Saturday, March 31, 2012
Friday, March 30, 2012
- The huge carbon footprint generated by attendees' travel
- The dissemination of misinformation due to abstracts that are not well reviewed, sometimes inaccurate, and many of which are never ultimately published as full-length articles
- Giving opinion leaders disproportionate influence
- Over-the-top exhibit halls
- Industry sponsored satellite meetings
Photo: The Serra Group
Thursday, March 29, 2012
|JournalWatch from qfever.com|
So why should anyone read your paper? More accurately, how can you convince me to read your paper if I don't even know it exists? Answer: You have to market it. Some authors at some institutions who publish in some journals (AJIC not ICHE) are lucky, since someone does the marketing for them. If you're not so lucky, you and your colleagues have to do the marketing. If you're looking for the how and why we should market our science, look no further than this month's issue of Nature Materials. It includes an editorial, commentary and interview of Marc Kuchner, astrophysicist and author of a new book titled Marketing for Scientists, each discussing the importance of science marketing.
This isn't just about selling your paper or raising your profile, nor is it limited to increasing your chances of NIH funding, but rather it has very large public health implications. We have spent years in infection prevention quietly studying methods to prevent the spread of resistant bacterial pathogens and reducing surgical infections with very little notice and certainly very little funding. By nature we are type-A, quiet and hard working folk, who don't want to rock the boat. Well, guess what? It ain't working.
To emphasize our lack of voice...Q: Who are the two most prominent public voices in quality improvement / infection prevention? A: Peter Pronovost (critical care) and Atul Gawande (surgery). Thank goodness someone is speaking up!
So what can we do?
1) When you publish a paper on antibacterial resistance or infection prevention, advertise it. Get on twitter or Facebook. Call your local paper's science reporter if they still have one, work with your hospital or university to do a press release, and demand the journal do a press release (see point #2)
2) Call ICHE and SHEA and insist on a press releases for your paper, even if it's not published in ICHE (joking on that last part). Currently, ICHE does a little monthly email thingy on 1-2 papers - not going to work! Ask them to emulate what APIC and AJIC do - much better!
3) Call your representative and ask why no one is doing anything about new antibiotics and why there are all these infections without treatment. Ask them why there is no direct funding from CMS for infection prevention services for acute and long-term care facilities. Use your science to start the conversation - say - "look what I just found!"
4) Start a local chapter of ID physicians, ICPs, microbiologists and others that focus on raising awareness for antibacterial resistance. Work together to communicate resistance trends in your locality and the findings of your research. (I know I'm dreaming)
5) Get your state and local health departments involved - send them your papers. I bet they know a way to get newspapers interested in resistance.
We aren't just scientists, we are stewards of our science. If you care enough to do the study and publish the paper, you should care 10x more that someone reads and uses your science!
...that's all I got for now, see you on twitter...
(live) image source: http://www.qfever.com/journalwatch.html
Wednesday, March 28, 2012
Photo: Alexander Joe/AFP
Tuesday, March 27, 2012
In three related randomized trials, Adam and Galinsky explored the science of "enclothed cognition" which suggests that people are influenced by (a) physically wearing specific clothes and (b) the symbolic meaning of the clothes.
In the first study they randomized 58 students to randomly wear a lab coat or their street clothes. Subjects were then given the Stroop task where they had to quickly state whether a string of letters were colored red or blue with some incongruent trials thrown in with the word "RED" written in blue and "BLUE" written in red. While each group took the same amount of time to complete the tasks, the subjects wearing lab coats made half as many errors on the incongruent trials. Thus, it appears that wearing a lab coat improved selective attention.
In the second (N=74) and third studies (N=99), they investigators explored the impact of the clothes "meaning." They divided the cohort into three random groups: (1) wearing a "doctor's" lab coat; (2) wearing a painter's lab coat and (3) seeing or identifying with a doctor's lab coat. The outcome they tested was sustained cognition by showing subjects identical photos except for four minor differences and asking them to find the four differences. Test yourself using the photo below while wearing and not wearing your white coat. (You can click to enlarge the photos)
The results were very interesting. The subjects in a doctor's coat found 20-30% more differences in the pictures than subjects in a painter's coat. Thus, wearing a lab coat improves sustained attention but only if it is a certain kind of lab coat - namely a doctor's white coat - the meaning of the coat matters.
