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Battling diarrhea with … yeast

Recently-published meta-analysis shows that the yeast Saccharomyces boulardii has “clear beneficial effects” on children with acute diarrhea. Pooling of 22 studies showed that duration and amount of diarrhea was significantly reduced in children who took the supplement. Interesting back story to the discovery of Saccharomyces boulardii: The yeast is found on the skin of lychee fruits. French scientist Henri Boulard discovered Saccharomyces boulardii in the 1920s after noticing that natives of Southeast Asia were chewing on the skin of lychee fruits in an attempt to control the symptoms or cholera. You can purchase Saccharomyces boulardii from Amazon without a prescription. Saccharomyces boulardii is related to another yeast – Saccharomyces cerevisiae – which is found on the skin of grapes and plums and is used in brewing beer and baking. Antibodies to Saccharomyces cerevisiae are often seen in patients who have inflammatory bowel disease such as Crohn’s disease and ulcerative colitis, suggesting that Saccharomyces cerevisiae may play a role in bowel inflammation. Then I begin wondering whether the link between beer and “beer belly” may be related to more than just the alcohol and the extra calories in the beer.

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Contaminated Stethoscopes COULD Be Harmless

An interesting study is making the rounds in the mainstream media. Instapundit, Scientific American, NBC News, Healthcare Business Tech Blog, MedPage Today, CBS Atlanta, and Consumer Reports have all reported on the study. Unfortunately, the study draws questionable conclusions. A group of scientists at the University of Geneva Hospitals (Switzerland) and affiliated with the World Health Organization recently published a study demonstrating that physicians’ stethoscopes harbor many bacteria. The study was titled “Contamination of Stethoscopes and Physicians’ Hands After a Physical Examination” and was published in this months’ Mayo Clinic Proceedings. First, the researchers note that physician stethoscopes can be contaminated after a physical examination. Agreed. The amount of contamination can be as much as that contained on the palm of the hand (but not the fingertips). OK wonderful. The number of colonies causing the level of contamination is “substantial” after a single physical exam. For fingertips, the average number of colony forming units transferred was 467. For stethoscopes, the average number of colony forming units transferred was 89. Not so sure that is “substantial,” but we’ll go with it. For MRSA carriers, the average number of CFUs transferred was 12 for the fingertips and 7 for the stethoscope. However … no transfer of any MRSA bacteria occurred in 24% of patients and the researchers just discarded the data from those patients for the final analysis. (“Because MRSA was not recovered from the physicians’ dominant hand or the stethoscope after the examination of 12 of 50 patients colonized with MRSA (24%), these patients were excluded from the final analysis”). Averaging in a bunch of data that don’t fit with their conclusions would only dilute their message. Then come the “scientific” conclusions: “By considering that stethoscopes are used repeatedly over the course of a day, come directly into contact with patients’ skin, and may harbor several thousands of bacteria (including MRSA) collected during a previous physical examination, we consider them as potentially significant vectors of transmission. Thus, failing to disinfect stethoscopes could constitute a serious patient safety issue akin to omitting hand hygiene.” Note the hypothetical pseudoscience contained in just these two sentences. Stethoscopes “MAY harbor several thousands of bacteria” – meaning that stethoscopes also “may NOT harbor” several thousands of bacteria and you haven’t proven anything. “WE consider them as potentially significant” – ah, the logical fallacy of an appeal to authority. WE are published in a national journal and are getting national media attention. No one else might consider them as potentially significant, but those who do not agree with US are obviously unqualified to make such decisions. Oh, and by the way, WE still haven’t shown any literature proving this point, so just believe our pseudoscience and move along. “THUS …” – a haughty prelude showing that you are trying to use your unfounded conclusions to get everyone to believe your ultimate point that … “failing to disinfect stethoscopes COULD constitute a serious patient safety issue” – BRILLIANT! Oh, and by the way, the moon COULD be made out of green cheese, the government COULD be putting nanobots in our vaccines, Juan Pablo COULD marry any woman he wanted on the Bachelor, and I COULD win the lottery. Without better research, there is no way to determine whether any of these possibilities is more likely to occur than any other of the possibilities. A scientific statement that something “COULD” occur is close to being meaningless, showing only the absence of an impossibility. The likelihood of that event occurring is anywhere between 0.0000000000000000001% and 100%. There are multiple parallel studies which also make leaps in logic about the possibility ...

