Renaissance man

The definition of a Renaissance man is a person who has broad intellectual interests and is accomplished in areas of both the arts and sciences. Who fits that definition better than Dick Wenzel? By day he's a great doctor, teacher and epidemiologist. By night, he's a novelist, tango dancer, and actor. His latest gig is VCU's production of Love Letters. 

Love Letters

Written by A. R. Gurney • Directed by David S. Leong 

Featuring Richard Wenzel & Nancy F. Langston

Starring former Dean of the VCU/MCV School of Nursing Dr. Nancy Langston and Dr. Richard Wenzel, world renowned doctor of infectious diseases and former chair of the VCU Dept of Internal Medicine. Love Letters is a charming 50-year love story told through the letters of Melissa and Andrew who share their hopes and ambitions, dreams and disappointments. A heartfelt evening of surprising comedy with an ending that will squeeze tears out of all but the stoniest hearts.

Friday afternoon blogging from Deltaville

Greetings from Deltaville, Virginia.  I had hoped to be north of here by now, but apparently boat engines are fickle.  We hope to be off tomorrow, though, and after that my infrequent blogging will become even less frequent, at least until we reach Boston.  I enjoyed seeing fellow blogger Mike Edmond, and look forward to dinner this evening with the Wenzels.

Speaking of Friday afternoons, you know the old saw that hospital outbreaks are always reported or detected on Friday afternoons? Well, according to this study in AJIC, there might be some truth to it!  Here's hoping that your Friday afternoon isn't rudely interrupted with an outbreak, but beware: Monday's are no better.

Odds and ends

Here are a few odds and ends that I've been mulling over--some related to infection prevention, some tangentially related, and some, well not at all.

• A new paper in the International Journal of Obesity looks to see whether response to influenza vaccine is impacted by obesity. This is important since during the H1N1 pandemic obesity was found to be a risk factor for morbidity and mortality. Interestingly, in this study of nearly 500 participants the investigators found that antibody production is not affected by BMI, but as BMI increases there is a significant decrease in antibody detected at 12 months. The implications of this paper could be huge given the increasing prevalence of obesity in the US.
• I just read Steven Berk's recently published book, Anatomy of a Kidnapping, on a quick trip to Vermont. Berk is an infectious diseases physician and medical school dean, who was kidnapped at gunpoint from his home in 2005. He writes that equanimity helped him to stay cool through the entire ordeal. Though this may have saved his life, I think it robbed some of the emotion from his prose, and I was left with little connection to what should have been a very compelling story. And if I were not on a plane without anything else to read, I would have closed the book for sure when he articulates his view that individuals should be allowed to purchase and own assault weapons.
• Coldplay's new album, Mylo Xyloto, is simply amazing. I can't quit listening to it. It's already setting records for the rate (there's a tie to epidemiology!) of digital downloads it's receiving.
• Dick Wenzel, the most famous hospital epidemiologist since Semmelweis, has in his "retirement"  published a novel and danced the tango for charity. This week he will debut in VCU's production of the musical Grease. He plays the DJ, Vince Fontaine. He still has a day job, too--this week he's attending on the Transplant ID Service. 

Economicks is hard!

I had the privilege of training in hospital epidemiology under Dr. Richard Wenzel, and alongside a number of really smart people (including fellow blogger Mike Edmond). We put a lot of time and energy into estimating the impact of HAIs on costs, lengths of hospital stay (LOS), and mortality…and our approach was simple and intuitive. If our HAI cases had a mean cost/LOS/mortality of x, and matched controls had mean cost/LOS/mortality of y, then the attributable cost/LOS/mortality must be x minus y. Right?

Yes, I’m oversimplifying, and I will give us credit for understanding that it was a little more complicated than that. However, at that time we were still trying to convince people that HAIs actually killed people, and that the damage they did was above and beyond that due to the patient’s underlying illness. So if our estimates were on the high side, it seemed OK (at least to me), since the main purpose was to jar people out of their complacency and increase resources for prevention.

The climate has changed. We know a lot more about the complexity of estimating the costs of HAIs (two excellent sources on this are here and here), and we’ve (at long last) succeeded in attracting needed attention to HAI prevention (from the public, from legislators, from the media, even from our hospital administrators!). So it now behooves us to “take it up a notch”, as advocated by Nicholas Graves and colleagues in a recent letter to the editor at ICHE (with response). You can read these at your leisure, but I want to highlight this section of their CID article, which I think is on target:

"The 'HAI costs a lot' approach to influencing decision making has served the infection control community well…..The time has arrived, however, for the methodological advances that have been achieved in this area to be implemented by researchers. Complete economic evaluations that include changes to all costs and health benefits should be performed...