So where does this leave us? First, I would want to see how persistent this effect is. Does the effect wear off very quickly after the "white coat ceremony"? Does it work immediately after you put on the white coat but then work less effectively by the end of rounds? Of course, does it have to be a "doctor's coat" in particular or can we slowly wean clinicians off their white coat addiction while maintaining the cognitive benefits with a creative replacement, say, a doctor's cummerbund?
Source: Adam H and Galinsky AD. J Soc Psych 2012
The course is made up of 3 modules: the Healthcare-associated Infection Prevention and Management Core Module, the Applied Infection Control Module and the Healthcare-associated Infection Advanced Epidemiology Module. Course fees are 1290 Euro for Society members, which includes hotel and food. Of note, 1290 Euro = $1721.2470 US if you sign up...exactly.......now! Oh, shucks, too late it just changed.
Update: 28 March at 1pm CT: Cost is now $1715.57
The course coordinators are Marc Bonten, Bart Gordts, Jan Kluytmans, Leonard Mermel and Andreas Voss. The course faculty spans the globe with five faculty from The Netherlands and two faculty from The Iowa. Sign up now!
- Marc J. M. Bonten, Utrecht, The Netherlands
- Ben Cooper, Oxford, UK
- Markus Dettenkofer, Freiburg, Germany
- Bart Gordts, Antwerpen, Brussel
- Loreen Herwaldt, The Iowa, USA
- Arno Hoes, Utrecht, The Netherlands
- Jan Kluytmans, Breda, The Netherlands
- Leonard Mermel, Rhode Island, USA
- Eli N. Perencevich, The Iowa, USA
- Evelina Tacconelli, Rome, Italy
- Christina Vandenbroucke-Grauls, Amsterdam, The Netherlands
- Andreas Voss, Nijmegen, The Netherlands
- Andreas F. Widmer, Basel, Switzerland
Saturday, March 24, 2012
Friday, March 23, 2012
|Jim Kim, Ophelia Dahl, and Paul Farmer, co-founders of Partners in Health|
I first learned of Dr. Kim several years ago when I read "Mountains beyond Mountains," a book about Paul Farmer and the start of Partners in Health. It's a wonderful book that should be required reading for anyone who works or wants to work in health care.
Addendum (3/25/12): Here's a good piece by Ezra Klein on why Kim is a good choice for this position.
Photo: Dartmouth Life
All right, nothing more here. Head on over to Maryn McKenna's SuperBug post to get the rest of the story. She's also provided links to her prior posts on the topic. Awesome!
Tuesday, March 20, 2012
They are looking for manuscripts exploring methods for controlling influenza outbreaks at the population level including TIV or LAIV vaccines, emerging vaccines and new technologies, barriers to or evaluation of vaccine effectiveness, school-located influenza vaccine programs (SLIV), prophylactic pharmaceutical interventions and treatment regimens and non-pharmaceutical interventions.
Manuscript Due: Friday, 15 June 2012
First Round of Reviews: Friday, 7 September 2012
Publication Date: Friday, 2 November 2012
Source: Influenza Research and Treatment Call for Papers
Monday, March 19, 2012
A decade ago, Anthony Harris and Yehuda Carmeli (and other folks) outlined optimal control-group selection in risk-factor studies for antibiotic resistant infections. (see here, here and here) Prior to these important studies, authors would frequently use patients infected with the susceptible organism as the control group. For example, when looking at risks for MRSA they would select MSSA controls, which is incorrect. Unfortunately, many authors still select the wrong control group and unknowingly publish conditional odds-ratios. I will discuss this more in a later post.
My first ever publication, and in some ways still my favorite, was a letter to the editor of CID that I wrote in 2000 pointing out a common flaw in outcome studies of infectious diseases. In the letter, I discussed a paper that looked at the outcomes (death) associated with methicillin-resistance in patients with S. aureus bacteremia. In the analysis, the authors controlled for septic shock in their regression model. I pointed out that shock is in the causal pathway between infection and death and, therefore, should not be controlled for in regression in models. This would be like controlling for car accidents when looking at the association between cell phone use and death. In infectious diseases, if you remove shock from the causal pathway, it is hard to see how you might otherwise die.
The error of controlling for intermediates is frequently repeated in ID outcome studies when, for example, authors control for illness severity using the APACHE score. If the APACHE is measured after the infection manifests, this variable would be in the causal pathway and should not be controlled for in the regression model. The APACHE should be measured before the infection manifests, as we did here. Jessina McGregor and JJ Furuno (both now at Oregon State) published a nice systematic review on optimal methods for ID outcome studies in CID back in 2007. Wouter Rottier (with Marc Bonten) just published a meta-analysis looking at the impact of confounders and intermediates (factors in the causal pathway) on ESBL-bacteremia outcomes. (JAC, March 5, 2012) I highly recommend that you read these studies prior to undertaking an ID outcome study.
