Wednesday, February 29, 2012

Michael Graves takes on hospital design

For many years I have been a huge fan of the work of Michael Graves, the American designer and architect. Several years ago he became paraplegic, and through his own medical care began to realize how poorly hospitals are designed. In this TED talk he shares his views on this problem as well as potential solutions. He even talks about infection prevention!

Tuesday, February 28, 2012

Meetings Make You Stupid

There's a funny post by Tim Dowling at the Guardian Blogs.  He discusses a recent study in the journal Philosophical Transactions of the Royal Society B that found the IQs were significantly lower after meetings. The decline was greatest in women.

In the Telegraph, Lead author Kenneth Kishida, a research scientist at the Virginia Tech Carilion Research Institute was quoted as saying: "Our study highlights the unexpected and dramatic consequences even subtle social signals in group settings may have on individual cognitive functioning... (and) given the potentially harmful effects of social-status assignments and the correlation with specific neural signals, future research should be devoted to what, exactly, society is selecting for in competitive learning and workplace environments."

Tim Dowling's suggestions for surviving meetings include:

• When something needs to be decided by several people in a department, call a meeting without telling anyone. The next day send emails to colleagues with the subject heading: "For all of you who missed the meeting, here is what we decided." Put down whatever you've decided.

 • Walk into a pre-scheduled meeting, sit down and have a bite of whatever nibbles might be on offer – egg sandwiches, for example – then jump up and say: "Oh my God! I completely forgot I was allergic to eggs!" Run out of the room, leaving your phone on the table to record proceedings. Listening back later, you may be surprised to hear how stupid everyone sounds.

• When you cannot get out of an office meeting, attend with a marmoset on your head, covered by a capacious but tight-fitting hat. Give the marmoset a couple of cans of Red Bull right before you go in. This should ensure that stress-inducing social cues associated with perceived rank in a work environment are among the very least of your worries.

(1) Tim Dowling, the Guardian Blogs 28 February 2012
(2) Rebecca Smith, the Telegraph, 27 February 2012
(3) Kishida KT et al. Philosophical Transactions of the Royal Society B, 5 March 2012

Good riddance... the Research Works Act, a bill which would have prohibited the federal government from requiring open access to research funded by the federal government. You read that correctly: you, dear taxpayer, get to pay for the research; then, when you want to read the results, you'll have to pay again!

A Slate commentary on this, here. As we've documented over the past month or so on this blog, the winds of open access seem to be picking up....

Tomorrow! #H5N1 Publication Discussion from the ASM Biodefense Meeting

Live Stream Details 
Date: Wednesday, February 29, 2012
Time: 7:15 a.m. - 8:15 a.m. EST

Monday, February 27, 2012

Another Reason to Fear Bats: Influenza

CDC scientists have discovered a novel influenza A virus in little yellow-shouldered bats in two areas of Guatemala. They report in the new PNAS that the novel hemagglutinin (HA) is called H17 and is thought to have diverged when other HAs did while the neuraminidase (NA) appears unrelated to known NAs. They were unable to grow the fruit bat virus in cell cultures or chicken embryos but suggest that it "is compatible for genetic exchange with human influenza viruses in human cells." Great, a new pandemic threat.

UPDATE: Very informative post on the subject by @aetiology

1) Tong S. et al. PNAS 27 Feb 2012
2) Gewin V. Nature News 27 Feb 2012

Learned Helplessness and Hand Hygiene

MSKCC's Kent Sepkowitz has a recent commentary in Lancet ID on hand hygiene.  He thinks that modern hospitals are too clean to benefit from hand-hygiene improvement efforts (I guess he hasn't read this paper). He concludes:

"The time has come for the infection control community to move on; please, no more cheerleading louder and harder to get thousands of people to improve their hygiene. We have to accept that our age-old dream of solving a complex problem cheaply and simply has failed. Instead, we must reacquaint ourselves with that lonely feeling familiar to clinicians when they realize a case is much more difficult than it appeared at first glance. In other words, we should embrace the intellectual audacity of our beloved Semmelweis but let go of his how-to manual. As he might tell us (loudly): an ineffective remedy is much worse than no remedy at all."