The information used to update these studies should be of high quality and bias free. Inexorable growth in health care costs is forcing decision makers to respond to scarcity and work toward extracting greater value from health care resources….The time when reliable economic arguments will be paramount for obtaining extra resources—and even retaining existing ones—is close. Those working toward reducing the number of HAIs should craft valid economic arguments on the basis of sound methods and use them to build strong and cost-effective infection control programs"

A Brief History of VCU

Michael Edmond and Richard Wenzel

Virginia Commonwealth University (VCU), located in Richmond, Virginia, is a growing and vibrant university, but little is known about how it got to be so big and succesful.

1838: Medical Department of Hampden-Sydney College opened in Richmond

1854: Richmond Department of Medicine broke away from Hampden-Sydney College and became the Medical College of Virginia

1968: A merger between the Richmond Professional Institute and the Medical College of Virginia formed the existing VCU

1995: Drs. Richard Wenzel and Michael Edmond leave the University of Iowa to join the VCU faculty. Their combined efforts improved the quality of care, quality of life and life-span of all Virginians. Thus, more people want to live in Virginia and enroll in VCU.

2011: VCU "stuns" Kansas 71-61 making the NCAA Final-Four in Basketball.
Number of Final-Four appearances by the University of Iowa since Drs. Wenzel and Edmond left for VCU: zero (just saying)

sources:
1) wikipedia VCU page
2) Richard Wenzel's VCU page
3) Michael Edmond's VCU page

Weekend fun

Many readers of this blog know Dick Wenzel, the legendary hospital epidemiologist. Several months ago he published his first novel. Now he has forged new territory. This weekend he appeared in Richmond's Dancing with the Stars. He performed the Argentine tango (see photo) and won the award for most dramatic performance. Is there anything this man can't do?

Addendum, 3/21/2011:  Here's the video--

Labyrinth of Terror

Many of the readers of this blog may be interested to know that Dick Wenzel has just published his first novel, Labyrinth of Terror. I just finished reading it and recommend it highly. It's not everyday that those of us who work in infection prevention can read a novel that deals with our world, but here's your chance. The story is set in London and the protagonist is an American hospital epidemiologist who helps a British colleague with an outbreak of healthcare associated infections in a London hospital. The book is fast paced, immediately drew me in, and was a very fun read. You can order it here.

H1N1: One year later

This morning's New York Times has an OpEd piece by Dick Wenzel in which he reflects on the H1N1 influenza pandemic over the past year. Click here to read it.

And the winner is...

Last night we were in Washington to see Dick Wenzel receive the Maxwell Finland Award for Scientific Achievement from the National Foundation for Infectious Diseases. This award recognizes scientists who have made outstanding contributions to the understanding of infectious diseases or public health. Criteria for selection include excellence in clinical and/or research activities, participation in the training of future leaders in the field, and positive impact on the health of humankind.

Those of you who know me know that it's really rare for me to even wear a tie let alone a tuxedo! But it was a great time and certainly a well deserved honor for Dick.

                                 Mike Edmond, Dick Wenzel, Gonzalo Bearman

Everybody loves chlorhexidine!

There are two randomized controlled trials* about surgical site infection (SSI) prevention published in the New England Journal of Medicine this week. In one multicenter study, investigators randomized 849 patients undergoing clean-contaminated surgery to preoperative skin preparation with chlorhexidine (CHG)-alcohol or povodone-iodine (P-I), using a primary outcome of SSI at 30 days postoperatively. By intent-to-treat analysis, CHG-alcohol use resulted in lower overall SSI rates (9.5% vs. 16.1% for P-I; p=0.004), and lower rates of superficial (4.2% vs. 8.6%) and deep (1% vs. 3%) incisional SSI.

So CHG, which is already preferred for skin prep prior to intravascular catheter placement, and which is being used increasingly to bathe ICU patients, in catheter dressings, and in oral care, should probably also be preferred for preoperative skin prep. CHG for everyone, everywhere!

In a second multicenter study, Dutch investigators screened 6771 newly admitted patients for S. aureus nasal carriage, using real-time PCR. Of the 1251 S. aureus carriers, 918 were randomized to receive 5 days of either nasal mupirocin (2% ointment twice daily) and CHG soap (daily), or placebo. The rate of healthcare-associated S. aureus infections was almost 60% lower in the mupirocin-CHG group (3.4%, versus 7.7% for placebo; relative risk 0.42 [0.23-0.75]. Most enrolled patients were surgical (88%), and most S. aureus infections were SSI (82%). Among surgical patients, the rate of deep SSI was lower in the mupirocin-CHG group (0.9 vs. 4.4%; RR 0.2 [0.07-0.62]).

