Doug Brunk

SAN DIEGO — Insulin was a surprise among the medications most commonly associated with patient falls in the hospital, results from a large single-center controlled study of 230 patients showed.

“Finding an association between insulin and falls was somewhat surprising and requires further study,” said Caroline O'Neil, research coordinator in the infectious diseases division at Washington University in St. Louis. “Previous community studies have found a connection between diabetes and falling. In our study, diabetes was not associated with falling, but use of insulin was. The question is whether insulin is a marker of more severe diabetes, or if these patients have low blood sugars or peripheral neuropathy that is increasing the risk of falling.”

Patients who fell were more likely than controls who did not fall to be taking hydantoin anticonvulsants (odds ratio 3.6), haloperidol (OR 3.4), benzodiazepines (OR 2.1), or insulin (OR 1.5).

Certain combinations of medications further increased the risk, especially the combination of hydantoins and insulin (OR 11.4), benzodiazepines and haloperidol (OR 5.7), benzodiazepines and hydantoins (OR 5.0), and benzodiazepines and insulin (OR 2.6). The data were presented in poster form at the annual meeting of the Society for Healthcare Epidemiology of America.

The study, which was led by Dr. Victoria J. Fraser, Ms. O'Neil, and her colleagues, evaluated 230 inpatients at the 1,250-bed Barnes Jewish Hospital in St. Louis. The patients were aged 21 years and older and had fallen in the hospital between July 1, 2007, and November 14, 2007; the study also included 690 randomly selected control patients who did not fall and were admitted within 1 day of the index case. Emergency department patients were excluded as were those from physical therapy, obstetrics/gynecology, oncology, and psychiatry units.

They used logistic regression to determine which medications and patient characteristics were risk factors for falls. The mean age of patients who fell was 62 years, 54% were male, and their average length of stay was 12 days.

“This study is among the largest and most detailed analyses of medication and other fall risk factors in the literature to date,” the researchers wrote. “Linking medication risk with nursing fall risk assessments may provide a more comprehensive and predictive view of a patient's risk for falls.”

Multivariate analysis also showed that the following variables were linked significantly with an increased risk of falls: history of falls within 3 months (OR 3.4), use of an assistive device (OR 3.3), BMI of 18 mg/kg

The study was funded by the National Institutes of Health and the Centers for Disease Control and Prevention. Ms. O'Neil said that she had no financial conflicts to disclose.

Patients who fell were more likely to be taking hydantoins, haloperidol, benzodiazepines, or insulin. MS. O'NEIL

SAN DIEGO — Insulin was a surprise among the medications most commonly associated with patient falls in the hospital, results from a large single-center controlled study of 230 patients showed.

“Finding an association between insulin and falls was somewhat surprising and requires further study,” said Caroline O'Neil, research coordinator in the infectious diseases division at Washington University in St. Louis. “Previous community studies have found a connection between diabetes and falling. In our study, diabetes was not associated with falling, but use of insulin was. The question is whether insulin is a marker of more severe diabetes, or if these patients have low blood sugars or peripheral neuropathy that is increasing the risk of falling.”

Patients who fell were more likely than controls who did not fall to be taking hydantoin anticonvulsants (odds ratio 3.6), haloperidol (OR 3.4), benzodiazepines (OR 2.1), or insulin (OR 1.5).

Certain combinations of medications further increased the risk, especially the combination of hydantoins and insulin (OR 11.4), benzodiazepines and haloperidol (OR 5.7), benzodiazepines and hydantoins (OR 5.0), and benzodiazepines and insulin (OR 2.6). The data were presented in poster form at the annual meeting of the Society for Healthcare Epidemiology of America.

The study, which was led by Dr. Victoria J. Fraser, Ms. O'Neil, and her colleagues, evaluated 230 inpatients at the 1,250-bed Barnes Jewish Hospital in St. Louis. The patients were aged 21 years and older and had fallen in the hospital between July 1, 2007, and November 14, 2007; the study also included 690 randomly selected control patients who did not fall and were admitted within 1 day of the index case. Emergency department patients were excluded as were those from physical therapy, obstetrics/gynecology, oncology, and psychiatry units.

They used logistic regression to determine which medications and patient characteristics were risk factors for falls. The mean age of patients who fell was 62 years, 54% were male, and their average length of stay was 12 days.

“This study is among the largest and most detailed analyses of medication and other fall risk factors in the literature to date,” the researchers wrote. “Linking medication risk with nursing fall risk assessments may provide a more comprehensive and predictive view of a patient's risk for falls.”

Multivariate analysis also showed that the following variables were linked significantly with an increased risk of falls: history of falls within 3 months (OR 3.4), use of an assistive device (OR 3.3), BMI of 18 mg/kg

The study was funded by the National Institutes of Health and the Centers for Disease Control and Prevention. Ms. O'Neil said that she had no financial conflicts to disclose.

Patients who fell were more likely to be taking hydantoins, haloperidol, benzodiazepines, or insulin. MS. O'NEIL

SAN DIEGO — Insulin was a surprise among the medications most commonly associated with patient falls in the hospital, results from a large single-center controlled study of 230 patients showed.

“Finding an association between insulin and falls was somewhat surprising and requires further study,” said Caroline O'Neil, research coordinator in the infectious diseases division at Washington University in St. Louis. “Previous community studies have found a connection between diabetes and falling. In our study, diabetes was not associated with falling, but use of insulin was. The question is whether insulin is a marker of more severe diabetes, or if these patients have low blood sugars or peripheral neuropathy that is increasing the risk of falling.”

Patients who fell were more likely than controls who did not fall to be taking hydantoin anticonvulsants (odds ratio 3.6), haloperidol (OR 3.4), benzodiazepines (OR 2.1), or insulin (OR 1.5).

Certain combinations of medications further increased the risk, especially the combination of hydantoins and insulin (OR 11.4), benzodiazepines and haloperidol (OR 5.7), benzodiazepines and hydantoins (OR 5.0), and benzodiazepines and insulin (OR 2.6). The data were presented in poster form at the annual meeting of the Society for Healthcare Epidemiology of America.

The study, which was led by Dr. Victoria J. Fraser, Ms. O'Neil, and her colleagues, evaluated 230 inpatients at the 1,250-bed Barnes Jewish Hospital in St. Louis. The patients were aged 21 years and older and had fallen in the hospital between July 1, 2007, and November 14, 2007; the study also included 690 randomly selected control patients who did not fall and were admitted within 1 day of the index case. Emergency department patients were excluded as were those from physical therapy, obstetrics/gynecology, oncology, and psychiatry units.

They used logistic regression to determine which medications and patient characteristics were risk factors for falls. The mean age of patients who fell was 62 years, 54% were male, and their average length of stay was 12 days.

“This study is among the largest and most detailed analyses of medication and other fall risk factors in the literature to date,” the researchers wrote. “Linking medication risk with nursing fall risk assessments may provide a more comprehensive and predictive view of a patient's risk for falls.”

Multivariate analysis also showed that the following variables were linked significantly with an increased risk of falls: history of falls within 3 months (OR 3.4), use of an assistive device (OR 3.3), BMI of 18 mg/kg

The study was funded by the National Institutes of Health and the Centers for Disease Control and Prevention. Ms. O'Neil said that she had no financial conflicts to disclose.

Patients who fell were more likely to be taking hydantoins, haloperidol, benzodiazepines, or insulin. MS. O'NEIL

SAN DIEGO — It may be time for North Americans to follow the British in their 2007 ban on white lab coats in the health care setting.

Researchers at Virginia Commonwealth University in Richmond used pigskin as an in vitro model to demonstrate that large inoculums of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and pan-resistant Acinetobacter (PRA) bacteria could be transferred from a white cotton lab coat to pigskin 1 minute, 5 minutes, and 30 minutes after inoculation.

“Previous research has indicated that you could isolate organisms from materials such as hospital curtains, neckties, and lab coats, but we wanted to find out if you could take the inoculum from the cloth of a lab coat, transfer it to skin, and isolate the inoculum from the skin,” Dawn L. Butler said in an interview during a poster session at the annual meeting of the Society for Healthcare Epidemiology of America. “We did.”

Ms. Butler, a second-year medical student at the university, and her associates diluted MRSA, VRE, and PRA and inoculated them onto swatches of one clean, cotton medical lab coat. Next, they rubbed sanitized pieces of pigskin across the inoculated swatches, and a touch prep of the pigskin onto selective media was performed to determine if the inoculated organism could be isolated from the pigskin.

These steps were performed for each of the three study isolates at 1 minute, 5 minutes, and 30 minutes. Selective media were used to prevent growth of contaminants, followed by incubation of the cloth swatches for 24 hours in thioglycolate broth to verify the viability of organisms. All of the swatches had grown organisms on respective selective media at 24 hours, confirming organism viability on the cotton lab coat.

“Everybody criticizes the British for banning white lab coats in the health care setting, saying that nobody's ever shown that lab coats can transmit an infection,” Dr. Michael Edmond, chair of the division of infectious diseases at VCU, said at the meeting. “This shows that it's biologically plausible, because in the laboratory we did transmit the organism from the coat to the skin.”

In a related poster, 141 physicians from nine VCU departments were surveyed about their attitudes regarding white lab coats. Most of the respondents (90%) were aged 29–39 years. Slightly more than half were men (52%) and the majority were medical residents (42%), followed by interns (35%), attending physicians (17%), and fellows (6%), reported Dr. J. Daniel Markley Jr., a second-year internal medicine resident at the university.

Previous studies have shown that nosocomial pathogens can persist on fabric for months, but when the survey participants were asked how long a microbe can survive on fabric, 2% said hours, 49% said days, 28% said weeks, 18% said months, and 3% said years.

In addition, 90% of respondents reported wearing their white coats daily or most days of the week, yet 62% said that they wait 2 weeks or longer to launder them.

Nearly half of respondents (49%) believed that patient perception of physicians would be adversely affected if white coats were discontinued, yet 74% believed that banning white coats could have a significant effect on hospital-acquired infection. Dr. Markley also reported that 87% of male physicians would stop wearing ties if recommended, 42% of respondents would stop wearing a watch, yet only 48% would comply with a “bare below the elbow” policy. They wouldn't want to wear a lab coat with short sleeves “because they don't want to be viewed as a dentist.”

The researchers had no conflicts to disclose.

We were able to take inoculum from a lab coat, transfer it to skin, and isolate it from the skin. MS. BUTLER

SAN DIEGO — It may be time for North Americans to follow the British in their 2007 ban on white lab coats in the health care setting.

Researchers at Virginia Commonwealth University in Richmond used pigskin as an in vitro model to demonstrate that large inoculums of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and pan-resistant Acinetobacter (PRA) bacteria could be transferred from a white cotton lab coat to pigskin 1 minute, 5 minutes, and 30 minutes after inoculation.

“Previous research has indicated that you could isolate organisms from materials such as hospital curtains, neckties, and lab coats, but we wanted to find out if you could take the inoculum from the cloth of a lab coat, transfer it to skin, and isolate the inoculum from the skin,” Dawn L. Butler said in an interview during a poster session at the annual meeting of the Society for Healthcare Epidemiology of America. “We did.”

Ms. Butler, a second-year medical student at the university, and her associates diluted MRSA, VRE, and PRA and inoculated them onto swatches of one clean, cotton medical lab coat. Next, they rubbed sanitized pieces of pigskin across the inoculated swatches, and a touch prep of the pigskin onto selective media was performed to determine if the inoculated organism could be isolated from the pigskin.

These steps were performed for each of the three study isolates at 1 minute, 5 minutes, and 30 minutes. Selective media were used to prevent growth of contaminants, followed by incubation of the cloth swatches for 24 hours in thioglycolate broth to verify the viability of organisms. All of the swatches had grown organisms on respective selective media at 24 hours, confirming organism viability on the cotton lab coat.

“Everybody criticizes the British for banning white lab coats in the health care setting, saying that nobody's ever shown that lab coats can transmit an infection,” Dr. Michael Edmond, chair of the division of infectious diseases at VCU, said at the meeting. “This shows that it's biologically plausible, because in the laboratory we did transmit the organism from the coat to the skin.”

In a related poster, 141 physicians from nine VCU departments were surveyed about their attitudes regarding white lab coats. Most of the respondents (90%) were aged 29–39 years. Slightly more than half were men (52%) and the majority were medical residents (42%), followed by interns (35%), attending physicians (17%), and fellows (6%), reported Dr. J. Daniel Markley Jr., a second-year internal medicine resident at the university.