Is he right?  I don't think so.  There have been only 4 hand-hygiene intervention studies in the past few decades of high enough quality to warrant inclusion in the 2011 Cochrane Review. I say before we throw in the towel, bury our collective heads in the sand and go all Eeyore, we should probably do a few more than 4 good studies.  I also suspect that if we could really figure out why MRSA has declined in recent years, it would come down to hand hygiene improvements and not some expensive PCR.

Sunday, February 26, 2012

Attending Super Bowl after refusing super-effective vaccine is super-stupid

Not much new to say about this that we haven’t already covered. If vaccine refusal becomes increasingly prevalent, imagine the consequences when highly communicable viruses meet hundreds of thousands of congregating susceptible hosts.

I’ll outsource my outrage to Charles Pierce.

h/t to our regular reader Noel Eldridge for linking us to the Slate piece on this.

Don't Believe the Pennsylvania Hospital-Acquired Infection Report

When reports include claims that are clearly wrong, I wouldn't trust their entirety.  That's the case with the recently released "Impact of Healthcare-associated Infections in Pennsylvania 2010."  Dan and Mike have every reason to be surprised by the very very low infection rates. I too hope that more details concerning the validation of the HAIs will be provided soon.

However, I don't think we have to wait for more details to see that the report is seriously flawed. The error is so obvious (and so frequently repeated in other reports), that it should almost make us laugh.  The serious error is that the Pennsylvania report attempts to estimate the costs and excess length of stay associated with hospital infections by including the outcomes that manifest BEFORE the infection. 

For a better explanation, here is what we said in the methods of a recent Archives of Internal Medicine paper: "Longer hospital stays and higher costs associated with HAI cases may, in part, be due to extended preinfection hospital exposure. Because extended LOS is an independent risk factor for infection, the preinfection LOS of patients with HAIs may be expected to exceed that of similar patients who did not acquire an HAI. Attributing preinfection LOS to HAIs would overstate the true costs of HAIs...A study of 490 nosocomial sepsis cases from 8 tertiary care centers found that the mean preonset LOS was approximately 40% of the total LOS for these hospitalizations." 

To quote from the PA reports methods: "The average payment reported is for the entire length of stay, and not just for the treatment related to the infection."  It's like they are FLAUNTING THEIR ERROR. When the reports states "the estimated average Medicare fee-for-service payment for hospital stays for patients who acquired an HAI was $21,378...(and) the estimated average Medicare fee-for-service payment for those without an HAI was $6,709", we know we can't trust the estimates.  In fact, if we can't trust those, why should we trust any of it?

My copy just went into the trash.

Saturday, February 25, 2012

Attention, Pennsylvania IPs and hospital epidemiologists!

I share Mike’s amazement at the low overall prevalence of healthcare-associated infections (HAIs) in recent reports from Pennsylvania (1% of all admitted patients for the years 2009 and 2010). Especially since the 5-10% estimates aren’t just from older studies. Recent studies-- in fact, virtually every study performed outside of high-stakes public reporting mandates--report similar estimates (see this WHO summary, pages 12-15, from which the I pasted part of a Figure to the right, with PA added in red). As Mike points out, an amazing achievement.

But I have to stay true to the name of this blog, so for the sake of argument I will now assume a highly impolite and cynical stance regarding this report. Here goes: I don’t believe it.

I think we have reason to assume that a healthy proportion of CLABSIs are “adjudicated away” by many centers, and lord only knows how many other HAIs (VAP, anyone?) vanish into the ether of consensus review, clinician veto, administrative adjustment, or just plain old bad surveillance. Recall also the SHEA 2011 presentation reporting evidence for gaming in the earlier PA data (using methods that can also be criticized, but the “difference-in-differences” analysis was persuasive enough for me to accept that there was both a real reduction in HAI rates, and evidence for gaming, since the PA public reporting mandate).

