Wednesday, February 29, 2012
Tuesday, February 28, 2012
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
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....
Date: Wednesday, February 29, 2012
Time: 7:15 a.m. - 8:15 a.m. EST
Monday, February 27, 2012
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
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
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.
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
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
Graphic: Leica News
Thursday, February 23, 2012
Source: Deshpande et al. J Antimicrob. Chemother 2012.
Wednesday, February 22, 2012
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
Graphic: Next Thing
Monday, February 20, 2012
UPDATE: Image removed.
From the CDC-HICPAC "Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008"
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)
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.
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
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.
Friday, February 17, 2012
Thursday, February 16, 2012
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
Seasonal Influenza Weekly Report Page
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
Graphic: Justin Ketterer
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.
Friday, February 10, 2012
Thursday, February 9, 2012
Wednesday, February 8, 2012
1) Walker AS, et al PLoS Medicine February 2012
2) Harbarth S and Samore MH et al. PLoS Medicine (Editorial)
Tuesday, February 7, 2012
Sunday, February 5, 2012
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
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
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:
Source: Maryn McKenna: Vaccine Development: Man vs MRSA, Nature 01 Feb 2012