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No More Dr. WhiteCoat?

An article in the New York Times made me shudder. No more white coats? According to a new study in the Journal of Infection Control and Hospital Epidemiology, there are now “guidance statements” about what health care providers should wear in the non-operating room hospital setting. The study discusses the available evidence regarding contamination of hospital attire with bacteria. Many studies show that there can be bacteria on a medical provider’s clothing – including scrubs, ties, and white coats. The authors then surveyed hospitals to determine policies related to the attire of health care providers. Out of 337 respondents, 65% believed that a health care provider’s attire was somewhat important or very important in the transmission of pathogens, yet only 11% of respondents enforced an attire policy. The authors didn’t state whether the survey respondents had any familiarity with the studies on clothing and transmission of pathogens, so the questions on the survey could very well have been leading in order to get the desired answers. The authors repeatedly note that there aren’t enough studies to make firm recommendations: “There is a paucity of data on the optimal approach to HCP attire in clinical, nonsurgical areas” “Appropriately designed studies are needed to better define the relationship between HCP attire and HAIs” “No clinical data yet exist to define the impact of HCP apparel on transmission” Yet despite this lack of evidence that clothing transmits infections to patients and despite a review of literature by Wilson et al. performed in 2007 showed that “the hypothesis that uniforms/clothing could be a vehicle for the transmission of infections is not supported by existing evidence”, the study authors then turn around and create a laundry list [no pun intended] of “guidance statements” designed to … prevent health care workers from transmitting infections to patients. “Studies” and the resulting unsupported recommendations such as this one are a huge problem in medicine right now. The Joint Commission manufactures similar junk science all the time – creating patient safety recommendations without one shred of evidence to support them. Their heads would implode if they had to substantiate the bases for all of their “patient safety goals.” Scientific evidence? Who needs scientific evidence? I just wrote about the same issue regarding “strong” recommendations for tPA use in stroke despite a collection of studies showing that tPA does more harm than good. Now a group of doctors representing prestigious universities all over the country is making “guidance statements” regarding hospital attire when they have NO scientific evidence for their “guidance.” Wash clothes? Fine. I don’t want bodily fluids on my white coat any more than patients want to see it there. Recommend further issues that need scientific studies? Good job. Let’s look into them to see if they make a difference in outcomes. But if you don’t have scientific evidence supporting your recommendations, then STOP MAKING THE RECOMMENDATIONS. Sorry, but I refuse to be called Dr. BareBelowTheElbows based on puffery and innuendo.

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Antibacterial Soap Latest on FDA’s Hit List