Previous studies have shown that nosocomial pathogens can persist on fabric for months, but when the survey participants were asked how long a microbe can survive on fabric, 2% said hours, 49% said days, 28% said weeks, 18% said months, and 3% said years.

In addition, 90% of respondents reported wearing their white coats daily or most days of the week, yet 62% said that they wait 2 weeks or longer to launder them.

Nearly half of respondents (49%) believed that patient perception of physicians would be adversely affected if white coats were discontinued, yet 74% believed that banning white coats could have a significant effect on hospital-acquired infection. Dr. Markley also reported that 87% of male physicians would stop wearing ties if recommended, 42% of respondents would stop wearing a watch, yet only 48% would comply with a “bare below the elbow” policy. They wouldn't want to wear a lab coat with short sleeves “because they don't want to be viewed as a dentist.”

The researchers had no conflicts to disclose.

We were able to take inoculum from a lab coat, transfer it to skin, and isolate it from the skin. MS. BUTLER

SAN DIEGO — It may be time for North Americans to follow the British in their 2007 ban on white lab coats in the health care setting.

Researchers at Virginia Commonwealth University in Richmond used pigskin as an in vitro model to demonstrate that large inoculums of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and pan-resistant Acinetobacter (PRA) bacteria could be transferred from a white cotton lab coat to pigskin 1 minute, 5 minutes, and 30 minutes after inoculation.

“Previous research has indicated that you could isolate organisms from materials such as hospital curtains, neckties, and lab coats, but we wanted to find out if you could take the inoculum from the cloth of a lab coat, transfer it to skin, and isolate the inoculum from the skin,” Dawn L. Butler said in an interview during a poster session at the annual meeting of the Society for Healthcare Epidemiology of America. “We did.”

Ms. Butler, a second-year medical student at the university, and her associates diluted MRSA, VRE, and PRA and inoculated them onto swatches of one clean, cotton medical lab coat. Next, they rubbed sanitized pieces of pigskin across the inoculated swatches, and a touch prep of the pigskin onto selective media was performed to determine if the inoculated organism could be isolated from the pigskin.

These steps were performed for each of the three study isolates at 1 minute, 5 minutes, and 30 minutes. Selective media were used to prevent growth of contaminants, followed by incubation of the cloth swatches for 24 hours in thioglycolate broth to verify the viability of organisms. All of the swatches had grown organisms on respective selective media at 24 hours, confirming organism viability on the cotton lab coat.

“Everybody criticizes the British for banning white lab coats in the health care setting, saying that nobody's ever shown that lab coats can transmit an infection,” Dr. Michael Edmond, chair of the division of infectious diseases at VCU, said at the meeting. “This shows that it's biologically plausible, because in the laboratory we did transmit the organism from the coat to the skin.”

In a related poster, 141 physicians from nine VCU departments were surveyed about their attitudes regarding white lab coats. Most of the respondents (90%) were aged 29–39 years. Slightly more than half were men (52%) and the majority were medical residents (42%), followed by interns (35%), attending physicians (17%), and fellows (6%), reported Dr. J. Daniel Markley Jr., a second-year internal medicine resident at the university.

Previous studies have shown that nosocomial pathogens can persist on fabric for months, but when the survey participants were asked how long a microbe can survive on fabric, 2% said hours, 49% said days, 28% said weeks, 18% said months, and 3% said years.

In addition, 90% of respondents reported wearing their white coats daily or most days of the week, yet 62% said that they wait 2 weeks or longer to launder them.

Nearly half of respondents (49%) believed that patient perception of physicians would be adversely affected if white coats were discontinued, yet 74% believed that banning white coats could have a significant effect on hospital-acquired infection. Dr. Markley also reported that 87% of male physicians would stop wearing ties if recommended, 42% of respondents would stop wearing a watch, yet only 48% would comply with a “bare below the elbow” policy. They wouldn't want to wear a lab coat with short sleeves “because they don't want to be viewed as a dentist.”

The researchers had no conflicts to disclose.

We were able to take inoculum from a lab coat, transfer it to skin, and isolate it from the skin. MS. BUTLER

SAN DIEGO — Any plan for marketing a medical practice should include a strategy for nurturing relationships with physicians who refer to you, Andrea T. Eliscu, R.N., advised at the annual conference of the Medical Group Management Association.

“Most of the medical groups I work with have spent so much time focused on other issues, such as recruiting staff and getting an electronic medical records system, that they don't know who's referring to their practices,” said Ms. Eliscu, a medical marketing consultant based in Orlando. “They spend very little time nurturing those relationships.”

Getting a handle on who's referring patients to you is easier said than done, with “so much outpatient medicine and lost camaraderie between physicians these days,” she acknowledged.

“The days of the doctor's lounge are gone,” she said. “That kind of connectivity is not there anymore. Everyone is working longer and harder than ever, and the marketplace is changing.”

One way to start is to create an electronic database that includes the contact information for referring physicians and tracks how many referrals they make on a monthly or quarterly basis. Ms. Eliscu recommends contacting the referring physicians to introduce yourself and ask if you're meeting their needs. “Find out what they want, not necessarily what you want to give them, because those aren't necessarily the same,” she said.

Devise a way to say “thank you” for the referrals. Maybe it's hosting an occasional lunch for the referring practice's office staff, or something as simple as a personal, handwritten thank-you note to the physician.

“In our high-tech, electronic, mass media world, this unexpected 'high touch' approach can have a huge impact,” she said. “Instead of the traditional holiday basket or gift, you could consider making a contribution in his or her honor to a local charity; it could be one that supports a health cause, the local university medical school, the food bank, or some other specific cause in which they are involved. The more personal and thoughtful the gift, the greater the value it will have to the recipient.”

She recently surveyed patients from a variety of practices about what they expect from their physicians when they make a referral. The majority of respondents expected their physicians to “know on a firsthand basis about the experience and expertise of the doctor they're being sent to,” said Ms. Eliscu, author of the book “A+ Marketing: Proven Tactics for Success” (Englewood, Colo.: MGMA, 2008).

Her term for today's medical patients is “prosumers” (people who are proactive about educating themselves before they consume health care services).

“Today's health care consumers shop around before making decisions,” she explained. “They're better educated and better informed than previous generations, they're critical, and they're looking for second opinions. They want and demand the best for themselves and their loved ones.”

In order to meet the demands of the prosumer, medical practices must increase awareness of their services and credentials and find a way to differentiate themselves from other providers. “Get into story telling as a way to communicate,” Ms. Eliscu recommended. “How many practices have a social networking component to their Web site, where patients can share experiences on a forum or e-mail the physician a question?”

The goal is for patients to “see themselves reflected in anything that you put out: your Web page, your patient brochures, your advertising.”

Marketing “is a promise,” she added. “The loyalty that you develop with your patients and their families is going to be the future of your prosperity.”

Her “4As” for effective marketing include the following:

PIAccess. If prosumers are repeatedly placed on hold for 10 minutes when they phone your office, they may write you off and seek a provider who's more responsive. Being prompt with office visit appointment times is also key.

PIAvailability. Prosumers “want you to not only return a phone call or answer an e-mail, but they need you to be available on their terms,” Ms. Eliscu said. “Part of the success of the retail clinics in places like Wal-Mart is that timely delivery of service. You're in and out in an hour.”

PIAccountability. Prosumers “want to know [whom they're] dealing with and what their name is,” she said. “Every member of your staff should have a name badge that says where they're from. That way, if I think you've done something great in terms of service, I can call the practice and say 'Susie from Cleveland did a great job. She was so sensitive when I was feeling so distraught.'”

PIAccommodation. Prosumers want your help to “work through the things they have to do, the appointments that they have to make,” she said. “It's not about what's convenient for the practice; it's about what's convenient for the prosumer.”

Start by creating an electronic data-base with contact information for referring doctors and their number of referrals. MS. ELISCU

SAN DIEGO — Any plan for marketing a medical practice should include a strategy for nurturing relationships with physicians who refer to you, Andrea T. Eliscu, R.N., advised at the annual conference of the Medical Group Management Association.

“Most of the medical groups I work with have spent so much time focused on other issues, such as recruiting staff and getting an electronic medical records system, that they don't know who's referring to their practices,” said Ms. Eliscu, a medical marketing consultant based in Orlando. “They spend very little time nurturing those relationships.”

Getting a handle on who's referring patients to you is easier said than done, with “so much outpatient medicine and lost camaraderie between physicians these days,” she acknowledged.

“The days of the doctor's lounge are gone,” she said. “That kind of connectivity is not there anymore. Everyone is working longer and harder than ever, and the marketplace is changing.”

One way to start is to create an electronic database that includes the contact information for referring physicians and tracks how many referrals they make on a monthly or quarterly basis. Ms. Eliscu recommends contacting the referring physicians to introduce yourself and ask if you're meeting their needs. “Find out what they want, not necessarily what you want to give them, because those aren't necessarily the same,” she said.

Devise a way to say “thank you” for the referrals. Maybe it's hosting an occasional lunch for the referring practice's office staff, or something as simple as a personal, handwritten thank-you note to the physician.

“In our high-tech, electronic, mass media world, this unexpected 'high touch' approach can have a huge impact,” she said. “Instead of the traditional holiday basket or gift, you could consider making a contribution in his or her honor to a local charity; it could be one that supports a health cause, the local university medical school, the food bank, or some other specific cause in which they are involved. The more personal and thoughtful the gift, the greater the value it will have to the recipient.”

She recently surveyed patients from a variety of practices about what they expect from their physicians when they make a referral. The majority of respondents expected their physicians to “know on a firsthand basis about the experience and expertise of the doctor they're being sent to,” said Ms. Eliscu, author of the book “A+ Marketing: Proven Tactics for Success” (Englewood, Colo.: MGMA, 2008).

Her term for today's medical patients is “prosumers” (people who are proactive about educating themselves before they consume health care services).

“Today's health care consumers shop around before making decisions,” she explained. “They're better educated and better informed than previous generations, they're critical, and they're looking for second opinions. They want and demand the best for themselves and their loved ones.”

In order to meet the demands of the prosumer, medical practices must increase awareness of their services and credentials and find a way to differentiate themselves from other providers. “Get into story telling as a way to communicate,” Ms. Eliscu recommended. “How many practices have a social networking component to their Web site, where patients can share experiences on a forum or e-mail the physician a question?”

The goal is for patients to “see themselves reflected in anything that you put out: your Web page, your patient brochures, your advertising.”

Marketing “is a promise,” she added. “The loyalty that you develop with your patients and their families is going to be the future of your prosperity.”

Her “4As” for effective marketing include the following:

PIAccess. If prosumers are repeatedly placed on hold for 10 minutes when they phone your office, they may write you off and seek a provider who's more responsive. Being prompt with office visit appointment times is also key.

PIAvailability. Prosumers “want you to not only return a phone call or answer an e-mail, but they need you to be available on their terms,” Ms. Eliscu said. “Part of the success of the retail clinics in places like Wal-Mart is that timely delivery of service. You're in and out in an hour.”

PIAccountability. Prosumers “want to know [whom they're] dealing with and what their name is,” she said. “Every member of your staff should have a name badge that says where they're from. That way, if I think you've done something great in terms of service, I can call the practice and say 'Susie from Cleveland did a great job. She was so sensitive when I was feeling so distraught.'”

PIAccommodation. Prosumers want your help to “work through the things they have to do, the appointments that they have to make,” she said. “It's not about what's convenient for the practice; it's about what's convenient for the prosumer.”

Start by creating an electronic data-base with contact information for referring doctors and their number of referrals. MS. ELISCU

SAN DIEGO — Any plan for marketing a medical practice should include a strategy for nurturing relationships with physicians who refer to you, Andrea T. Eliscu, R.N., advised at the annual conference of the Medical Group Management Association.

“Most of the medical groups I work with have spent so much time focused on other issues, such as recruiting staff and getting an electronic medical records system, that they don't know who's referring to their practices,” said Ms. Eliscu, a medical marketing consultant based in Orlando. “They spend very little time nurturing those relationships.”

Getting a handle on who's referring patients to you is easier said than done, with “so much outpatient medicine and lost camaraderie between physicians these days,” she acknowledged.