Now that I’ve thrown down the gauntlet, Pennsylvania, please convince me that these data are accurate. The report references validation—how was it done? Was your own hospital subject to audit of HAI rates? How many records were reviewed, if chart review was performed? What were the credentials of the auditors? As a “consumer” of health care, would you base your decisions about where to receive care on facility level data from your state reporting program?

Friday, February 24, 2012

Pretty damn good!

The 2010 report on healthcare associated infections in Pennsylvania was recently released. Since Pennsylvania mandates the reporting of all HAIs, this probably represents the most robust data that currently exist. The most important statistic in the report, I think, is that 1.1% of patients admitted to acute care hospitals developed an infection. That shows tremendous progress since previous studies estimated that 5-10% of patients developed nosocomial infections. Of the infections reported in Pennsylvania, over half were surgical site infections, 20% were urinary tract infections, and bloodstream infections accounted for approximately 10%.

Graphic:  Leica News

Don't mess with my microbiota

A new study out in the Journal of Antimicrobial Chemotherapy suggests that colonic microbiota takes a good long time to reconstitute. In this multicenter case-control study, the risk for C. difficile disease was increased for 3 months after receipt of antibiotics. I can barely remember what I had for dinner two nights ago, so I'd be a poor historian if somebody was interviewing me that long after I completed an unnecessary antibiotic course for a viral upper respiratory tract infection.

Thursday, February 23, 2012

The Human Microbiome: 10^15 Microbiol Cells in 1 Lecture!

By Josh Neufeld, University of Waterloo  

For iDevices (here)

No NDM-1 in Healthy Mumbai Population! But ESBL in 24%

A Mumbai group screened 1000 consecutive fecal samples in healthy outpatients collected from January to June 2011 for carbapenem resistance using standard methods. In all samples, none were carbapenem resistant.  However, they found 227 E coli and 12 Klebsiella species that were ESBL producers. Compared to their 2004 study that found ESBL in 11% of healthy people, the increase to 24% is pretty alarming.  So good news and bad news in the same report. Just one comment: The same Mumbai group reported significant numbers (49 isolates) of NDM-1 containing Gram-negative bacilli in a study that included 310 carbapenem-resistant bacteria collected from Sept 2009 to May 2010.

Source: Deshpande et al. J Antimicrob. Chemother 2012.

Wednesday, February 22, 2012

Call me when your disease kills more than HIV….

HIV has become the standard against which all infectious public health threats are now measured. First with MRSA, now with hepatitis C virus (HCV), the media are abuzz with the news that another infection kills more people than HIV does. There are many reasons for this meme, perhaps the most instructive is that the resources put into research and prevention efforts for HIV are astronomical compared with those for many other infectious disease threats (a point Eli has made clearly). This investment has paid off, too, in the form of steadily falling HIV-associated mortality rates in developed nations. I look forward to the day when shark attacks, or “events of undetermined intent”, kill more people than HIV. Check out Table 2 in this document to see if your disease-of-interest kills more than HIV.

Maybe if we invested as much in research and prevention of multiple-drug resistant bacterial infections and other healthcare-associated infections, we’d see similar success.

Tuesday, February 21, 2012

Some free legal advice for the hospital epidemiologist

As I was scanning my email today, a link in Medscape caught my eye: Can hospitals force patients to remain in isolation? Short answer, according to the healthcare attorney interviewed, is no. Keeping a patient in contact precautions against their will constitutes false imprisonment. Wow! If word of this leaked to patients with MDROs, this could be the end of isolation as we know it.

Graphic:  Next Thing

Monday, February 20, 2012

Infectious Risks of Transvaginal Ultrasound

Transvaginal ultrasounds carry infection risks, although published estimates of rates are lacking. With the Commonwealth of Virginia poised to mandate ultrasounds prior to an abortion, and other states certainly to follow, it is important to review the CDC guidelines for the cleaning and disinfection of vaginal probes. There are also other issues at stake, like the doctor-patient relationship. Mandatory reporting of all infections secondary to this procedure should be considered.