Anthony Harris and I have also written extensively on the appropriate use and analysis of quasi-experimental studies looking at interventions to prevent hospital-acquired infections. In a trilogy of CID review articles, we reviewed the optimal quasi-experimental designs (2004), the frequency of each design's use (2005) and appropriate statistical analysis of time-series data (2007). If you're planning on doing a non-randomized study of any infection prevention intervention, please look these papers over. Following the optimal methods outlined in these reviews will improve your studies and also increase the chances that your intervention study's results will make the grade and be included in future systematic reviews, such as Cochrane reviews.
Image Reference: DA Grimes, Lancet 2002;359:57-61
Friday, March 16, 2012
As you read Dr. Chan’s address, which focuses on EU efforts, think about how our fragmented healthcare system and dysfunctional political environment affect efforts to prevent and control resistance. Are you interested in tracking how antibiotics are used in the United States? Sorry, we don’t have those data. Would it be useful to expand our surveillance for antimicrobial resistance to a truly nationwide program? Nah, that won’t happen—CDC and public health budget cuts may make it impossible to sustain even the existing Emerging Infections Program. Would you like to see more funding of research to determine which prevention approaches are most effective, and which antibiotic treatments provide the best outcomes (and which are unnecessary)? Not likely, in the current climate.
In combination with underfunding of prevention, the current political hysteria over the Affordable Care Act is likely to have a major negative impact on antimicrobial stewardship and antimicrobial resistance control. The current opposition narrative—where any suggestion that “less is more” is a hidden agenda to install death panels to kill us all (“no antibiotics for you!”)—is anathema to good antimicrobial stewardship.
Wednesday, March 14, 2012
That’s what you’ll find when you read the April issue of ICHE. The entire issue is dedicated to antimicrobial stewardship, and includes several excellent articles. So consider it your Spring Break reading.
There’s even an article from Eli’s old stomping ground, describing what happens when you take an effective antimicrobial stewardship program and flush it (spoiler alert: turns out to be a bad idea). Lest we forget, the Maryland group is still the only one to demonstrate, in a randomized controlled trial, the effectiveness of adding computerized clinical decision support for stewardship efforts. So go back and read that paper too, while you’re at it.
I’ll end with this quote from our friends Arjun Srinivasan and Neil Fishman, from the intro to the special issue:
There has perhaps never been a more critical juncture for antimicrobial stewardship. There is growing interest from key stakeholders—clinicians, healthcare administrators, and policy makers—and a growing body of evidence demonstrating the benefits of stewardship. We now need to harness the interest and the science to move toward making stewardship programs an integral part of all healthcare facilities. Education and messaging will play an important role. For too long, our message on the benefits of stewardship has been too narrowly focused on reducing costs and potentially reducing antibiotic resistance. The former is not compelling to most clinicians, and the latter, while generally accepted, has been difficult to demonstrate clearly since the emergence and spread of resistance is so complicated and multifactorial. Moving forward, we need to emphasize that antibiotic stewardship is, fundamentally, a critical patient safety and public health issue for all healthcare settings that can improve the quality of care.
Photo: Alexander Fleming, from Wikimedia Commons
Monday, March 12, 2012
…over the CDC budget, which Eli blogged about last week. As their budget gets cut further and further, the CDC leans more heavily on the Prevention and Public Health Fund (“Prevention Fund”) to pay for core functions. The problem is that the Prevention Fund was originally designed to fund new initiatives, not to fill in for ill-advised core budget cuts. And since the fund was established as part of the Affordable Care Act, it has now become a political target (and was already cut drastically as part of the payroll tax cut extension and Medicare “doc fix” deal). If you require further evidence of the tenuous status of the Prevention Fund, know that it has been termed “an Obamacare slush fund” by the GOP (note to whoever came up with that genius terminology: you are a colossal ***).
“If public health measures are effective, the problems they are aimed at are often solved or never even materialize, thereby making them virtually invisible.
Few individuals have personal interactions with or know what epidemiologists, health program coordinators, virology trainers, and outreach specialists do. When individuals are spared from a disease because the air in their office building is clean, it is not immediately clear whom to thank or if thanks are even necessary. As a consequence, public health professionals, programs, and policies are largely invisible to the public and taken for granted.”