“The days of the doctor's lounge are gone,” she said. “That kind of connectivity is not there anymore. Everyone is working longer and harder than ever, and the marketplace is changing.”

One way to start is to create an electronic database that includes the contact information for referring physicians and tracks how many referrals they make on a monthly or quarterly basis. Ms. Eliscu recommends contacting the referring physicians to introduce yourself and ask if you're meeting their needs. “Find out what they want, not necessarily what you want to give them, because those aren't necessarily the same,” she said.

Devise a way to say “thank you” for the referrals. Maybe it's hosting an occasional lunch for the referring practice's office staff, or something as simple as a personal, handwritten thank-you note to the physician.

“In our high-tech, electronic, mass media world, this unexpected 'high touch' approach can have a huge impact,” she said. “Instead of the traditional holiday basket or gift, you could consider making a contribution in his or her honor to a local charity; it could be one that supports a health cause, the local university medical school, the food bank, or some other specific cause in which they are involved. The more personal and thoughtful the gift, the greater the value it will have to the recipient.”

She recently surveyed patients from a variety of practices about what they expect from their physicians when they make a referral. The majority of respondents expected their physicians to “know on a firsthand basis about the experience and expertise of the doctor they're being sent to,” said Ms. Eliscu, author of the book “A+ Marketing: Proven Tactics for Success” (Englewood, Colo.: MGMA, 2008).

Her term for today's medical patients is “prosumers” (people who are proactive about educating themselves before they consume health care services).

“Today's health care consumers shop around before making decisions,” she explained. “They're better educated and better informed than previous generations, they're critical, and they're looking for second opinions. They want and demand the best for themselves and their loved ones.”

In order to meet the demands of the prosumer, medical practices must increase awareness of their services and credentials and find a way to differentiate themselves from other providers. “Get into story telling as a way to communicate,” Ms. Eliscu recommended. “How many practices have a social networking component to their Web site, where patients can share experiences on a forum or e-mail the physician a question?”

The goal is for patients to “see themselves reflected in anything that you put out: your Web page, your patient brochures, your advertising.”

Marketing “is a promise,” she added. “The loyalty that you develop with your patients and their families is going to be the future of your prosperity.”

Her “4As” for effective marketing include the following:

PIAccess. If prosumers are repeatedly placed on hold for 10 minutes when they phone your office, they may write you off and seek a provider who's more responsive. Being prompt with office visit appointment times is also key.

PIAvailability. Prosumers “want you to not only return a phone call or answer an e-mail, but they need you to be available on their terms,” Ms. Eliscu said. “Part of the success of the retail clinics in places like Wal-Mart is that timely delivery of service. You're in and out in an hour.”

PIAccountability. Prosumers “want to know [whom they're] dealing with and what their name is,” she said. “Every member of your staff should have a name badge that says where they're from. That way, if I think you've done something great in terms of service, I can call the practice and say 'Susie from Cleveland did a great job. She was so sensitive when I was feeling so distraught.'”

PIAccommodation. Prosumers want your help to “work through the things they have to do, the appointments that they have to make,” she said. “It's not about what's convenient for the practice; it's about what's convenient for the prosumer.”

Start by creating an electronic data-base with contact information for referring doctors and their number of referrals. MS. ELISCU

SAN DIEGO — Clindamycin and trimethoprim-sulfamethoxazole are the most commonly used agents to treat community-acquired methicillin-resistant Staphylococcus aureus on an outpatient basis, but neither is perfect, according to one expert

“The issue with clindamycin is that if you have big loads of bacteria, inducible resistance can develop,” Dr. Alice L. Pong said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. “So even though the bug might be susceptible on paper, over time it might develop resistance.”

Other strikes against clindamycin include its poor palatability—“most kids will throw it up,” she said—and the potential for gastrointestinal side effects, especially vomiting and diarrhea.

The recommended dosage is 20-40 mg/kg per day IV divided every 6-8 hours, and 10-30 mg/kg per day orally divided every 6-8 hours

Trimethoprim-sulfamethoxazole is more convenient than clindamycin because it requires twice-a-day administration, and “it doesn't taste too bad,” said Dr. Pong of the division of infectious diseases at Rady Children's Hospital, San Diego.

However, it's not effective for group A streptococci, “so if you don't have a culture and you don't know whether it's group A streptococci or S. aureus, you might run into trouble.”

There are limited data regarding trimethoprim-sulfamethoxazole's efficacy in treating community-acquired methicillin-resistant S. aureus (CA-MRSA), but “in many cases, it probably works as well as anything else,” she said.

The recommended dosage is 8-12 mg/kg per day trimethoprim/40-60 mg/kg per day sulfamethoxazole given every 12 hours.

Doxycycline is another outpatient option for treating CA-MRSA, “and it works well for acne, too,” she said. Approved for use in children aged 8 years and older, it has limited efficacy against group A streptococci.

The recommended dosage is 2-4 mg/kg per day given every 12 hours.

Rifampin is yet another treatment option, but the drug cannot be used alone because rapid resistance will ensue. The recommended dosage is 10-20 mg/kg per day IV or orally every 12-24 hours.

Quinolones such as levofloxacin are widely used for the treatment of MRSA in adults but are not approved for use in children in this situation. Dr. Pong said that she and her colleagues have used quinolones for treating MRSA in children “only in situations where there is no other antibiotic available.”

Linezolid, a member of the new oxazolidinone class of drugs, is an expensive treatment option that is active at the ribosomal binding site of the bacterial cell. “If you're going to give it for a prolonged period of time, you need to watch the complete blood count because linezolid can cause bone marrow suppression,” Dr. Pong warned.

“But it works pretty well. We occasionally put kids on this as a drug when they are discharged home from the hospital and they've improved on vancomycin or when their organism comes back as resistant to clindamycin and trimethoprim-sulfamethoxazole.”

Practical ways to decrease antibiotic resistance, she said, include avoiding unnecessary use of antibiotics, removing foreign devices as soon as possible, preventing the transmission of resistant organisms, and practicing good infection control, especially hand washing.

Dr. Pong reported that she had no financial conflicts to disclose.

SAN DIEGO — Clindamycin and trimethoprim-sulfamethoxazole are the most commonly used agents to treat community-acquired methicillin-resistant Staphylococcus aureus on an outpatient basis, but neither is perfect, according to one expert

“The issue with clindamycin is that if you have big loads of bacteria, inducible resistance can develop,” Dr. Alice L. Pong said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. “So even though the bug might be susceptible on paper, over time it might develop resistance.”

Other strikes against clindamycin include its poor palatability—“most kids will throw it up,” she said—and the potential for gastrointestinal side effects, especially vomiting and diarrhea.

The recommended dosage is 20-40 mg/kg per day IV divided every 6-8 hours, and 10-30 mg/kg per day orally divided every 6-8 hours

Trimethoprim-sulfamethoxazole is more convenient than clindamycin because it requires twice-a-day administration, and “it doesn't taste too bad,” said Dr. Pong of the division of infectious diseases at Rady Children's Hospital, San Diego.

However, it's not effective for group A streptococci, “so if you don't have a culture and you don't know whether it's group A streptococci or S. aureus, you might run into trouble.”

There are limited data regarding trimethoprim-sulfamethoxazole's efficacy in treating community-acquired methicillin-resistant S. aureus (CA-MRSA), but “in many cases, it probably works as well as anything else,” she said.

The recommended dosage is 8-12 mg/kg per day trimethoprim/40-60 mg/kg per day sulfamethoxazole given every 12 hours.

Doxycycline is another outpatient option for treating CA-MRSA, “and it works well for acne, too,” she said. Approved for use in children aged 8 years and older, it has limited efficacy against group A streptococci.

The recommended dosage is 2-4 mg/kg per day given every 12 hours.

Rifampin is yet another treatment option, but the drug cannot be used alone because rapid resistance will ensue. The recommended dosage is 10-20 mg/kg per day IV or orally every 12-24 hours.

Quinolones such as levofloxacin are widely used for the treatment of MRSA in adults but are not approved for use in children in this situation. Dr. Pong said that she and her colleagues have used quinolones for treating MRSA in children “only in situations where there is no other antibiotic available.”

Linezolid, a member of the new oxazolidinone class of drugs, is an expensive treatment option that is active at the ribosomal binding site of the bacterial cell. “If you're going to give it for a prolonged period of time, you need to watch the complete blood count because linezolid can cause bone marrow suppression,” Dr. Pong warned.

“But it works pretty well. We occasionally put kids on this as a drug when they are discharged home from the hospital and they've improved on vancomycin or when their organism comes back as resistant to clindamycin and trimethoprim-sulfamethoxazole.”

Practical ways to decrease antibiotic resistance, she said, include avoiding unnecessary use of antibiotics, removing foreign devices as soon as possible, preventing the transmission of resistant organisms, and practicing good infection control, especially hand washing.

Dr. Pong reported that she had no financial conflicts to disclose.

SAN DIEGO — Clindamycin and trimethoprim-sulfamethoxazole are the most commonly used agents to treat community-acquired methicillin-resistant Staphylococcus aureus on an outpatient basis, but neither is perfect, according to one expert

“The issue with clindamycin is that if you have big loads of bacteria, inducible resistance can develop,” Dr. Alice L. Pong said at a meeting sponsored by Rady Children's Hospital and the American Academy of Pediatrics. “So even though the bug might be susceptible on paper, over time it might develop resistance.”

Other strikes against clindamycin include its poor palatability—“most kids will throw it up,” she said—and the potential for gastrointestinal side effects, especially vomiting and diarrhea.

The recommended dosage is 20-40 mg/kg per day IV divided every 6-8 hours, and 10-30 mg/kg per day orally divided every 6-8 hours

Trimethoprim-sulfamethoxazole is more convenient than clindamycin because it requires twice-a-day administration, and “it doesn't taste too bad,” said Dr. Pong of the division of infectious diseases at Rady Children's Hospital, San Diego.

However, it's not effective for group A streptococci, “so if you don't have a culture and you don't know whether it's group A streptococci or S. aureus, you might run into trouble.”

There are limited data regarding trimethoprim-sulfamethoxazole's efficacy in treating community-acquired methicillin-resistant S. aureus (CA-MRSA), but “in many cases, it probably works as well as anything else,” she said.

The recommended dosage is 8-12 mg/kg per day trimethoprim/40-60 mg/kg per day sulfamethoxazole given every 12 hours.

Doxycycline is another outpatient option for treating CA-MRSA, “and it works well for acne, too,” she said. Approved for use in children aged 8 years and older, it has limited efficacy against group A streptococci.

The recommended dosage is 2-4 mg/kg per day given every 12 hours.

Rifampin is yet another treatment option, but the drug cannot be used alone because rapid resistance will ensue. The recommended dosage is 10-20 mg/kg per day IV or orally every 12-24 hours.

Quinolones such as levofloxacin are widely used for the treatment of MRSA in adults but are not approved for use in children in this situation. Dr. Pong said that she and her colleagues have used quinolones for treating MRSA in children “only in situations where there is no other antibiotic available.”

Linezolid, a member of the new oxazolidinone class of drugs, is an expensive treatment option that is active at the ribosomal binding site of the bacterial cell. “If you're going to give it for a prolonged period of time, you need to watch the complete blood count because linezolid can cause bone marrow suppression,” Dr. Pong warned.

“But it works pretty well. We occasionally put kids on this as a drug when they are discharged home from the hospital and they've improved on vancomycin or when their organism comes back as resistant to clindamycin and trimethoprim-sulfamethoxazole.”

Practical ways to decrease antibiotic resistance, she said, include avoiding unnecessary use of antibiotics, removing foreign devices as soon as possible, preventing the transmission of resistant organisms, and practicing good infection control, especially hand washing.

Dr. Pong reported that she had no financial conflicts to disclose.

Clinical features that separate Lyme meningitis from other causes of aseptic meningitis in children include longer duration of headache, the presence of cranial nerve palsies, and cerebrospinal fluid mononuclear cell predominance, results from a single-center study in Rhode Island demonstrated.

Those are key findings from a validation study of a clinical prediction model developed in 2006 to help clinicians distinguish Lyme meningitis from other causes of aseptic meningitis in children. It marks the first time the model has been prospectively evaluated in children living in a Lyme-endemic region of the United States.