Vaginal probes are used in sonographic scanning. A vaginal probe and all endocavitary probes without a probe cover are semicritical devices because they have direct contact with mucous membranes (e.g., vagina, rectum, pharynx). While use of the probe cover could be considered as changing the category, this guideline proposes use of a new condom/probe cover for the probe for each patient, and because condoms/probe covers can fail (195, 197-199), the probe also should be high-level disinfected. The relevance of this recommendation is reinforced with the findings that sterile transvaginal ultrasound probe covers have a very high rate of perforations even before use (0%, 25%, and 65% perforations from three suppliers). (199)

One study found, after oocyte retrieval use, a very high rate of perforations in used endovaginal probe covers from two suppliers (75% and 81%) (199), other studies demonstrated a lower rate of perforations after use of condoms (2.0% and 0.9%) (197 200). Condoms have been found superior to commercially available probe covers for covering the ultrasound probe (1.7% for condoms versus 8.3% leakage for probe covers) (201). These studies underscore the need for routine probe disinfection between examinations. Although most ultrasound manufacturers recommend use of 2% glutaraldehyde for high-level disinfection of contaminated transvaginal transducers, the this agent has been questioned (202) because it might shorten the life of the transducer and might have toxic effects on the gametes and embryos (203).

An alternative procedure for disinfecting the vaginal transducer involves the mechanical removal of the gel from the transducer, cleaning the transducer in soap and water, wiping the transducer with 70% alcohol or soaking it for 2 minutes in 500 ppm chlorine, and rinsing with tap water and air drying (204). The effectiveness of this and other methods (200) has not been validated in either rigorous laboratory experiments or in clinical use. High-level disinfection with a product (e.g., hydrogen peroxide) that is not toxic to staff, patients, probes, and retrieved cells should be used until the effectiveness of alternative procedures against microbes of importance at the cavitary site is demonstrated by well-designed experimental scientific studies. Other probes such as rectal, cryosurgical, and transesophageal probes or devices also should be high-level disinfected between patients.

As with other high-level disinfection procedures, proper cleaning of probes is necessary to ensure the success of the subsequent disinfection (205). One study demonstrated that vegetative bacteria inoculated on vaginal ultrasound probes decreased when the probes were cleaned with a towel (206). No information is available about either the level of contamination of such probes by potential viral pathogens such as HBV and HPV or their removal by cleaning (such as with a towel). Because these pathogens might be present in vaginal and rectal secretions and contaminate probes during use, high-level disinfection of the probes after such use is recommended.

195. Fritz S, Hust MH, Ochs C, Gratwohl I, Staiger M, Braun B. Use of a latex cover sheath for transesophageal echocardiography (TEE) instead of regular disinfection of the echoscope? Clin. Cardiol. 1993;16:737-40.
196. Lawrentschuk N, Chamberlain M. Sterile disposable sheath sytsem for flexible cytoscopes. Urology 2005;66:1310-3.
197. Milki AA, Fisch JD. Vaginal ultrasound probe cover leakage: implications for patient care. Fertil. Steril. 1998;69:409-11.
198. Storment JM, Monga M, Blanco JD. Ineffectiveness of latex condoms in preventing contamination of the transvaginal ultrasound transducer head. South. Med. J. 1997;90:206-8.
199. Hignett M, Claman P. High rates of perforation are found in endovaginal ultrasound probe covers before and after oocyte retrieval for in vitro fertilization-embryo transfer. J. Assist. Reprod. Genet. 1995;12:606-9.
200. Amis S, Ruddy M, Kibbler CC, Economides DL, MacLean AB. Assessment of condoms as probe covers for transvaginal sonography. J. Clin. Ultrasound 2000;28:295-8.
201. Rooks VJ, Yancey MK, Elg SA, Brueske L. Comparison of probe sheaths for endovaginal sonography. Obstet. Gynecol. 1996;87:27-9.
202. Odwin CS, Fleischer AC, Kepple DM, Chiang DT. Probe covers and disinfectants for transvaginal transducers. J. Diagnostic Med. Sonography 1990;6:130-5.
203. Benson WG. Exposure to glutaraldehyde. J. Soc. Occup. Med. 1984;34:63-4.
204. Garland SM, de Crespigny L. Prevention of infection in obstetrical and gynaecological ultrasound practice. Aust. N. Z. J. Obstet Gynaecol. 1996;36:392-5.
205. Fowler C, McCracken D. US probes: risk of cross infection and ways to reduce it--comparison of cleaning methods. Radiology 1999;213:299-300.
206. Muradali D, Gold WL, Phillips A, Wilson S. Can ultrasound probes and coupling gel be a source of nosocomial infection in patients undergoing sonography? An in vivo and in vitro study. AJR. Am. J. Roentgenol. 1995;164:1521-4.