The Washington Post recently published an article showing how an antibacterial chemical in soap is now on FDA’s hit list. The FDA is reportedly going to require that manufacturers prove antibacterial soaps are safe and more effective than regular soap and water. The problem that I had with the FDA’s request for more research to prove the safety and efficacy of triclosan, the ingredient under scrutiny, was that a PubMed search shows 1915 articles using the keyword “triclosan”. What more research does the CDC want? According to an FDA Consumer Update triclosan has “altered hormone regulation” in animals and other studies [not cited in the FDA update] have “raised the possibility” that the chemical may make bacteria resistant to antibiotics. First of all, I’m not going to take sides on whether using antimicrobial soap is always a good or bad thing. Personally, I think that using it under circumstances where there is greater risk for transmission of disease is appropriate. Cutting up raw chicken? Use antibacterial soap afterwards. Changing a diaper full of foul-smelling diarrhea? Ditto. Hospital patient contact? Maybe. ICU patients? Probably. Post op patients? Yes. To me, it ends up being a judgment call. If there’s no harm in using it, what’s the problem? So let’s look at some data. Research Already Shows Triclosan is Safe and Effective Below are just a smattering of the studies I found demonstrating the safety and effectiveness of triclosan. Remember that triclosan has been approved for use since 1972. This 1989 study showed that triclosan was safe for use in mouthwash and toothpaste. This August 1999 study showed that both 1% triclosan and 4% chlorhexidine were effective at reducing pathogens on hands in a surgical unit, but that triclosan also killed MRSA while chlorhexidine did not. This April 2000 review showed that triclosan “is a widely accepted antimicrobial ingredient because of its safety and antimicrobial efficacy” and “has demonstrated immediate, persistent, broad-spectrum antimicrobial effectiveness and utility in clinical health care settings.” 2% triclosan was shown effective in reducing MRSA skin colonization (where the organism is present on the skin but is not causing an “infection”). 1% triclosan was used in one Australian study to cause a “highly significant reduction” in the number of MRSA carriers and infections in a Cardiothoracic Surgical Unit. Adding .3% (or 0.3% if you’re following some inane Joint Commission rules for medical charting) triclosan to handwashing and bathing soaps caused an “immediate termination” in the acute phase of a MRSA outbreak in a nursery and maintained the MRSA-free status for more than 3 years. 1.5% triclosan soap decreased the spread of shigella as compared to plain soap and water when used after changing diapers of babies with diarrhea. And although not a study involving hand soap, this 2013 study showed that when sutures coated with triclosan were used during colorectal surgeries, the incidence of wound infections was cut in half. Claims That Triclosan “Alters Hormone Regulation” Are Speculative Triclosan is somewhat structurally similar to thyroid hormones. The theory is that using triclosan would cause the body to shut down its thyroid hormone production, causing “altered hormone regulation.” If you’re a North American bullfrog, triclosan may be a problem. This study showed that triclosan altered thryroid hormone receptor expression in premetamorphic tadpoles. Off of the lilypad, when people used .3% triclosan toothpaste for 4 years, researchers did find a significant decrease in the free thyroxine levels at the end of five years … in the control subjects who weren’t using the triclosan. In other words, using triclosan was associated with protected thyroxine levels and hormone regulation, not altered hormone regulation. ...

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Characteristics of Drug Seeking Patients

A study in the Annals of Emergency Medicine (.pdf file) lists what it believes are several characteristics of drug seeking patients: A patient requesting opioid medications by name doubled chances of the patient being a drug-seeker Multiple visits for same complaint increased chances of drug seeking motives by 2.5 times A “suspicious history” increased the chances of being a drug-seeker by 1.9 times Symptoms out of proportion to examination increased the chances of being a drug-seeker by 1.8 times Going to a specific hospital site made it more than three times more likely that a patient was looking for opiates The study also showed could pick out drug-seeking patients 2 out of 3 times just by their intuition. Looking up a patient on the state databases caused physicians to give opioids to 6.5% of patients that would not have gotten them and caused them to rip up opioid prescriptions for 3% of patients what would have otherwise received them. 23% of emergency department patients are drug seekers? This Annals study also showed that 23% of more than 500 patients presenting to the emergency department for complaints of toothache, headache or back pain met the definition of a drug seeker. This is probably an overestimate of the total number of drug-seeking patients seeking emergency medical care since those complaints are only a small percentage of all the complaints that are logged in emergency departments, but the study does show how pervasive that drug-seeking behavior appears to be in patients with those presenting complaints. When opiates are withheld from patients suffering from legitimate pain, more anger needs to be directed toward the many patients who scam the system, not toward the doctors who are reluctant to be hit with criminal charges when a drug seeking patient overdoses.

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