The implications of this study are less clear, since the relative importance of the two topical therapies (nasal mupirocin and CHG soap) is unknown. Many centers now routinely use pre-operative CHG bathing for elective procedures. Until we know whether screening and targeted decolonization is superior to the preoperative bathing of all patients with CHG soap, this approach should be reserved for high risk procedures (e.g. cardiac surgery, orthopedic implants).

Dick Wenzel wrote a nice editorial about both pieces, and uses the opportunity to make a point we’ve made several times before in this blog: interventions that can be applied to all patients and that reduce all infections are preferred to organism-specific approaches that carry the added expense and logistical difficulty associated with identifying all carriers of an organism.

*COI alert: Both studies were industry supported—one by Cardinal Health, and one by grants from GlaxoSmithKline, Roche, bioMerieux, and 3M.

A grand celebration

Mike Edmond and Gonzalo Bearman with Dick Wenzel

Last night we celebrated Dr. Richard Wenzel's achievements as he prepares to step down as Chair of Internal Medicine at Virginia Commonwealth University. Many of his former trainees were in attendance. Widely regarded as the world's leading hospital epidemiologist, he has published over 500 papers and three textbooks, along with founding two journals. An endowed professorship has been established to honor his numerous contributions to VCU. See the photo gallery here.

I have included my prepared remarks from last night's program:

Although it may seem somewhat odd, I decided on the subspecialty of infectious diseases as a career choice when I was a second year medical student. Perhaps even more strange, I decided to become a hospital epidemiologist when I was a third year medical student. So I carefully laid out my plan to complete an internal medicine residency, fellowship in infectious diseases and a Masters in Public Health, so that I would be ready to be a hospital epidemiologist. And that's exactly what I did. Years later, when I had completed my MPH degree and was three-quarters of the way through my ID fellowship, I somewhat suddenly came to the realization that I didn't know the first thing about hospital epidemiology. So I began to ask infectious diseases physicians that I knew how I could become a hospital epidemiologist, and every single answer started like this: "there's this guy in Iowa and he wrote the book, and if you're serious about this, that is where you need to go." Less than a year later, I drove across the country and settled in to a new chapter of my life in Iowa City.

I went to Iowa City with more than a little trepidation, but based only on my brief interactions with Dick Wenzel to that point, I knew this was the right thing to do. I soon found myself part of a vibrant community of young doctors with the aspiration of becoming hospital epidemiologists, all like me, who came to Iowa City to learn from him. We were at the global epicenter of hospital infection control.

With a person as accomplished as Dick, who has a CV so large that  it requires wheels, it would be easy to say that the record speaks for itself. But that would only give you half the story. So I want to focus my comments on something known only to those he has trained, his role as a mentor.

Over the course of his career, Dick has trained 50 hospital epidemiologists who now lead infection prevention programs around the world. I suspect that all of them would describe their fellowship as a magical time--a time of exploring exciting ideas, of learning to think critically and to refine analytical skills, of feeling that you were a part of a community of scholars—past and present—all sharing the same goals. All of this was wonderfully and carefully shepherded by Dick. There was never a time when any of us ever felt that he was too busy to discuss our research. He never missed an opportunity to promote the work we were doing or to give us opportunities to share authorship with him. His enthusiasm for the work was infectious and most importantly, he inspired all of us. In his warm, encouraging manner, he made you feel good about your work while he taught you to do it even better. He handed down to us a way of thinking and approaching problems. Without question, he served all of us as the ideal mentor, and in doing so launched all of our careers. As a testament to his mentorship, when he asked me to come to Richmond and join the VCU faculty in 1995, I didn't say “yes”, I simply said: “what day do I start?” And I moved here without ever having visited Richmond previously.

There is an upside to being in the remedial program for fellows as I have been. Unlike my counterparts who all graduated and moved on, I have had the great fortune of continuing to learn from Dick for the past 17 years. And I have to say that when I think of my favorite moments of work life here at VCU, it's when just the two of us sit in his office and discuss the important issues in our field.

I think the mark of a good mentor is the degree of affection in which your trainees hold you across time and space. And by that measure, Dick is the gold standard. If you have ever attended a national or international meeting with him, you quickly see that he holds rock star status, as a crowd of people persistently follow him through hotel and convention hall lobbies.

Now tonight is a wonderful night to celebrate Dick's many achievements, but we would be remiss if we stopped there, because JoGail has been so much a part of all that he has done. She has been instrumental in helping fellows and their families not just move to and settle into a new part of the country, but in many cases to a brand new continent. She has a special ability to relate to and understand people. Her warmth and sincerity make all who meet her feel immediately at ease. Together JoGail and Dick have so graciously welcomed all of the fellows into their home and their family.

And so Dick and JoGail, on behalf of all the fellows that you have mentored, I'll leave you with the elegantly simple words of Sebastian from Shakespeare’s Twelfth Night:  I can no other answer make, but thanks and thanks and ever thanks.