Sunday, February 19, 2012

Zero: the enemy of objectivity

I had a busy travel week, first at the Remington course and then a HICPAC meeting. It was interesting to begin the week giving a lecture on VAP prevention, and then to end the week discussing changes to the VAP definition that increase objectivity, and even make it amenable to a purely electronic reporting algorithm. Since this proposed new measure is already being reviewed by the National Quality Forum, I thought I would share the general outline with the course attendees. A couple of them came up to me afterwards, nervous about a more objective definition. You see, by virtue of the fact that the new definition is based mostly on objective measures of sustained respiratory decline in a stable/improving ventilated patient, it isn’t meant to define VAP, but rather “ventilator associated complication”, or “VAC”. There are subcategories of VAC for events associated with an inflammatory response and/or signs of infection (call them “iVAC”), but the main measure destined for public reporting is meant to be VAC.

The problem? For those centers that have successfully pushed their VAP rate to “zero”, by whatever means necessary, the new VAC definition is threatening. Not only will a new definition unmask the gaming that occurs with subjective definitions, but the number of VACs will greatly exceed the VAPs at most centers. Take a look at the table below (double-click it to expand it), from a recent PLoS One paper that compared VAC and VAP at three hospitals in the Prevention Epicenters program. There were more than twice as many VACs as VAPs. Also of interest, VAC was associated with in-hospital mortality. VAP, not so much….not at all, in fact.

Although VAC may be the first in line, the concept is the same for other definitional changes—achieving greater objectivity in surveillance definitions requires that our unhealthy focus on zero (or “elimination”) must itself be eliminated.

For more VAP-happy goodness, check out this thought piece by Mike Klompas, the master of all things VAP.

Thursday, February 16, 2012

Coercive Self-Citation: Uncomfortably Common

A Policy Forum piece in Science by Wilhite and Fong explores the incidence of editorial coercive citation using a survey of ~6700 researchers.  Authors in economics, sociology, psychology, and business were surveyed and 832 related journals were examined. Their definition of coercive self-citation is when editors "(i) give no indication that the manuscript was lacking in attribution; (ii) make no suggestion as to specific articles, authors, or a body of work requiring review; and (iii) only guide authors to add citations from the editor's journal."

They found that 175 journals were called coercers with one journal being named 49 times. Since the mean submission rate per journal was 55 articles, some journals appear to coercer most authors. Importantly, they found that 64% were less likely to submit to a journal if coerced but sadly, 57% would add "superfluous citations" prior to submitting a manuscript to a known coercer. Only seven percent of authors would refuse to add citations if coerced.

They then looked at "risk-factors" for coercion using regression analysis and found that researchers of more junior rank were more likely to be coerced compared to full professors. In conclusion, they suggest that something needs to be done, but not many options for intervention are available. Enough for now but it's worth a read.

Source: Allen Wilhite and Eric Fong, Science 3 Feb 2012 (335) 542-3.

h/t Preeti Malani

Wednesday, February 15, 2012

Looks like Influenza Activity is Picking Up

In Week 5 ending Feb 4, most of the activity remains H3N2; however,  2009 H1N1 has increased in recent weeks, especially in regions 6 and 9. You can scroll to the bottom of the blog to see the latest activity on the US Map.  I hope that the proposed public health budget cuts don't impact the collection and distribution of this important public health data.
Source: CDC's Seasonal Influenza Weekly Report Page

The Parable of Free Food and #OpenAccess

One day a wizard made an amazing Food Teleporting Duplicator. Free food for all.  What could go wrong?  The Guardian (Mike Taylor) posted this amazing story of farmers and distributors and people. There are some important lessons for open access academic publishing.  Enjoy.