The study “validates what clinicians have thought with regard to Lyme disease, that is, we can use acute clinical presentations to help differentiate Lyme meningitis from other causes of aseptic meningitis,” Dr. Sharon Nachman of the department of pediatrics at the State University of New York at Stony Brook wrote in a commentary about the work (Pediatrics 2009;123:1408).

The original prediction model applied in the analysis is a logistic-regression model that uses history, physical, and laboratory findings to predict Lyme meningitis (LM) in children; the model was developed by researchers led by Dr. Robert A. Avery of the department of pediatrics at Jefferson Medical College, Philadelphia (Pediatrics 2006;117:e1-7).

To prospectively validate this model, investigators led by Dr. Aris C. Garro of the division of pediatric emergency medicine at Rhode Island Hospital, Providence, studied 50 children aged 2-18 years who presented to Hasbro Children's Hospital in Providence with a lumbar puncture for meningitis that showed a cerebrospinal fluid white blood cell count of more than 8 cells/mcL.

Cases of definite LM were defined as cerebrospinal fluid pleocystosis with positive Lyme serology confirmed by immunoblot or erythema migrans rash. Cases of possible LM were defined as cerebrospinal fluid pleocytosis with positive cerebrospinal fluid Lyme antibody.

The researchers applied the original prediction model to their cohort. They also used 10% increments of calculated probability of LM to determine sensitivity, specificity, and likelihood ratios for definite and possible LM (Pediatrics 2009;123:e829-34).

The researchers found that certain probability percentage ranges could be used to categorize the children's risk of LM as low, intermediate, or high. For example, calculated probabilities of less than 10% resulted in a 100% negative predictive value (low risk, with a negative likelihood ratio of 0.006); calculated probabilities of 10%-50% placed patients into an intermediate-risk group; and calculated probabilities of greater than 50% placed patients into a high-risk group, with a positive likelihood ratio of 100.

Dr. Garro and his associates also discovered that if a child had less than 7 days of headache, less than 70% mononuclear cells, and no cranial nerve 7 palsy or other cranial neuropathy, the probability of LM was always less than 10%.

“We propose this 'Rule of 7's' as an easily remembered set of criteria that clinicians may be able to use to identify patients at low risk of LM,” they wrote. “Future studies should evaluate this rule before it can be adopted into clinical practice.”

The researchers acknowledged certain limitations of the study, including its small sample size and the fact that two-tier serum Lyme disease testing was not required for study entry, “allowing for possible misclassification of cases.”

They concluded that the chief use of the clinical prediction model “is to limit unnecessary use of parenteral antibiotics in patients presenting with meningitis during peak enteroviral and [Lyme disease] seasons. Additional data from a larger, multicenter, prospective study in areas endemic for [Lyme disease] would provide additional validation for the use of this model in clinical practice.”

Funding for the study was provided by the University Emergency Medicine Foundation at Rhode Island Hospital.

Clinical features that separate Lyme meningitis from other causes of aseptic meningitis in children include longer duration of headache, the presence of cranial nerve palsies, and cerebrospinal fluid mononuclear cell predominance, results from a single-center study in Rhode Island demonstrated.

Those are key findings from a validation study of a clinical prediction model developed in 2006 to help clinicians distinguish Lyme meningitis from other causes of aseptic meningitis in children. It marks the first time the model has been prospectively evaluated in children living in a Lyme-endemic region of the United States.

The study “validates what clinicians have thought with regard to Lyme disease, that is, we can use acute clinical presentations to help differentiate Lyme meningitis from other causes of aseptic meningitis,” Dr. Sharon Nachman of the department of pediatrics at the State University of New York at Stony Brook wrote in a commentary about the work (Pediatrics 2009;123:1408).

The original prediction model applied in the analysis is a logistic-regression model that uses history, physical, and laboratory findings to predict Lyme meningitis (LM) in children; the model was developed by researchers led by Dr. Robert A. Avery of the department of pediatrics at Jefferson Medical College, Philadelphia (Pediatrics 2006;117:e1-7).

To prospectively validate this model, investigators led by Dr. Aris C. Garro of the division of pediatric emergency medicine at Rhode Island Hospital, Providence, studied 50 children aged 2-18 years who presented to Hasbro Children's Hospital in Providence with a lumbar puncture for meningitis that showed a cerebrospinal fluid white blood cell count of more than 8 cells/mcL.

Cases of definite LM were defined as cerebrospinal fluid pleocystosis with positive Lyme serology confirmed by immunoblot or erythema migrans rash. Cases of possible LM were defined as cerebrospinal fluid pleocytosis with positive cerebrospinal fluid Lyme antibody.

The researchers applied the original prediction model to their cohort. They also used 10% increments of calculated probability of LM to determine sensitivity, specificity, and likelihood ratios for definite and possible LM (Pediatrics 2009;123:e829-34).

The researchers found that certain probability percentage ranges could be used to categorize the children's risk of LM as low, intermediate, or high. For example, calculated probabilities of less than 10% resulted in a 100% negative predictive value (low risk, with a negative likelihood ratio of 0.006); calculated probabilities of 10%-50% placed patients into an intermediate-risk group; and calculated probabilities of greater than 50% placed patients into a high-risk group, with a positive likelihood ratio of 100.

Dr. Garro and his associates also discovered that if a child had less than 7 days of headache, less than 70% mononuclear cells, and no cranial nerve 7 palsy or other cranial neuropathy, the probability of LM was always less than 10%.

“We propose this 'Rule of 7's' as an easily remembered set of criteria that clinicians may be able to use to identify patients at low risk of LM,” they wrote. “Future studies should evaluate this rule before it can be adopted into clinical practice.”

The researchers acknowledged certain limitations of the study, including its small sample size and the fact that two-tier serum Lyme disease testing was not required for study entry, “allowing for possible misclassification of cases.”

They concluded that the chief use of the clinical prediction model “is to limit unnecessary use of parenteral antibiotics in patients presenting with meningitis during peak enteroviral and [Lyme disease] seasons. Additional data from a larger, multicenter, prospective study in areas endemic for [Lyme disease] would provide additional validation for the use of this model in clinical practice.”

Funding for the study was provided by the University Emergency Medicine Foundation at Rhode Island Hospital.

Clinical features that separate Lyme meningitis from other causes of aseptic meningitis in children include longer duration of headache, the presence of cranial nerve palsies, and cerebrospinal fluid mononuclear cell predominance, results from a single-center study in Rhode Island demonstrated.

Those are key findings from a validation study of a clinical prediction model developed in 2006 to help clinicians distinguish Lyme meningitis from other causes of aseptic meningitis in children. It marks the first time the model has been prospectively evaluated in children living in a Lyme-endemic region of the United States.

The study “validates what clinicians have thought with regard to Lyme disease, that is, we can use acute clinical presentations to help differentiate Lyme meningitis from other causes of aseptic meningitis,” Dr. Sharon Nachman of the department of pediatrics at the State University of New York at Stony Brook wrote in a commentary about the work (Pediatrics 2009;123:1408).

The original prediction model applied in the analysis is a logistic-regression model that uses history, physical, and laboratory findings to predict Lyme meningitis (LM) in children; the model was developed by researchers led by Dr. Robert A. Avery of the department of pediatrics at Jefferson Medical College, Philadelphia (Pediatrics 2006;117:e1-7).

To prospectively validate this model, investigators led by Dr. Aris C. Garro of the division of pediatric emergency medicine at Rhode Island Hospital, Providence, studied 50 children aged 2-18 years who presented to Hasbro Children's Hospital in Providence with a lumbar puncture for meningitis that showed a cerebrospinal fluid white blood cell count of more than 8 cells/mcL.

Cases of definite LM were defined as cerebrospinal fluid pleocystosis with positive Lyme serology confirmed by immunoblot or erythema migrans rash. Cases of possible LM were defined as cerebrospinal fluid pleocytosis with positive cerebrospinal fluid Lyme antibody.

The researchers applied the original prediction model to their cohort. They also used 10% increments of calculated probability of LM to determine sensitivity, specificity, and likelihood ratios for definite and possible LM (Pediatrics 2009;123:e829-34).

The researchers found that certain probability percentage ranges could be used to categorize the children's risk of LM as low, intermediate, or high. For example, calculated probabilities of less than 10% resulted in a 100% negative predictive value (low risk, with a negative likelihood ratio of 0.006); calculated probabilities of 10%-50% placed patients into an intermediate-risk group; and calculated probabilities of greater than 50% placed patients into a high-risk group, with a positive likelihood ratio of 100.

Dr. Garro and his associates also discovered that if a child had less than 7 days of headache, less than 70% mononuclear cells, and no cranial nerve 7 palsy or other cranial neuropathy, the probability of LM was always less than 10%.

“We propose this 'Rule of 7's' as an easily remembered set of criteria that clinicians may be able to use to identify patients at low risk of LM,” they wrote. “Future studies should evaluate this rule before it can be adopted into clinical practice.”

The researchers acknowledged certain limitations of the study, including its small sample size and the fact that two-tier serum Lyme disease testing was not required for study entry, “allowing for possible misclassification of cases.”

They concluded that the chief use of the clinical prediction model “is to limit unnecessary use of parenteral antibiotics in patients presenting with meningitis during peak enteroviral and [Lyme disease] seasons. Additional data from a larger, multicenter, prospective study in areas endemic for [Lyme disease] would provide additional validation for the use of this model in clinical practice.”

Funding for the study was provided by the University Emergency Medicine Foundation at Rhode Island Hospital.

SAN DIEGO — It may be time for North Americans to follow the British in their 2007 ban on white lab coats in the health care setting.

Researchers at Virginia Commonwealth University in Richmond used pigskin as an in vitro model to demonstrate that large inoculums of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and pan-resistant Acinetobacter (PRA) bacteria could be transferred from a white cotton lab coat to pigskin 1 minute, 5 minutes, and 30 minutes after inoculation.

“Previous research has indicated that you could isolate organisms from materials such as hospital curtains, neckties, and lab coats, but we wanted to find out if you could take the inoculum from the cloth of a lab coat, transfer it to skin, and isolate the inoculum from the skin,” Dawn L. Butler said in an interview during a poster session at the annual meeting of the Society for Healthcare Epidemiology of America. “We did.”

Ms. Butler, a second-year medical student at the university, and her associates diluted MRSA, VRE, and PRA and inoculated them onto swatches of one clean, cotton medical lab coat. Next, they rubbed sanitized pieces of pigskin across the inoculated swatches, and a touch prep of the pigskin onto selective media was performed to determine if the inoculated organism could be isolated from the pigskin.

These steps were performed for each of the three study isolates at 1 minute, 5 minutes, and 30 minutes. Selective media were used to prevent growth of contaminants, followed by incubation of the cloth swatches for 24 hours in thioglycolate broth to verify the viability of organisms.

All of the swatches had grown organisms on respective selective media at 24 hours, confirming organism viability on the cotton lab coat.

“Everybody criticizes the British for banning white lab coats in the health care setting, saying that nobody's ever shown that lab coats can transmit an infection,” Dr. Michael Edmond, chair of the division of infectious diseases at VCU, said at the meeting. “This shows that it's biologically plausible, because in the laboratory we did transmit the organism from the coat to the skin.”

In a related poster, 141 physicians from nine VCU departments were surveyed about their attitudes regarding white lab coats. Most of the respondents (90%) were aged 29–39 years. Slightly more than half were men (52%) and the majority were medical residents (42%), followed by interns (35%), attending physicians (17%), and fellows (6%), reported Dr. J. Daniel Markley Jr., a second-year internal medicine resident at the university.

Previous studies have shown that nosocomial pathogens can persist on fabric for months, but when the survey participants were asked how long a microbe can survive on fabric, 2% said hours, 49% said days, 28% said weeks, 18% said months, and 3% said years.

While 90% of respondents reported wearing their white coats daily or most days of the week, 62% said that they wait 2 weeks or longer to launder them.

Nearly half of respondents (49%) believed that patient perception of physicians would be adversely affected if white coats were discontinued, yet 74% believed that banning white coats could have a significant effect on hospital-acquired infection.

Dr. Markley also reported that 87% of male physicians would stop wearing ties if recommended and 42% of respondents would stop wearing a watch, but only 48% would comply with a “bare below the elbow” policy. They wouldn't want to wear a lab coat with short sleeves “because they don't want to be viewed as a dentist,” Dr. Markley said.

The researchers had no conflicts of interest to disclose.