The Boss in the Paper of Record

Today's New York Times has an interesting article written by Dr. Larry Altman on current persepctives regarding swine flu. The story features Dr. Richard Wenzel and his thoughts about the epidemic based on his first-hand observations made in Latin America.

PHOTO: Jay Paul for the New York Times

Postcard from Latin America #5

Dr. Richard Wenzel writes from Argentina:

Schools are closed, and will be for 4 weeks, and all high risk, young adults (e.g., pregnant women) are not allowed to work. Only young adults screened at hospitals can get oseltamivir. Met with the Minister of Health of Buenos Aires, and he told me yesterday that of 85 deaths in the region - half of the total deaths in Argentina- one fourth were in pregnant women. In Sao Paulo, Sergio Wey told me that there pregnancy was the leading risk factor for severity. In Argentina obesity is a close second risk factor for dying with H1N1. Also in Argentina I was told that diarrhea occurred in 10-20 percent, in the 12 percent range I heard about in Mexico. So far no one has tested stool for virus. I also heard about severe cases in Chile and Argentina in solid organ and bone marrow transplant patients. Not sure how many were nosocomial.

Postcard from Latin America #4

Dr. Richard Wenzel writes from Chile:

Made rounds in the adult and peds ICU of one of the university hospitals- hospital clinico UC. They nodded concurrence that about one-third of non-icu admissions have no fever. More interesting they volunteered that half of the outpatients with H1N1 confirmed had no fever. Each had anecdotes that they have screened patients with rhinorrhea only and confirmed H1N1. The point is that the clinical expression of H1N1 is extremely broad. Obviously screening patients with fever will miss many. Lastly, for counting patients, if fever is part of the case definition, the denominator will be greatly underestimated.

The adult in the ICU was an obese 34 year old man whose weight was 150 Kg and BMI was 40. Obesity was recognized informally in Mexico City when I was there earlier. The recent MMWR notes obesity as well. Obviously the question is whether the weight per se is an issue, and maybe these patients have no reserve when they get viral pneumonia. However, I suspect that insulin resistance is a factor: many have underlying hypertension and diabetes (i.e., metabolic syndrome).

Of interest is how H1N1 is managed in Chile vs Brazil. Here clinicians make a clinical diagnosis- confirmation is not essential - and order oseltamivir. The drug is given to patients free of charge.

Postcard from Latin America #3

Another email from Dr. Wenzel as he travels through Latin America:

Arrived earlier in Chile and will be at the Ministry of Health tomorrow. H1N1 spreading here in their winter but I'll know more tomorrow. Chile prepared well after Mexico. I'll get first hand information in Argentina about their preparations later in the week.

Postcard from Latin America #2

More from Dr. Wenzel as he visits several countries in Latin America:

Had dinner with former fellows- Claudio Pannuti and Sergio Wey- and their colleagues in Brazil. There is an upsurge in influenza thought to correlate with vacationers returning from Argentina and Chile. Pregnancy is the risk factor for severity of illness in cases that they have seen. What is unusual is how the government is managing the outbreak. Ill patients with ILI can be screened in this megacity of approximately 15 million by law only at 7 hospital ERs. The screen is with an immunoblot with a sensitivity of 70 percent. If and only if a patient with a positive screen also has some defined high risk elements will oseltamivir be given. A confirmatory PCR test is then done and sent to a single lab. The results of the PCR are available only after 10 or more days. The important point is that ID specialists cannot write a prescription for oseltamivir or screen for flu; this is controlled by law by the physicians at the 7 EDs.

Postcards from Latin America

Our mentor, Dr. Richard Wenzel, is back in Mexico and from there will be heading to Argentina, where an H1N1 outbreak is in full swing and for which a travel alert was just issued. Here is an excerpt from his e-mail yesterday:

Mexico has a new spike of H1N1 cases and the focus is especially high in Chiapas in the south. They have many on respirators with approximately 50 percent mortality - reminiscent of the severe cases in April in Mexico City. Just as in the cases earlier in Mexico City, the Chiapas cases have underlying conditions in only half. Also cases now appearing in Cancun and Merida. Very odd for flu to be here in summer. The big question is how Mexico might distribute the 20 million doses only that they will have by December--to young adults vs high risk young adults vs children who may be efficient transmitters. Even when they target a group, there will be too few doses, and how do you announce the program?

The WHO has quietly announced that it will no longer be tracking H1N1 cases and deaths. The numbers they report have always been grossly inaccurate estimates, given that only a fraction of actual cases are tested. Nations are now asked to report their first few cases only, and to be vigilant for clusters of deaths attributable to H1N1.

I’ve also noticed that, despite all the hullabaloo about the name of this virus when it first swept across the U.S., “swine flu” is now back in vogue. Even the NY Times is back to using “swine flu”.