I agree with this, but I think the issue is even larger, and more depressing. The statement above assumes that if people were just informed of the consequences of not supporting prevention efforts, they would act differently. I don’t think so. I’m hearing more political candidates question the basic social contract, the very assumption that government has a legitimate role in providing for the common good (and that we all have an obligation to pay for it). I encourage you to listen to this podcast, entitled, “What Kind of Country”, which details some trade-offs that local governments are making when money runs out and citizens are no longer interested in paying to provide for the common good. I was particularly struck by the story of individual citizens refusing a small tax increase to keep all the streetlights on in their town, but willing to pay $300 out of pocket to keep the lights near their own house burning.
Saturday, March 10, 2012
Thursday, March 8, 2012
Wednesday, March 7, 2012
Branswell quotes one of our favorite Canadian's Allison McGeer who said "there's lots of evidence that it's not as simple as temperature. People have been looking for temperature and humidity indications for a long time — and there may well be some contribution — but if it is, it's subtle and complex. It's very clear that it's not just having a milder than usual winter that makes a difference." The article also mentions that vaccination rates in Canada and the United States are around 35-40%, which should not be high enough to explain the magnitude of annual influenza epidemics. Of course vaccination rates are only relevant if the vaccine is effective.
In the most recent issue of Archives of Internal Medicine, Kenny Wong and colleagues from the University of Toronto studied the effectiveness of influenza vaccination in a large cohort of community-dwelling Ontario residents over 65yo. Using administrative data from 2000 to 2009 and controlling for selection bias using an instrumental variable approach, they report minimal effectiveness in reducing all-cause mortality. Looking at a composite outcome of mortality plus admissions for pneumonia, they did find vaccine to be protective. For an excellent review of this paper, prior studies and the use of instrumental variables, see this most excellent post by Robert Roos over at CIDRAP. The summary of all of this is: with current vaccines, those over 65 can have their shot and get the flu too.
1) Wong K, et al. Arch Intern Med. 27 Feb 2012
2) Branswell H, Winnipeg Free Press. 6 Mar 2012
3) Roos R, CIDRAP. 1 Mar 2012
Tuesday, March 6, 2012
The CDC media telebriefing took place at noon ET today, and we are already beginning to see the news media responding. One main message can be illustrated via Figure 1 from the MMWR report, below. The rest you can read for yourself.
This is serious business. In 2008, Great Britain came in 4th in overall medal count, a scant 26 medals behind Russia. From what I can tell, the only thing that held them back was a spike in transient infections!
Monday, March 5, 2012
series on the intersection of religion and infection control. A few days ago, The New York Daily News reported that an infant died in a Brooklyn hospital due to disseminated herpes simplex virus type I infection. The virus was transmitted to the baby via a practice, metzitzah b'peh, performed by some mohels following circumcision whereby the mohel uses his mouth to suck blood from the wound. In a related piece, a rabbi and mohel in the Broward-Palm Beach New Times blog, provides details on how the procedure can be performed safely while still fulfilling Talmudic requirements. Several other cases of neonatal herpes infection (see full text paper from Pediatrics here) and at least one death have been previously reported. Additional information from the New York City Health Department can be viewed here.
Graphic: The ceremony of Brit-Milah by Herman Gold.
I lived in Rudy Giuliani's New York City during the implementation of this strategy, but I'm not here to defend his law enforcement policies one way or another, since I'm not an expert. Crime did fall, but it might have been for other reasons. What I'm more interested in is if there could be an analogous theory in hospitals? Is there a safe hospital theory? It made me wonder if clinicians in safer or cleaner hospitals are more apt to practice hand hygiene or have higher compliance with CLABSI checklists.
I'm not aware of much data in this regard. Two of the better analyses were done by Pat Stone's group at Columbia (I was a co-author). Looking at data from 415 ICUs in 250 hospitals they found that there was no convincing evidence of a cross-over effect between CLABSI and VAP; that is compliance with the CALBSI Bundle elements was never associated with a decrease in VAP rates. In a separate paper, they found that compliance with the VAP bundle did not lower CLABSI rates. So for at least two device infections, there appears to be no such thing as a safe hospital. Lankford et al. in EID (2003) hypothesized that hand hygiene would increase after construction of a shiny new hospital. It actually decreased from 53% to 23%. Hopefully Mike and Dan can add to this list of studies.