Source: Mike Taylor, The Guardian, 10 Feb 2012: "The parable of the farmers and the Teleporting Duplicator" 

h/t Michael Eisen


Tuesday, February 14, 2012

Don't mess with mathematicians!

Today's New York Times has a piece on a movement organized by mathematicians to boycott Elsevier, the behemoth publisher of academic journals. Nearly 6,000 researchers have joined the boycott of publishing in, peer reviewing for, or serving on the editorial boards of Elsevier journals. The tipping point was apparently the movement by Elsevier and other publishers to attempt to undo the NIH rule requiring studies funded by taxpayers to be made freely available to readers without subscription fees. In this document, the organizers nicely lay out their arguments on how for-profit publishers are exploiting academicians and academic libraries. I wish the mathematicians an eternal supply of sharpened pencils and much success in battling Goliath.

Graphic: Justin Ketterer

Silver lining in rising MDR-N. gonorrhoeae?

We've written about poor funding for MDR-bacterial prevention studies and antimicrobial discovery. In fact, our NIH funding paper with Dan Kwon and Marin Schweizer looking at NIAID support for ESCKAPE-pathogen studies was just published in ARIC. It's a major problem, as there has been almost no governmental or private funding for antibacterial discovery in decades. Don't even get me started on funding for infection prevention studies. Only 4 good studies on hand-hygiene improvement since the 1950's, seriously?

With that background, I read with interest Gail Bolan's (CDC) editorial in this past week's NEJM.  In it she sounds the alarm for resistance in gonococcus based on a recent 17-fold rise in 3rd-generation cephalosporin resistance (cefixime) from 0.1% to 1.7% with higher rates in Western states. (See graph above) This rise in cephalosporin resistance follows sulfa resistance in the 1940s, PCN and TCN resistance in the 1980s, and fluoroquinolone resistance by 2007.

An interesting fact shared in the article is that when resistance to a particular drug class reaches 5%, the CDC's Gonococcal Isolate Surveillance Project(GISP) changes treatment recommendations to a new class of antibiotics. Sadly, only third-generation cephalosporins are left. I wonder if this class switch at 5% is contributing to the rise in resistance?  That question will remain unanswered - no funding. Also, imagine having a 5% threshold in hospitalized patients.  We would have run out of choices years ago!

So what is the silver lining in all of this?  I have a suspicion that politicians and others might be motivated by an STD with an annual incidence of 600,000 in the US. I'm not saying that politicians are at higher risk for STDs, no judging, but STDs put many people at risk, so there will be pressure to respond to this.  The silver lining is that antibacterials designed or discovered that are effective in treating GC will likely have efficacy for other MDR-bacteria, such as Acinetobacter. 

Thus, when Bolan and colleagues suggest that "the immediate priority is replenishing the drug pipeline to treat gonococcal infections," I have hope that people will listen.  There are few grassroots organizations fighting for antibiotic discovery, but there may be soon.  I hope so; our hospitalized patients are counting on it.

Brown M&Ms

My favorite excerpt from Atul Gawande's The Checklist is the story of David Lee Roth and the brown M&Ms. It's a really powerful anecdote on the utility of checklists. Here's a video of Roth telling the story. Enjoy!

Friday, February 10, 2012

Conflict of interest?

Sometimes a picture's worth a thousand words...

Thursday, February 9, 2012

Lying About Prognosis Might Not Be Lying

There is a lot of chatter (or here) about Lisa Iezzoni's study on physician openness and honesty, that was recently published in Health Affairs.  We've discussed the importance of disclosing medical errors numerous times, as well as the importance of disclosing financial conflicts of interest, so physicians who aren't honest in those domains, will get little sympathy here.  However, one aspect of the survey findings, I think, deserves more discussion, namely the disclosure of prognosis.

To quote from the article: "...more than half said that they had described a prognosis more positively than the facts warranted."