It's possible to 'take the inoculum from the cloth of a lab coat, transfer it to skin, and isolate [it] from the skin.' MS. BUTLER

SAN DIEGO — It may be time for North Americans to follow the British in their 2007 ban on white lab coats in the health care setting.

Researchers at Virginia Commonwealth University in Richmond used pigskin as an in vitro model to demonstrate that large inoculums of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and pan-resistant Acinetobacter (PRA) bacteria could be transferred from a white cotton lab coat to pigskin 1 minute, 5 minutes, and 30 minutes after inoculation.

“Previous research has indicated that you could isolate organisms from materials such as hospital curtains, neckties, and lab coats, but we wanted to find out if you could take the inoculum from the cloth of a lab coat, transfer it to skin, and isolate the inoculum from the skin,” Dawn L. Butler said in an interview during a poster session at the annual meeting of the Society for Healthcare Epidemiology of America. “We did.”

Ms. Butler, a second-year medical student at the university, and her associates diluted MRSA, VRE, and PRA and inoculated them onto swatches of one clean, cotton medical lab coat. Next, they rubbed sanitized pieces of pigskin across the inoculated swatches, and a touch prep of the pigskin onto selective media was performed to determine if the inoculated organism could be isolated from the pigskin.

These steps were performed for each of the three study isolates at 1 minute, 5 minutes, and 30 minutes. Selective media were used to prevent growth of contaminants, followed by incubation of the cloth swatches for 24 hours in thioglycolate broth to verify the viability of organisms.

All of the swatches had grown organisms on respective selective media at 24 hours, confirming organism viability on the cotton lab coat.

“Everybody criticizes the British for banning white lab coats in the health care setting, saying that nobody's ever shown that lab coats can transmit an infection,” Dr. Michael Edmond, chair of the division of infectious diseases at VCU, said at the meeting. “This shows that it's biologically plausible, because in the laboratory we did transmit the organism from the coat to the skin.”

In a related poster, 141 physicians from nine VCU departments were surveyed about their attitudes regarding white lab coats. Most of the respondents (90%) were aged 29–39 years. Slightly more than half were men (52%) and the majority were medical residents (42%), followed by interns (35%), attending physicians (17%), and fellows (6%), reported Dr. J. Daniel Markley Jr., a second-year internal medicine resident at the university.

Previous studies have shown that nosocomial pathogens can persist on fabric for months, but when the survey participants were asked how long a microbe can survive on fabric, 2% said hours, 49% said days, 28% said weeks, 18% said months, and 3% said years.

While 90% of respondents reported wearing their white coats daily or most days of the week, 62% said that they wait 2 weeks or longer to launder them.

Nearly half of respondents (49%) believed that patient perception of physicians would be adversely affected if white coats were discontinued, yet 74% believed that banning white coats could have a significant effect on hospital-acquired infection.

Dr. Markley also reported that 87% of male physicians would stop wearing ties if recommended and 42% of respondents would stop wearing a watch, but only 48% would comply with a “bare below the elbow” policy. They wouldn't want to wear a lab coat with short sleeves “because they don't want to be viewed as a dentist,” Dr. Markley said.

The researchers had no conflicts of interest to disclose.

It's possible to 'take the inoculum from the cloth of a lab coat, transfer it to skin, and isolate [it] from the skin.' MS. BUTLER

SAN DIEGO — It may be time for North Americans to follow the British in their 2007 ban on white lab coats in the health care setting.

Researchers at Virginia Commonwealth University in Richmond used pigskin as an in vitro model to demonstrate that large inoculums of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and pan-resistant Acinetobacter (PRA) bacteria could be transferred from a white cotton lab coat to pigskin 1 minute, 5 minutes, and 30 minutes after inoculation.

“Previous research has indicated that you could isolate organisms from materials such as hospital curtains, neckties, and lab coats, but we wanted to find out if you could take the inoculum from the cloth of a lab coat, transfer it to skin, and isolate the inoculum from the skin,” Dawn L. Butler said in an interview during a poster session at the annual meeting of the Society for Healthcare Epidemiology of America. “We did.”

Ms. Butler, a second-year medical student at the university, and her associates diluted MRSA, VRE, and PRA and inoculated them onto swatches of one clean, cotton medical lab coat. Next, they rubbed sanitized pieces of pigskin across the inoculated swatches, and a touch prep of the pigskin onto selective media was performed to determine if the inoculated organism could be isolated from the pigskin.

These steps were performed for each of the three study isolates at 1 minute, 5 minutes, and 30 minutes. Selective media were used to prevent growth of contaminants, followed by incubation of the cloth swatches for 24 hours in thioglycolate broth to verify the viability of organisms.

All of the swatches had grown organisms on respective selective media at 24 hours, confirming organism viability on the cotton lab coat.

“Everybody criticizes the British for banning white lab coats in the health care setting, saying that nobody's ever shown that lab coats can transmit an infection,” Dr. Michael Edmond, chair of the division of infectious diseases at VCU, said at the meeting. “This shows that it's biologically plausible, because in the laboratory we did transmit the organism from the coat to the skin.”

In a related poster, 141 physicians from nine VCU departments were surveyed about their attitudes regarding white lab coats. Most of the respondents (90%) were aged 29–39 years. Slightly more than half were men (52%) and the majority were medical residents (42%), followed by interns (35%), attending physicians (17%), and fellows (6%), reported Dr. J. Daniel Markley Jr., a second-year internal medicine resident at the university.

Previous studies have shown that nosocomial pathogens can persist on fabric for months, but when the survey participants were asked how long a microbe can survive on fabric, 2% said hours, 49% said days, 28% said weeks, 18% said months, and 3% said years.

While 90% of respondents reported wearing their white coats daily or most days of the week, 62% said that they wait 2 weeks or longer to launder them.

Nearly half of respondents (49%) believed that patient perception of physicians would be adversely affected if white coats were discontinued, yet 74% believed that banning white coats could have a significant effect on hospital-acquired infection.

Dr. Markley also reported that 87% of male physicians would stop wearing ties if recommended and 42% of respondents would stop wearing a watch, but only 48% would comply with a “bare below the elbow” policy. They wouldn't want to wear a lab coat with short sleeves “because they don't want to be viewed as a dentist,” Dr. Markley said.

The researchers had no conflicts of interest to disclose.

It's possible to 'take the inoculum from the cloth of a lab coat, transfer it to skin, and isolate [it] from the skin.' MS. BUTLER

SAN DIEGO — The incidence of health care-associated invasive methicillin-resistant Staphylococcus aureus infections in the United States fell 12.5% between 2005 and 2007, a decline that was statistically significant.

The decline was even greater among patients with hospital-onset bloodstream MRSA infections, according to preliminary results from a study of data from the Active Bacterial Core (ABC) surveillance program. The ABC is a component of the Emerging Infections Program Network, a collaboration between the Centers for Disease Control and Prevention (CDC), state health departments, and universities.

Although the result are encouraging, they are preliminary and require further prospective analysis, lead investigator Dr. Alexander J. Kallen cautioned at the annual meeting of the Society for Healthcare Epidemiology of America.

“The 2007 data set has not been finalized, and although only a small number of additional reports are expected, this may result in some changes in these estimates,” said Dr. Kallen, a medical officer with the CDC's Division of Healthcare Quality Promotion in Atlanta.

The ABC surveillance program began tracking MRSA infections in 2004 and includes a catchment area of about 15 million people at facilities in nine states—California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New York, Oregon, and Tennessee.

Dr. Kallen and his associates evaluated only MRSA-causing, invasive health care-associated infections—defined as MRSA isolated from a normally sterile site—in a resident of the surveillance area from 2005 to 2007. This included hospital-onset isolates, defined as isolates cultured more than 2 calendar days after admission when the day of admission is day 0, and health care-associated community-onset isolates, which were cultured 2 days or less after admission in patients with a recent health care exposure. Health care exposures included presence of a central venous catheter at the time of admission, a history of dialysis, an overnight stay in a health care facility, or surgery within the previous year.

In another component of the study, clinicians at eight of the nine facilities were asked to complete a 42-question survey about MRSA-related infection control practices.

Nearly 90% of the isolates were from a bloodstream infection; the next most common syndrome was pneumonia or empyema, followed by skin and soft tissue infection, Dr. Kallen reported.

Between 2005 and 2007, the overall incidence of all invasive MRSA infections fell 12.5%, from 42.7 per 100,000 patients to 34.4 per 100,000 patients, which was statistically significant.

When the researchers studied the subset of patients with bloodstream infections, defined as a positive blood culture, they observed a 21% decrease in hospital-onset infections between 2005 and 2007 and a 12% decrease in health care-associated community-acquired infections during the same time period. Both reductions were statistically significant.

Meanwhile, the incidence of MRSA bloodstream infections in dialysis patients fell 7% during the time period, a reduction that did not reach statistical significance.

According to the survey portion of the study, nearly 70% of responding facilities performed some type of active surveillance testing. More than 80% of facilities used contact precautions for MRSA patients, used dedicated equipment for MRSA patients, could detect previously MRSA-colonized or infected patients at admission, and maintained at least simple measures of MRSA incidence or prevalence.

Limitations of the study include the fact that ABC “is a population-based surveillance system and that use of the catchment area population as a denominator for this analysis of health care-associated infections may be suboptimal,” Dr. Kallen said.

He emphasized that he and his associates “cannot determine the precise cause for this fall in MRSA incidence from our data. This is one cross-sectional study. However, health care facilities we polled had implemented a large number of MRSA-control interventions.”

Dr. Kallen had no conflicts of interest to disclose.

'Health care facilities we polled had implemented a large number of MRSA-control interventions.' DR. KALLEN

Nearly 90% of the MRSA isolates were from a bloodstream infection. Courtesy Dr. Derek Jones

SAN DIEGO — The incidence of health care-associated invasive methicillin-resistant Staphylococcus aureus infections in the United States fell 12.5% between 2005 and 2007, a decline that was statistically significant.

The decline was even greater among patients with hospital-onset bloodstream MRSA infections, according to preliminary results from a study of data from the Active Bacterial Core (ABC) surveillance program. The ABC is a component of the Emerging Infections Program Network, a collaboration between the Centers for Disease Control and Prevention (CDC), state health departments, and universities.

Although the result are encouraging, they are preliminary and require further prospective analysis, lead investigator Dr. Alexander J. Kallen cautioned at the annual meeting of the Society for Healthcare Epidemiology of America.

“The 2007 data set has not been finalized, and although only a small number of additional reports are expected, this may result in some changes in these estimates,” said Dr. Kallen, a medical officer with the CDC's Division of Healthcare Quality Promotion in Atlanta.

The ABC surveillance program began tracking MRSA infections in 2004 and includes a catchment area of about 15 million people at facilities in nine states—California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New York, Oregon, and Tennessee.

Dr. Kallen and his associates evaluated only MRSA-causing, invasive health care-associated infections—defined as MRSA isolated from a normally sterile site—in a resident of the surveillance area from 2005 to 2007. This included hospital-onset isolates, defined as isolates cultured more than 2 calendar days after admission when the day of admission is day 0, and health care-associated community-onset isolates, which were cultured 2 days or less after admission in patients with a recent health care exposure. Health care exposures included presence of a central venous catheter at the time of admission, a history of dialysis, an overnight stay in a health care facility, or surgery within the previous year.

In another component of the study, clinicians at eight of the nine facilities were asked to complete a 42-question survey about MRSA-related infection control practices.

Nearly 90% of the isolates were from a bloodstream infection; the next most common syndrome was pneumonia or empyema, followed by skin and soft tissue infection, Dr. Kallen reported.

Between 2005 and 2007, the overall incidence of all invasive MRSA infections fell 12.5%, from 42.7 per 100,000 patients to 34.4 per 100,000 patients, which was statistically significant.

When the researchers studied the subset of patients with bloodstream infections, defined as a positive blood culture, they observed a 21% decrease in hospital-onset infections between 2005 and 2007 and a 12% decrease in health care-associated community-acquired infections during the same time period. Both reductions were statistically significant.

Meanwhile, the incidence of MRSA bloodstream infections in dialysis patients fell 7% during the time period, a reduction that did not reach statistical significance.

According to the survey portion of the study, nearly 70% of responding facilities performed some type of active surveillance testing. More than 80% of facilities used contact precautions for MRSA patients, used dedicated equipment for MRSA patients, could detect previously MRSA-colonized or infected patients at admission, and maintained at least simple measures of MRSA incidence or prevalence.