There has been a lot more research on what makes a quality hospital outside of infection prevention. Twenty years ago, there was an important study in Medical Care that looked at disease-specific mortality in acute myocardial infarction, congestive heart failure, pneumonia, stroke, obstructive lung disease, or gastrointestinal hemorrhage in 30 hospitals. They found little correlation between disease-specific mortality rates within each hospital. So, MI mortality was not correlated with CHF mortality, even if they were likely to be treated by the same physicians and nurses. If mortality isn't a quality indicator, one wonders if other quality indicators have any relevance.
And what is a post without a non-scientific anecdote? Several years ago, when I was the hospital epidemiologist at a large hospital in Baltimore, we had high rates of MDR-Acinetobacter infections. This led our group to conduct a pilot study looking at the impact of universal gown and gloves in ICU-settings. At the time a new Chief Medical Officer, who happened to be a pulmonary-critical care specialist, started attending in our ICUs. He was struck at the level of gown/glove compliance that he saw and declared that he had never seen such a safe hospital. This actually meant something, since he had just moved from Barnes Jewish Hospital in St. Louis; home to one of my heroes, Vicki Fraser. Were we really safer than BJH? I don't know, but the sight of all of those gowns and gloves did make it appear that we were really trying our best to be safe. Soon after, our CLABSI rates fell drastically, after a lot of effort sure, but the culture was changing. Maybe there is something in this theory that applies to hospitals after all? Too bad there appears to be no such thing as a "safe" hospital.
Sunday, March 4, 2012
The big message, of course, is “get the catheters out!” Which brings me to a recent study in Archives of Internal Medicine, reporting results from the statewide Keystone initiative to reduce urinary catheter use in Michigan hospitals. The good news is that the interventions (clinician education and daily assessment of catheter necessity during nursing rounds) were effective, resulting in an almost 30% reduction in catheter use in participating hospitals. The bad news is that even after the intervention, less than 60% of catheter use was for indications defined as “appropriate” based upon HICPAC guidelines. These guidelines aren’t all-inclusive as regards appropriate catheter use, but it seems clear that every hospital still has a lot of room for improvement here.
Friday, March 2, 2012
Per a recent Nature-News article, the cuts would impact the CDC core budget and impact grants to "local, county and state public-health departments to monitor infectious diseases or track food-borne outbreaks." If these cuts stand, the CDC budget will have fallen by 20% since 2010.
Just last week, Trish Perl circulated an email query asking what key concerns we have in infection prevention over the next 2-3 years. Many were concerned about increased work demands for public reporting and mandates. Mike and Dan had several other concerns they will hopefully share with us in future posts. My main concern was the loss of the CDCs voice in the fight against antibiotic resistant bacteria as their funding is slowly cut. I guess it will be quickly and not slowly.
Source: Meredith Wadman in Nature 483, 19 (01 March 2012) doi:10.1038/483019a
|Rich Savel in the center|
1) "Though the results of a single, large RCT are important, they clearly are not sufficient for future agents to be rapidly integrated into national guidelines or consensus statements."
2) "Another important lesson is that pharmaceutical companies should stay as far removed as possible from development of guidelines promulgated by national medical societies. One of the most important things such a society has is its reputation, which it must be careful not to tarnish. Although this can often be a great challenge, it has become quite clear from the controversies surrounding APC that the relationship between pharmaceutical corporations on the one hand and academia and national medical societies on the other should be kept distinct and transparent."
3) and finally - “... the single most important lesson from the rise and fall of APC is that we should maintain skepticism: maintain it until the trial can be reproduced; maintain it in the face of trusted medical societies integrating recommendations for agents before sufficient evidence is presented; and maintain it until all potential conflicts of interest have been shared. EBM is not merely one way to practice; it is the only way. In addition to understanding all of the dynamic complexities and nuances of EBM, we must develop a healthy skepticism toward new research results and apply that approach liberally as the scientific method does its important job of confirming the validity of those results."
Full Disclosure: Rich and I were residents at NYH-Cornell back in the 1990s and we were also co-Assistant Chief Residents at Memorial Sloan Kettering under Kent Sepkowitz. Rich has gone on to great things as co-editor of the AJCC and medical directorship of the surgical intensive care unit at Montefiore Medical Center, Albert Einstein College of Medicine in NYC. Rich is also the editor and founder of the SCCM iCritical Care Podcast - which rocks.
Thursday, March 1, 2012
Source: Kent Sepkowitz, Slate, 1 March 2012
h/t ed yong