Is this really "lying"?  What is the importance of disclosing mean, median or mode survival?  Will patients or families even understand the difference?  How do you explain a normal or skewed survival curve?  If you can't describe the distribution or they don't understand it, is that dishonesty? Importantly, how does this all impact "hope"?

One article, written many years ago (1985) by Stephen J Gould, the Harvard evolutionary biologist, does a better job describing why "The Median Isn't the Message" than anything I could write. He tells how he reacted to his 1982 mesothelioma diagnosis. He lived until 2002. This essay has been highly influential to me throughout my medical career.

Wednesday, February 8, 2012

In Hospital C. difficile Transmission? Not so much.

There is an important paper in PLoS Medicine by Sarah Walker et al. in the UK that measured the proportion of C. diff cases in hospitalized patients that were acquired during their index hospital stay.  The results are pretty surprising. Using MLST, only ~25% of cases could be linked to inpatient transmission, ranging from 37% in renal/transplant down to 6% in specialist surgery.  Additionally, many of the C. difficile cases linked to in-hospital transmission manifest soon after the index case appeared clinically. In the accompanying editorial, Harbarth and Samore suggest that this means "the hospital environment was not, as has previously been claimed, a long-lasting reservoir for this pathogen."


1) Walker AS, et al PLoS Medicine February 2012
2) Harbarth S and Samore MH et al. PLoS Medicine (Editorial)

Tuesday, February 7, 2012

Dr. Berwick goes to Washington

The Story is one of the podcasts I listen to while I walk to work. This week’s episode is well worth a listen—an excellent interview with Don Berwick about his time with CMS. I can’t comment much more without making this a political blog, which is not my intent. But I urge you to listen at least to the story of his meetings with two senators, starting at about 14:45 into the podcast (downloadable from the website or from iTunes).

Monday, February 6, 2012

Batting .400: Baseball Good, Doctors Not So Good

Brian Goldman, an Emergency Medicine physician in Toronto, discusses mistakes in medicine including the causes (e.g. cognitive bias) and the culture of denial that prevents us from openly and honestly discussing and, therefore, reducing the risk of mistakes.  He mentions the VA in the 200+ comments below the talk on the TED website: "The VA has pioneered the widespread use of decision support - including comprehensive use of clinical practice guidelines - to get MDs to consolidate their practice patterns around evidence-based approaches. The result is that VA hospitals are treating patients better and at lower cost."   Link for iDevices: Brian Goldman

Sunday, February 5, 2012

High stakes and low rates

The recent scandal surrounding a college that submitted inflated SAT scores to improve their ranking in the US News & World Report should remind us of a simple fact—the higher the stakes, the more likely cheating will occur.

Now that CMS is publishing ICU CLABSI data on their hospital compare website, and using the data in payment formulas, the stakes for hospitals could hardly be higher. And available data suggests that many hospitals stray from strict application of NHSN definitions, reporting misleadingly low CLABSI rates. We’ll soon be publishing results from a survey we did of hundreds of infectious diseases clinicians involved in CLABSI reporting at their institutions. Given patient scenarios that clearly met the NHSN definition for primary CLABSI, what percent do you think responded that they would report them as primary CLABSIs? I can’t go into detail given that this is as-yet-unpublished data, but I suspect the results will surprise even those most critical of publicly-reported HAI data. So I’m dismayed when I read quotes like “several hospitals that serve the sickest patients have been able to achieve infection rates of zero for several years”. The statement is obviously false—but even if it were true, it simply means that the hospital isn’t applying NHSN definitions correctly.

Saturday, February 4, 2012

Don't tie one on!

A new study in the Journal of Hospital Infection seeks to shed some light on an area of true controversy in infection prevention: whether clothing is involved in the transmission of organisms between providers and patients. The party line thinking in the infection prevention world goes something like this: infrequently laundered white coats and neckties do not transmit pathogens to patients, but if a patient is infected or colonized with MRSA, VRE or MDR-gram negative organisms wear a plastic gown when you enter his room. I have yet to have anyone explain to me the logic behind this paradoxical thinking. In my simple mind, clothing either has the potential to transmit pathogens or it does not. If it does, then minimize that risk. Shedding white coats, ties and long sleeves makes sense to me. The real question, I believe, is not whether infections are reduced by these simple interventions, but to what degree.