Limitations of the study include the fact that ABC “is a population-based surveillance system and that use of the catchment area population as a denominator for this analysis of health care-associated infections may be suboptimal,” Dr. Kallen said.

He emphasized that he and his associates “cannot determine the precise cause for this fall in MRSA incidence from our data. This is one cross-sectional study. However, health care facilities we polled had implemented a large number of MRSA-control interventions.”

Dr. Kallen had no conflicts of interest to disclose.

'Health care facilities we polled had implemented a large number of MRSA-control interventions.' DR. KALLEN

Nearly 90% of the MRSA isolates were from a bloodstream infection. Courtesy Dr. Derek Jones

SAN DIEGO — The incidence of health care-associated invasive methicillin-resistant Staphylococcus aureus infections in the United States fell 12.5% between 2005 and 2007, a decline that was statistically significant.

The decline was even greater among patients with hospital-onset bloodstream MRSA infections, according to preliminary results from a study of data from the Active Bacterial Core (ABC) surveillance program. The ABC is a component of the Emerging Infections Program Network, a collaboration between the Centers for Disease Control and Prevention (CDC), state health departments, and universities.

Although the result are encouraging, they are preliminary and require further prospective analysis, lead investigator Dr. Alexander J. Kallen cautioned at the annual meeting of the Society for Healthcare Epidemiology of America.

“The 2007 data set has not been finalized, and although only a small number of additional reports are expected, this may result in some changes in these estimates,” said Dr. Kallen, a medical officer with the CDC's Division of Healthcare Quality Promotion in Atlanta.

The ABC surveillance program began tracking MRSA infections in 2004 and includes a catchment area of about 15 million people at facilities in nine states—California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New York, Oregon, and Tennessee.

Dr. Kallen and his associates evaluated only MRSA-causing, invasive health care-associated infections—defined as MRSA isolated from a normally sterile site—in a resident of the surveillance area from 2005 to 2007. This included hospital-onset isolates, defined as isolates cultured more than 2 calendar days after admission when the day of admission is day 0, and health care-associated community-onset isolates, which were cultured 2 days or less after admission in patients with a recent health care exposure. Health care exposures included presence of a central venous catheter at the time of admission, a history of dialysis, an overnight stay in a health care facility, or surgery within the previous year.

In another component of the study, clinicians at eight of the nine facilities were asked to complete a 42-question survey about MRSA-related infection control practices.

Nearly 90% of the isolates were from a bloodstream infection; the next most common syndrome was pneumonia or empyema, followed by skin and soft tissue infection, Dr. Kallen reported.

Between 2005 and 2007, the overall incidence of all invasive MRSA infections fell 12.5%, from 42.7 per 100,000 patients to 34.4 per 100,000 patients, which was statistically significant.

When the researchers studied the subset of patients with bloodstream infections, defined as a positive blood culture, they observed a 21% decrease in hospital-onset infections between 2005 and 2007 and a 12% decrease in health care-associated community-acquired infections during the same time period. Both reductions were statistically significant.

Meanwhile, the incidence of MRSA bloodstream infections in dialysis patients fell 7% during the time period, a reduction that did not reach statistical significance.

According to the survey portion of the study, nearly 70% of responding facilities performed some type of active surveillance testing. More than 80% of facilities used contact precautions for MRSA patients, used dedicated equipment for MRSA patients, could detect previously MRSA-colonized or infected patients at admission, and maintained at least simple measures of MRSA incidence or prevalence.

Limitations of the study include the fact that ABC “is a population-based surveillance system and that use of the catchment area population as a denominator for this analysis of health care-associated infections may be suboptimal,” Dr. Kallen said.

He emphasized that he and his associates “cannot determine the precise cause for this fall in MRSA incidence from our data. This is one cross-sectional study. However, health care facilities we polled had implemented a large number of MRSA-control interventions.”

Dr. Kallen had no conflicts of interest to disclose.

'Health care facilities we polled had implemented a large number of MRSA-control interventions.' DR. KALLEN

Nearly 90% of the MRSA isolates were from a bloodstream infection. Courtesy Dr. Derek Jones

During voluntary tours of duty as an Army medical officer for Operation Iraqi Freedom—Camp Spearhead, Shuaiba, Kuwait, in 2003 and Forward Operating Base Warrior, Kirkuk, Iraq, in 2005—Dr. Charles L. Garbarino kept family members and friends informed about his experiences by typing e-mails and scribbling other thoughts in a diary.

When he returned home from his second tour of duty, those same family members and friends encouraged him to write a book about his experiences as a pediatrician who cared for soldiers in the combat zone.

"People said to me, 'you have to write a book,'" said Dr. Garbarino, a colonel in the New Jersey National Guard who practices pediatrics in West Orange, N.J. "They'd say, 'Your e-mails were so touching and they brought out so many emotions. You made us realize what war really is; you have to tell your story.' I said, 'I'm a street kid from Brooklyn and you want me to write a book.'"

A friend introduced him to Marc S. Goldberg, a writer who helped him sift through those e-mails and diaries to assemble "Pediatrician Soldier: The Man the Kids Call 'Dr. Charlie' Goes to War" (Bloomington, Ind.: inuiverse.com

Presented in essay form, the book includes Dr. Garbarino's candid thoughts about what it means to be deployed as a soldier; the pediatrician's role in caring for a soldier in a combat zone; postdeployment medical care; how posttraumatic stress disorder affects soldiers and their families; the impact of deployment on the family structure; and the role civilian pediatricians can play in caring for children of deployed soldiers.

A palpable theme throughout the book is the importance of bringing compassion to all aspects of medical care. In Iraq and in other theaters of combat in the Middle East, he explained, "what we have for the soldiers resembles a M*A*S*H unit. You're doing the best you can. But the thing is, there is a lot more hand holding and compassion when you're out in that battlefield or in that combat zone with the soldier. People here in the United States don't appreciate how much they have and how good the medical care is. Many people in Iraq get medical care from veterinarians."

During his 90-day assignment at Camp Spearhead, a soldier came to Dr. Garbarino complaining of chest pain. Every symptom suggested he was having a major heart attack.

"I was in a tent in the middle of nowhere, and I had to take him to a medical facility about 45 minutes away," recalled Dr. Garbarino, who was the first N. J. Army National Guard physician deployed for Operation Iraqi Freedom. "I was so afraid for him that I rode along with him in the ambulance. I said, 'We're going to have a long ride together. Let's talk.' He said, 'Can we pray?' I said, 'That would be fine.' I'm not one that goes to church regularly—I maybe go three to four times a year—but on the way we prayed and read the Bible, and he felt peace. I felt peace."

During an office visit with another soldier at Forward Operating Base Warrior, Dr. Garbarino addressed the man's chief complaint but noticed that his eyes were welling up with tears. "I told him, 'I'll be right back,'" Dr. Garbarino said. "I went into the next room, put on my Mickey Mouse shirt, put on my red clown nose that was given to me by Dr. Patch Adams, and I put on my twirly hat. Then I came back to the exam room and said, 'Hi. I'm your doctor.' And he just started to laugh. Then I held his hand and he cried. That, I think, is paramount. Physicians have to realize that just holding someone's hand is just as important as anything else."

A self-described no-nonsense kid from Brooklyn, Dr. Garbarino refuses to consider himself a hero for the service he provided on those two tours. "The real heroes are all the fallen soldiers and those who have come back emotionally, physically, or mentally traumatized," he emphasized. "Those are your heroes, as are all the people these soldiers left behind when they went to war. There is one hero in my family. It's not me; it's my wife, Lydia."

He went on to note that when soldiers return from deployment, "We all return changed. I had some PTSD when I returned. One day, I was sleeping and I woke up in a cold sweat, saying, 'I gotta get it! I gotta get it!' I finally realized I was home, and that what I was reaching for was my weapon. I've been okay, but so many soldiers are coming back with physical problems such as missing limbs, or they've been mentally traumatized. They hear somebody drop a box and they duck."

All royalties from "Pediatrician Soldier" benefit Our Military Kids, an organization that provides support to children of deployed and severely injured National Guard and Military Reserve personnel (www.ourmilitarykids.org

"Pediatrician Soldier" is available at www.amazon.comwww.barnesandnoble.comwww.iuniverse.com

"Physicians have to realize that just holding someone's hand is just as important as anything else," said Dr. Charles L. Garbarino, pictured in Kirkuk, Iraq, during one of his two tours of duty. Courtesy Dr. Charles L. Garbarino

During voluntary tours of duty as an Army medical officer for Operation Iraqi Freedom—Camp Spearhead, Shuaiba, Kuwait, in 2003 and Forward Operating Base Warrior, Kirkuk, Iraq, in 2005—Dr. Charles L. Garbarino kept family members and friends informed about his experiences by typing e-mails and scribbling other thoughts in a diary.

When he returned home from his second tour of duty, those same family members and friends encouraged him to write a book about his experiences as a pediatrician who cared for soldiers in the combat zone.

"People said to me, 'you have to write a book,'" said Dr. Garbarino, a colonel in the New Jersey National Guard who practices pediatrics in West Orange, N.J. "They'd say, 'Your e-mails were so touching and they brought out so many emotions. You made us realize what war really is; you have to tell your story.' I said, 'I'm a street kid from Brooklyn and you want me to write a book.'"

A friend introduced him to Marc S. Goldberg, a writer who helped him sift through those e-mails and diaries to assemble "Pediatrician Soldier: The Man the Kids Call 'Dr. Charlie' Goes to War" (Bloomington, Ind.: inuiverse.com

Presented in essay form, the book includes Dr. Garbarino's candid thoughts about what it means to be deployed as a soldier; the pediatrician's role in caring for a soldier in a combat zone; postdeployment medical care; how posttraumatic stress disorder affects soldiers and their families; the impact of deployment on the family structure; and the role civilian pediatricians can play in caring for children of deployed soldiers.

A palpable theme throughout the book is the importance of bringing compassion to all aspects of medical care. In Iraq and in other theaters of combat in the Middle East, he explained, "what we have for the soldiers resembles a M*A*S*H unit. You're doing the best you can. But the thing is, there is a lot more hand holding and compassion when you're out in that battlefield or in that combat zone with the soldier. People here in the United States don't appreciate how much they have and how good the medical care is. Many people in Iraq get medical care from veterinarians."

During his 90-day assignment at Camp Spearhead, a soldier came to Dr. Garbarino complaining of chest pain. Every symptom suggested he was having a major heart attack.

"I was in a tent in the middle of nowhere, and I had to take him to a medical facility about 45 minutes away," recalled Dr. Garbarino, who was the first N. J. Army National Guard physician deployed for Operation Iraqi Freedom. "I was so afraid for him that I rode along with him in the ambulance. I said, 'We're going to have a long ride together. Let's talk.' He said, 'Can we pray?' I said, 'That would be fine.' I'm not one that goes to church regularly—I maybe go three to four times a year—but on the way we prayed and read the Bible, and he felt peace. I felt peace."

During an office visit with another soldier at Forward Operating Base Warrior, Dr. Garbarino addressed the man's chief complaint but noticed that his eyes were welling up with tears. "I told him, 'I'll be right back,'" Dr. Garbarino said. "I went into the next room, put on my Mickey Mouse shirt, put on my red clown nose that was given to me by Dr. Patch Adams, and I put on my twirly hat. Then I came back to the exam room and said, 'Hi. I'm your doctor.' And he just started to laugh. Then I held his hand and he cried. That, I think, is paramount. Physicians have to realize that just holding someone's hand is just as important as anything else."

A self-described no-nonsense kid from Brooklyn, Dr. Garbarino refuses to consider himself a hero for the service he provided on those two tours. "The real heroes are all the fallen soldiers and those who have come back emotionally, physically, or mentally traumatized," he emphasized. "Those are your heroes, as are all the people these soldiers left behind when they went to war. There is one hero in my family. It's not me; it's my wife, Lydia."

He went on to note that when soldiers return from deployment, "We all return changed. I had some PTSD when I returned. One day, I was sleeping and I woke up in a cold sweat, saying, 'I gotta get it! I gotta get it!' I finally realized I was home, and that what I was reaching for was my weapon. I've been okay, but so many soldiers are coming back with physical problems such as missing limbs, or they've been mentally traumatized. They hear somebody drop a box and they duck."

