WHO, then maybe you need the 64GB. Most of what I described, apart from iWork (Pages/Keynote) can also be done on the iPhone, but reading PDFs for long periods can be tough.


Antibiotics for irritable bowel syndrome? I suppose the biological plausibility argument would be that IBS is a result either of bacterial overgrowth or of an as-yet-unidentified pathogen that is responsive to rifaximin. I haven't been following this literature at all, but my understanding is that other antibiotic trials have not been fruitful (at least for long term alleviation of symptoms), so before I run with an abstract about a study funded by the makers of the drug, I'd like to see more data--starting with the results of this trial being published in a peer-reviewed journal.

Monday, May 3, 2010

Running a hospital without clean water

Click here to read an article from today's Boston Globe on the lack of clean potable water at Massachusetts General Hospital due to a pipe rupture.

Sunday, May 2, 2010

Holy crap!

As if hospital epidemiologists don't have enough to worry about, there's a new paper in Clinical Infectious Diseases that demonstrates that C. difficile is commonly aerosolized. It's yet another reason why hospitals should move quickly to all private rooms.

Obesity and surgical site infections

Abstracts being presented at a national GI meeting this week demonstrate the impact of obesity on surgical complications. One study found that patients with a waist circumference of 45 inches or more were three times more likely to develop a surgical site infection after rectal cancer surgery. The authors of another study demonstrate increased surgical complications in obese patients and go on to criticize pay-for-performance programs that reward surgeons for better outcomes given that a patient's obesity is out of the surgeon's control. Moreover, they claim that since obesity is more common among minority patients, these policies may have adverse unintended consequences that result in discrimination.

Saturday, May 1, 2010

Calling all hand hygiene observers!

Tired of clumsy clipboards, cumbersome data entry, and nerdy pocket protectors for your pens and pencils?

Then try iScrub Lite, a handy (and free!) new app developed here at Iowa by Phil Polgreen and colleagues. iScrub allows you to record hand hygiene adherence on your iPhone, iTouch or iPad, and automatically e-mail the datafile to the account of your choice. It is CDC and WHO-approved, and will be discussed during this CDC COCA phone call next week:

Title: New Frontiers in Implementation and Measurement of Hand Hygiene Practices
Presenters: Katherine Ellingson, PhD (DHQP) and Christopher Hlady, PhD Candidate (University of Iowa)
Date: May 4, 2010 (Tuesday)
Time: 1:00pm- 2:00pm EST
Call-in: 1-800-779-7680
Passcode: 5831606
Please note that this COCA call will utilize a new webinar format. Use the links below to access the webinar presentation during the call.
Direct Access
In the event that you cannot access the web portion directly use:
Conference ID: PW7659840
Audience Passcode: 5831606