In the JHI study, a physician simulated a physical exam on a mannequin. The physician wore 4 different combinations of shirts and neckties (short sleeved shirt, long sleeved shirt, with tie, without tie). Prior to each simulated physical exam, specified areas of the shirts and ties were inoculated with Micrococcus luteus. After the exam, the mannequin was then cultured for the presence of Micrococcus. Each clothing combo experiment was repeated 5 times.

The clothing combo resulting in the highest rate of mannequin contamination was long sleeves + tie (transmission occurred in 4/5 experiments) and lowest with short sleeves sans tie (0/5). Looking at each item separately, long sleeved shirts were associated with more frequent transmission than short sleeved (5/10 vs 2/10), and ties more frequently than no ties (6/10 vs 1/10). Based on the application of a statistical test to the proportions shown above, the investigators concluded that ties increased the risk of transmission of bacteria, but long sleeves did not. Given that there were only 20 experiments I don't think we can draw many conclusions here, except that it's another study which adds to the biologic plausibility that clothing may be involved in transmission of pathogens in the hospital. As a guy who still follows the bare-below-the-elbow approach (i.e., what follows may reflect my bias), I find it intriguing that the only clothing combo in which no transmission occurred was short sleeves + no tie. Aren't we still trying to get to zero?

Photo: Brown Medicine

Wednesday, February 1, 2012

Lyme Disease: Where it is and isn't

In my outpatient practice, I commonly see patients referred with a diagnosis of Lyme Disease. However, the overwhelming majority of these patients do not have an illness consistent with this infection. Most have negative serology, although the negative serology is not infrequently misinterpreted  by the referring physician (e.g., I commonly see patients who may have a single band positive on a western blot IgG, which does not meet diagnostic criteria for Lyme Disease but the "positive" band is circled on the lab sheet by the doctor and the patient comes to see me). Other patients do have positive western blots by CDC criteria, yet the clinical picture is not consistent with Lyme Disease. Over the 16 years I have worked in Richmond, I can recall only one patient that I thought truly had Lyme Disease and in this patient the tick bite had occurred elsewhere in a highly endemic area. The problem, of course, is when you are faced with a positive test and a patient who has symptoms, even atypical ones, there is often a bias towards treatment. Unfortunately, much of the epidemiology of Lyme Disease is based on diagnostic testing that remains inaccurate.

So I was almost euphoric when I saw a new paper in the American Journal of Tropical Medicine and Hygiene that took a very different approach in elucidating the epidemiology of Lyme Disease. In this CDC-funded study, over 5,000 Ixodes scapularis ticks from the 37 states where the tick is found (upper midwestern and eastern US) were tested for Borrelia burgdorferi, the causative agent of Lyme Disease. Based on the data collected a risk map was constructed:
The map shows two major foci of infected ticks--the eastern seaboard from northern Virginia to Maine, and the upper midwest with a concentration in Wisconsin and Minnesota. Interestingly, no infected ticks were found in central Virginia, which confirms my clinical observation. Nonetheless, we desperately need better diagnostic testing for Lyme Disease.

Map:  NPR

MRSA vs Man vs MRSA: CA-MRSA and Vaccines

Maryn McKenna has a new Nature Feature on Robert Daum's early CA-MRSA report and his vaccine development efforts.  The article spans the period 1995 to present and discusses old and new vaccines, including Daum's  TH17-targeted approach.  A nugget I didn't know is that Daum had an 18-month struggle with JAMA editors prior to publication of his early description of CA-MRSA cases in pediatric patients.  The article is now considered to be an early warning of the epidemic.  Probably shouldn't rely on publications in academic journals for early warning signals.  What are you waiting for?  Head on over there for the full read.

Source: Maryn McKenna: Vaccine Development: Man vs MRSA, Nature 01 Feb 2012