All royalties from "Pediatrician Soldier" benefit Our Military Kids, an organization that provides support to children of deployed and severely injured National Guard and Military Reserve personnel (www.ourmilitarykids.org

"Pediatrician Soldier" is available at www.amazon.comwww.barnesandnoble.comwww.iuniverse.com

"Physicians have to realize that just holding someone's hand is just as important as anything else," said Dr. Charles L. Garbarino, pictured in Kirkuk, Iraq, during one of his two tours of duty. Courtesy Dr. Charles L. Garbarino

During voluntary tours of duty as an Army medical officer for Operation Iraqi Freedom—Camp Spearhead, Shuaiba, Kuwait, in 2003 and Forward Operating Base Warrior, Kirkuk, Iraq, in 2005—Dr. Charles L. Garbarino kept family members and friends informed about his experiences by typing e-mails and scribbling other thoughts in a diary.

When he returned home from his second tour of duty, those same family members and friends encouraged him to write a book about his experiences as a pediatrician who cared for soldiers in the combat zone.

"People said to me, 'you have to write a book,'" said Dr. Garbarino, a colonel in the New Jersey National Guard who practices pediatrics in West Orange, N.J. "They'd say, 'Your e-mails were so touching and they brought out so many emotions. You made us realize what war really is; you have to tell your story.' I said, 'I'm a street kid from Brooklyn and you want me to write a book.'"

A friend introduced him to Marc S. Goldberg, a writer who helped him sift through those e-mails and diaries to assemble "Pediatrician Soldier: The Man the Kids Call 'Dr. Charlie' Goes to War" (Bloomington, Ind.: inuiverse.com

Presented in essay form, the book includes Dr. Garbarino's candid thoughts about what it means to be deployed as a soldier; the pediatrician's role in caring for a soldier in a combat zone; postdeployment medical care; how posttraumatic stress disorder affects soldiers and their families; the impact of deployment on the family structure; and the role civilian pediatricians can play in caring for children of deployed soldiers.

A palpable theme throughout the book is the importance of bringing compassion to all aspects of medical care. In Iraq and in other theaters of combat in the Middle East, he explained, "what we have for the soldiers resembles a M*A*S*H unit. You're doing the best you can. But the thing is, there is a lot more hand holding and compassion when you're out in that battlefield or in that combat zone with the soldier. People here in the United States don't appreciate how much they have and how good the medical care is. Many people in Iraq get medical care from veterinarians."

During his 90-day assignment at Camp Spearhead, a soldier came to Dr. Garbarino complaining of chest pain. Every symptom suggested he was having a major heart attack.

"I was in a tent in the middle of nowhere, and I had to take him to a medical facility about 45 minutes away," recalled Dr. Garbarino, who was the first N. J. Army National Guard physician deployed for Operation Iraqi Freedom. "I was so afraid for him that I rode along with him in the ambulance. I said, 'We're going to have a long ride together. Let's talk.' He said, 'Can we pray?' I said, 'That would be fine.' I'm not one that goes to church regularly—I maybe go three to four times a year—but on the way we prayed and read the Bible, and he felt peace. I felt peace."

During an office visit with another soldier at Forward Operating Base Warrior, Dr. Garbarino addressed the man's chief complaint but noticed that his eyes were welling up with tears. "I told him, 'I'll be right back,'" Dr. Garbarino said. "I went into the next room, put on my Mickey Mouse shirt, put on my red clown nose that was given to me by Dr. Patch Adams, and I put on my twirly hat. Then I came back to the exam room and said, 'Hi. I'm your doctor.' And he just started to laugh. Then I held his hand and he cried. That, I think, is paramount. Physicians have to realize that just holding someone's hand is just as important as anything else."

A self-described no-nonsense kid from Brooklyn, Dr. Garbarino refuses to consider himself a hero for the service he provided on those two tours. "The real heroes are all the fallen soldiers and those who have come back emotionally, physically, or mentally traumatized," he emphasized. "Those are your heroes, as are all the people these soldiers left behind when they went to war. There is one hero in my family. It's not me; it's my wife, Lydia."

He went on to note that when soldiers return from deployment, "We all return changed. I had some PTSD when I returned. One day, I was sleeping and I woke up in a cold sweat, saying, 'I gotta get it! I gotta get it!' I finally realized I was home, and that what I was reaching for was my weapon. I've been okay, but so many soldiers are coming back with physical problems such as missing limbs, or they've been mentally traumatized. They hear somebody drop a box and they duck."

All royalties from "Pediatrician Soldier" benefit Our Military Kids, an organization that provides support to children of deployed and severely injured National Guard and Military Reserve personnel (www.ourmilitarykids.org

"Pediatrician Soldier" is available at www.amazon.comwww.barnesandnoble.comwww.iuniverse.com

"Physicians have to realize that just holding someone's hand is just as important as anything else," said Dr. Charles L. Garbarino, pictured in Kirkuk, Iraq, during one of his two tours of duty. Courtesy Dr. Charles L. Garbarino

SAN DIEGO — The incidence of health care-associated invasive methicillin-resistant Staphylococcus aureus infections in the United States fell 12.5% between 2005 and 2007, a decline that was statistically significant.

The decline was even greater among patients with hospital-onset bloodstream MRSA infections, according to preliminary results from a study of data from the Active Bacterial Core (ABC) surveillance program. The ABC is a component of the Emerging Infections Program Network, a collaboration between the Centers for Disease Control and Prevention (CDC), state health departments, and universities.

Although the results are encouraging, they are preliminary and require further prospective analysis, lead investigator Dr. Alexander J. Kallen cautioned at the annual meeting of the Society for Healthcare Epidemiology of America.

"The 2007 data set has not been finalized, and although only a small number of additional reports are expected, this may result in some changes in these estimates," said Dr. Kallen, a medical officer with the CDC's Division of Healthcare Quality Promotion in Atlanta.

The ABC surveillance program began tracking MRSA infections in 2004 and includes a catchment area of about 15 million people at facilities in nine states—California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New York, Oregon, and Tennessee.

Dr. Kallen and his associates evaluated only MRSA-causing, invasive health care-associated infections—defined as MRSA isolated from a normally sterile site—in a resident of the surveillance area from 2005 to 2007. This included hospital-onset isolates, defined as isolates cultured more than 2 calendar days after admission when the day of admission is day 0, and health care-associated community-onset isolates, which were cultured 2 days or less after admission in patients with a recent health care exposure. Health care exposures included presence of a central venous catheter at the time of admission, a history of dialysis, an overnight stay in a health care facility, or surgery within the previous year.

To determine population-based incidence by year, the researchers used a denominator based on United States census estimates for the catchment area.

In another component of the study, clinicians at eight of the nine facilities were asked to complete a 42-question survey about MRSA-related infection control practices. Nearly 90% of isolates were from a bloodstream infection; the next most common syndrome was pneumonia or empyema, followed by skin and soft tissue infection, Dr. Kallen reported.

Between 2005 and 2007, the overall incidence of all invasive MRSA infections fell 12.5%, from 42.7 per 100,000 patients to 34.4 per 100,000 patients, which was statistically significant.

When the researchers studied the subset of patients with bloodstream infections, defined as a positive blood culture, they observed a 21% decrease in hospital-onset infections between 2005 and 2007 and a 12% decrease in health care-associated community-acquired infections during the same time period. Both reductions were statistically significant.

Meanwhile, incidence of MRSA bloodstream infections in dialysis patients fell 7% in the time period, a reduction that did not reach statistical significance.

According to the survey portion of the study, nearly 70% of responding facilities performed some type of active surveillance testing. More than 80% of facilities used contact precautions for MRSA patients, used dedicated equipment for MRSA patients, could detect previously MRSA-colonized or infected patients at admission, and maintained at least simple measures of MRSA incidence or prevalence.

Limitations of the study include the fact that ABC "is a population-based surveillance system and that use of the catchment area population as a denominator for this analysis of health care-associated infections may be suboptimal," Dr. Kallen said.

He went on to emphasize that he and his associates "cannot determine the precise cause for this fall in MRSA incidence from our data. This is one cross-sectional study. However, health care facilities we polled had implemented a large number of MRSA-control interventions."

Dr. Kallen had no financial conflicts to disclose.

The overall incidence of all invasive MRSA infections dropped by a statistically significant 12.5%. DR. KALLEN

Nearly 90% of MRSAisolates were from a bloodstream infection; the next most common was pneumonia or empyema, followed by skin and soft tissue infection. Courtesy Dr. Derek Jones

SAN DIEGO — The incidence of health care-associated invasive methicillin-resistant Staphylococcus aureus infections in the United States fell 12.5% between 2005 and 2007, a decline that was statistically significant.

The decline was even greater among patients with hospital-onset bloodstream MRSA infections, according to preliminary results from a study of data from the Active Bacterial Core (ABC) surveillance program. The ABC is a component of the Emerging Infections Program Network, a collaboration between the Centers for Disease Control and Prevention (CDC), state health departments, and universities.

Although the results are encouraging, they are preliminary and require further prospective analysis, lead investigator Dr. Alexander J. Kallen cautioned at the annual meeting of the Society for Healthcare Epidemiology of America.

"The 2007 data set has not been finalized, and although only a small number of additional reports are expected, this may result in some changes in these estimates," said Dr. Kallen, a medical officer with the CDC's Division of Healthcare Quality Promotion in Atlanta.

The ABC surveillance program began tracking MRSA infections in 2004 and includes a catchment area of about 15 million people at facilities in nine states—California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New York, Oregon, and Tennessee.

Dr. Kallen and his associates evaluated only MRSA-causing, invasive health care-associated infections—defined as MRSA isolated from a normally sterile site—in a resident of the surveillance area from 2005 to 2007. This included hospital-onset isolates, defined as isolates cultured more than 2 calendar days after admission when the day of admission is day 0, and health care-associated community-onset isolates, which were cultured 2 days or less after admission in patients with a recent health care exposure. Health care exposures included presence of a central venous catheter at the time of admission, a history of dialysis, an overnight stay in a health care facility, or surgery within the previous year.

To determine population-based incidence by year, the researchers used a denominator based on United States census estimates for the catchment area.

In another component of the study, clinicians at eight of the nine facilities were asked to complete a 42-question survey about MRSA-related infection control practices. Nearly 90% of isolates were from a bloodstream infection; the next most common syndrome was pneumonia or empyema, followed by skin and soft tissue infection, Dr. Kallen reported.

Between 2005 and 2007, the overall incidence of all invasive MRSA infections fell 12.5%, from 42.7 per 100,000 patients to 34.4 per 100,000 patients, which was statistically significant.

When the researchers studied the subset of patients with bloodstream infections, defined as a positive blood culture, they observed a 21% decrease in hospital-onset infections between 2005 and 2007 and a 12% decrease in health care-associated community-acquired infections during the same time period. Both reductions were statistically significant.

Meanwhile, incidence of MRSA bloodstream infections in dialysis patients fell 7% in the time period, a reduction that did not reach statistical significance.

According to the survey portion of the study, nearly 70% of responding facilities performed some type of active surveillance testing. More than 80% of facilities used contact precautions for MRSA patients, used dedicated equipment for MRSA patients, could detect previously MRSA-colonized or infected patients at admission, and maintained at least simple measures of MRSA incidence or prevalence.

Limitations of the study include the fact that ABC "is a population-based surveillance system and that use of the catchment area population as a denominator for this analysis of health care-associated infections may be suboptimal," Dr. Kallen said.

He went on to emphasize that he and his associates "cannot determine the precise cause for this fall in MRSA incidence from our data. This is one cross-sectional study. However, health care facilities we polled had implemented a large number of MRSA-control interventions."

Dr. Kallen had no financial conflicts to disclose.

The overall incidence of all invasive MRSA infections dropped by a statistically significant 12.5%. DR. KALLEN

Nearly 90% of MRSAisolates were from a bloodstream infection; the next most common was pneumonia or empyema, followed by skin and soft tissue infection. Courtesy Dr. Derek Jones

SAN DIEGO — The incidence of health care-associated invasive methicillin-resistant Staphylococcus aureus infections in the United States fell 12.5% between 2005 and 2007, a decline that was statistically significant.

The decline was even greater among patients with hospital-onset bloodstream MRSA infections, according to preliminary results from a study of data from the Active Bacterial Core (ABC) surveillance program. The ABC is a component of the Emerging Infections Program Network, a collaboration between the Centers for Disease Control and Prevention (CDC), state health departments, and universities.

Although the results are encouraging, they are preliminary and require further prospective analysis, lead investigator Dr. Alexander J. Kallen cautioned at the annual meeting of the Society for Healthcare Epidemiology of America.

"The 2007 data set has not been finalized, and although only a small number of additional reports are expected, this may result in some changes in these estimates," said Dr. Kallen, a medical officer with the CDC's Division of Healthcare Quality Promotion in Atlanta.

The ABC surveillance program began tracking MRSA infections in 2004 and includes a catchment area of about 15 million people at facilities in nine states—California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New York, Oregon, and Tennessee.

Dr. Kallen and his associates evaluated only MRSA-causing, invasive health care-associated infections—defined as MRSA isolated from a normally sterile site—in a resident of the surveillance area from 2005 to 2007. This included hospital-onset isolates, defined as isolates cultured more than 2 calendar days after admission when the day of admission is day 0, and health care-associated community-onset isolates, which were cultured 2 days or less after admission in patients with a recent health care exposure. Health care exposures included presence of a central venous catheter at the time of admission, a history of dialysis, an overnight stay in a health care facility, or surgery within the previous year.

To determine population-based incidence by year, the researchers used a denominator based on United States census estimates for the catchment area.

In another component of the study, clinicians at eight of the nine facilities were asked to complete a 42-question survey about MRSA-related infection control practices. Nearly 90% of isolates were from a bloodstream infection; the next most common syndrome was pneumonia or empyema, followed by skin and soft tissue infection, Dr. Kallen reported.

Between 2005 and 2007, the overall incidence of all invasive MRSA infections fell 12.5%, from 42.7 per 100,000 patients to 34.4 per 100,000 patients, which was statistically significant.

When the researchers studied the subset of patients with bloodstream infections, defined as a positive blood culture, they observed a 21% decrease in hospital-onset infections between 2005 and 2007 and a 12% decrease in health care-associated community-acquired infections during the same time period. Both reductions were statistically significant.

Meanwhile, incidence of MRSA bloodstream infections in dialysis patients fell 7% in the time period, a reduction that did not reach statistical significance.

According to the survey portion of the study, nearly 70% of responding facilities performed some type of active surveillance testing. More than 80% of facilities used contact precautions for MRSA patients, used dedicated equipment for MRSA patients, could detect previously MRSA-colonized or infected patients at admission, and maintained at least simple measures of MRSA incidence or prevalence.

Limitations of the study include the fact that ABC "is a population-based surveillance system and that use of the catchment area population as a denominator for this analysis of health care-associated infections may be suboptimal," Dr. Kallen said.

He went on to emphasize that he and his associates "cannot determine the precise cause for this fall in MRSA incidence from our data. This is one cross-sectional study. However, health care facilities we polled had implemented a large number of MRSA-control interventions."

Dr. Kallen had no financial conflicts to disclose.

The overall incidence of all invasive MRSA infections dropped by a statistically significant 12.5%. DR. KALLEN

Nearly 90% of MRSAisolates were from a bloodstream infection; the next most common was pneumonia or empyema, followed by skin and soft tissue infection. Courtesy Dr. Derek Jones

SAN DIEGO — It may be time for North Americans to follow the British in their 2007 ban on white lab coats in the health care setting.

Researchers at Virginia Commonwealth University in Richmond used pigskin as an in vitro model to demonstrate that large inoculums of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and pan-resistant Acinetobacter (PRA) bacteria could be transferred from a white cotton lab coat to pigskin 1 minute, 5 minutes, and 30 minutes after inoculation.

"Previous research has indicated that you could isolate organisms from materials such as hospital curtains, neckties, and lab coats, but we wanted to find out if you could take the inoculum from the cloth of a lab coat, transfer it to skin, and isolate the inoculum from the skin," Dawn L. Butler said in an interview during a poster session at the annual meeting of the Society for Healthcare Epidemiology of America. "We did."

Ms. Butler, a second-year medical student at the university, and her associates diluted MRSA, VRE, and PRA and inoculated them onto swatches of one clean, cotton medical lab coat. Next, they rubbed sanitized pieces of pigskin across the inoculated swatches, and a touch prep of the pigskin onto selective media was performed to determine if the inoculated organism could be isolated from the pigskin.

These steps were performed for each of the three study isolates at 1 minute, 5 minutes, and 30 minutes. Selective media were used to prevent the growth of contaminants, followed by incubation of the cloth swatches for 24 hours in thioglycolate broth to verify the viability of organisms.

All of the swatches had grown organisms on respective selective media at 24 hours, confirming organism viability on the cotton lab coat.

"Everybody criticizes the British for banning white lab coats in the health care setting, saying that nobody's ever shown that lab coats can transmit an infection," Dr. Michael Edmond, chair of the division of infectious diseases at VCU, said at the meeting. "This shows that it's biologically plausible, because in the laboratory we did transmit the organism from the coat to the skin."

In a related poster, 141 physicians from nine VCU departments were surveyed about their attitudes regarding white lab coats. Most of the respondents (90%) were aged 29-39 years. Slightly more than half were men (52%) and the majority were medical residents (42%), followed by interns (35%), attending physicians (17%), and fellows (6%), reported Dr. J. Daniel Markley Jr., a second-year internal medicine resident at the university.

Previous studies have shown that nosocomial pathogens can persist on fabric for months, but when the survey participants were asked how long a microbe can survive on fabric, 2% said hours, 49% said days, 28% said weeks, 18% said months, and 3% said years.

In addition, 90% of respondents reported wearing white coats daily or most days of the week, yet 62% said that they wait 2 weeks or longer to launder them.

Nearly half of respondents (49%) believed that patient perception of physicians would be adversely affected if white coats were discontinued, yet 74% believed that banning white coats could have a significant effect on hospital-acquired infection.

Dr. Markley also reported that 87% of male physicians would stop wearing ties if recommended, 42% of respondents would stop wearing a watch, yet only 48% would comply with a "bare below the elbow" policy. They wouldn't want to wear a lab coat with short sleeves "because they don't want to be viewed as a dentist," Dr. Markley said.

The researchers had no conflicts to disclose.

All swatches had grown organisms on respective selective mediaat 24 hours, confirming organism viability. MS. BUTLER

SAN DIEGO — It may be time for North Americans to follow the British in their 2007 ban on white lab coats in the health care setting.

Researchers at Virginia Commonwealth University in Richmond used pigskin as an in vitro model to demonstrate that large inoculums of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and pan-resistant Acinetobacter (PRA) bacteria could be transferred from a white cotton lab coat to pigskin 1 minute, 5 minutes, and 30 minutes after inoculation.

"Previous research has indicated that you could isolate organisms from materials such as hospital curtains, neckties, and lab coats, but we wanted to find out if you could take the inoculum from the cloth of a lab coat, transfer it to skin, and isolate the inoculum from the skin," Dawn L. Butler said in an interview during a poster session at the annual meeting of the Society for Healthcare Epidemiology of America. "We did."

Ms. Butler, a second-year medical student at the university, and her associates diluted MRSA, VRE, and PRA and inoculated them onto swatches of one clean, cotton medical lab coat. Next, they rubbed sanitized pieces of pigskin across the inoculated swatches, and a touch prep of the pigskin onto selective media was performed to determine if the inoculated organism could be isolated from the pigskin.

These steps were performed for each of the three study isolates at 1 minute, 5 minutes, and 30 minutes. Selective media were used to prevent the growth of contaminants, followed by incubation of the cloth swatches for 24 hours in thioglycolate broth to verify the viability of organisms.

All of the swatches had grown organisms on respective selective media at 24 hours, confirming organism viability on the cotton lab coat.

"Everybody criticizes the British for banning white lab coats in the health care setting, saying that nobody's ever shown that lab coats can transmit an infection," Dr. Michael Edmond, chair of the division of infectious diseases at VCU, said at the meeting. "This shows that it's biologically plausible, because in the laboratory we did transmit the organism from the coat to the skin."

In a related poster, 141 physicians from nine VCU departments were surveyed about their attitudes regarding white lab coats. Most of the respondents (90%) were aged 29-39 years. Slightly more than half were men (52%) and the majority were medical residents (42%), followed by interns (35%), attending physicians (17%), and fellows (6%), reported Dr. J. Daniel Markley Jr., a second-year internal medicine resident at the university.

Previous studies have shown that nosocomial pathogens can persist on fabric for months, but when the survey participants were asked how long a microbe can survive on fabric, 2% said hours, 49% said days, 28% said weeks, 18% said months, and 3% said years.

In addition, 90% of respondents reported wearing white coats daily or most days of the week, yet 62% said that they wait 2 weeks or longer to launder them.

Nearly half of respondents (49%) believed that patient perception of physicians would be adversely affected if white coats were discontinued, yet 74% believed that banning white coats could have a significant effect on hospital-acquired infection.

Dr. Markley also reported that 87% of male physicians would stop wearing ties if recommended, 42% of respondents would stop wearing a watch, yet only 48% would comply with a "bare below the elbow" policy. They wouldn't want to wear a lab coat with short sleeves "because they don't want to be viewed as a dentist," Dr. Markley said.

The researchers had no conflicts to disclose.

All swatches had grown organisms on respective selective mediaat 24 hours, confirming organism viability. MS. BUTLER

SAN DIEGO — It may be time for North Americans to follow the British in their 2007 ban on white lab coats in the health care setting.

Researchers at Virginia Commonwealth University in Richmond used pigskin as an in vitro model to demonstrate that large inoculums of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and pan-resistant Acinetobacter (PRA) bacteria could be transferred from a white cotton lab coat to pigskin 1 minute, 5 minutes, and 30 minutes after inoculation.

"Previous research has indicated that you could isolate organisms from materials such as hospital curtains, neckties, and lab coats, but we wanted to find out if you could take the inoculum from the cloth of a lab coat, transfer it to skin, and isolate the inoculum from the skin," Dawn L. Butler said in an interview during a poster session at the annual meeting of the Society for Healthcare Epidemiology of America. "We did."

Ms. Butler, a second-year medical student at the university, and her associates diluted MRSA, VRE, and PRA and inoculated them onto swatches of one clean, cotton medical lab coat. Next, they rubbed sanitized pieces of pigskin across the inoculated swatches, and a touch prep of the pigskin onto selective media was performed to determine if the inoculated organism could be isolated from the pigskin.

These steps were performed for each of the three study isolates at 1 minute, 5 minutes, and 30 minutes. Selective media were used to prevent the growth of contaminants, followed by incubation of the cloth swatches for 24 hours in thioglycolate broth to verify the viability of organisms.

All of the swatches had grown organisms on respective selective media at 24 hours, confirming organism viability on the cotton lab coat.

"Everybody criticizes the British for banning white lab coats in the health care setting, saying that nobody's ever shown that lab coats can transmit an infection," Dr. Michael Edmond, chair of the division of infectious diseases at VCU, said at the meeting. "This shows that it's biologically plausible, because in the laboratory we did transmit the organism from the coat to the skin."

In a related poster, 141 physicians from nine VCU departments were surveyed about their attitudes regarding white lab coats. Most of the respondents (90%) were aged 29-39 years. Slightly more than half were men (52%) and the majority were medical residents (42%), followed by interns (35%), attending physicians (17%), and fellows (6%), reported Dr. J. Daniel Markley Jr., a second-year internal medicine resident at the university.

Previous studies have shown that nosocomial pathogens can persist on fabric for months, but when the survey participants were asked how long a microbe can survive on fabric, 2% said hours, 49% said days, 28% said weeks, 18% said months, and 3% said years.

In addition, 90% of respondents reported wearing white coats daily or most days of the week, yet 62% said that they wait 2 weeks or longer to launder them.

Nearly half of respondents (49%) believed that patient perception of physicians would be adversely affected if white coats were discontinued, yet 74% believed that banning white coats could have a significant effect on hospital-acquired infection.

Dr. Markley also reported that 87% of male physicians would stop wearing ties if recommended, 42% of respondents would stop wearing a watch, yet only 48% would comply with a "bare below the elbow" policy. They wouldn't want to wear a lab coat with short sleeves "because they don't want to be viewed as a dentist," Dr. Markley said.

The researchers had no conflicts to disclose.

All swatches had grown organisms on respective selective mediaat 24 hours, confirming organism viability. MS. BUTLER