Pushing tobacco on the web: is YouTube telling or selling you something?

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Circumcision and HIV prevention: Manitoba researchers make a medical breakthrough

An HIV study led by the University of Manitoba's Dr. Stephen Moses has been named the year's top medical breakthrough by Time magazine. Dr. Moses was one of the principal investigators in research that found male circumcision can reduce the risk of HIV infection in men who have heterosexual sex.

Collaborating with researchers from universities in the U.S. and Nairobi, Dr. Moses conducted clinical trials in Kenya and Uganda, following thousands of HIV-negative men over a number of years to determine what effect circumcision would have on the spread of HIV. Their results show that circumcised men were roughly 50 per cent less likely than uncircumcised men to acquire HIV during sex with women. The trials were halted a year ago after early data showed high levels of success, and the results were published in the The Lancet earlier this year.

"It’s nice that the issue has got this kind of recognition in the popular press," Dr. Moses told the Winnipeg Free Press. The notion that circumcision can protect against HIV transmission has been accepted in the scientific community, and increasingly in the world health community. Dr. Moses predicts that "circumcision is going to start to be taken up more widely as a public-health measure to protect against HIV." While circumcision is no magic bullet against HIV, it can help reduce the spread of infection along with safer-sex practices and improved screening and treatment of sexually transmitted infections.

Dr. Moses is now working with the government of India and state governments to try to mitigate the impact of HIV in India, and prevent the spread of the virus. His work is largely based in the southern state of Karnataka, where the aim is to enhance care for people living with HIV.

Time.com currently lists the HIV study as the biggest breakthrough of 2007, followed by the development of a test for metastatic breast cancer and a human vaccine against avian flu.

Does circumcision help men who have sex with men?
Dr. Allan Ronald, an infectious disease specialist in Winnipeg who has also done important work in African HIV research, added some perspective in an interview with CBC Radio One last week. He stated that, although the results of Dr. Moses' research are convincing, they are not likely to have the same relevance for North America. Referring to recent research, Dr. Ronald cautioned that circumcision is not as effective in reducing the rate of HIV infection among men who have sex with men (MSM). He was referring to an article by researchers with the Centers for Disease Control in Atlanta, which was published in PLoS Medicine this month [4], which reported: "Most sexual transmission of HIV in the US [and Canada] occurs through male–male sex, most often infecting the receptive partner in penile–anal intercourse. The results from the African trials demonstrated that circumcision was protective for men who were the insertive partner in vaginal intercourse, suggesting that the utility of male circumcision in preventing HIV transmission among MSM may be limited." Another study published this month reinforces this statement, concluding that "there was no evidence that being circumcised was protective against HIV infection among black MSM or Latino MSM" in the United States [1].

Circumcision certainly has a role in the prevention of HIV transmission. However, because of the many differences between the underlying HIV epidemics in Africa and the developed world, differences in the prevalence of male circumcision, and the considerable gaps in knowledge that exist regarding the potential impact of circumcision on HIV transmission by male–male sex, the extent of this role on a population basis is unknown.The PLoS article calls for more discussion of the benefits and risks of circumcision before any recommendations are drafted. Among the issues to be considered are gaps in the research (for example, differences in shedding of HIV by rectal versus vaginal mucosa), barriers and facilitators to acceptance of adult male circumcision, buy-in from the at-risk communities, cultural and ethical questions, cost benefits, and insurance.

A contentious issue
Male circumcision is a contentious issue still. It has its vocal opponents and strong defenders on the web, while the published literature is generally favourable [2,3,4,6]. Canadian statistics show fewer infant sons being circumcised. Infant circumcision rates dropped to 9.2% in 2005. The rate of male circumcision in the United States is high by comparison: about 57% nationwide. Roughly 3% of male children in the UK are being circumcised. Owing to the sometimes intensely partisan positions taken by opponents of circumcision, librarians and researchers should be cautious when searching the web for information.

Non-heterosexual and injection drug HIV transmission must be considered
Although circumcision is a very important issue, it should not be forgotten that, for example, it is estimated that just under half of all people living with HIV in China in 2006 were infected while injecting drugs with contaminated equipment, and drug use remains the main mode (66%) of HIV transmission in the Russian Federation [5]. In the United States 18% of HIV infections occurred among injecting drug users, and more than half of all newly diagnosed HIV infections (53%) in 2005 were among men who have sex with men [5]. Canadian statistics are similar: 19% injection drug users and 43.2% MSM. Circumcision must always be regarded as one more method to reduce the HIV infection rate. In those parts of the world where heterosexually acquired infections account for the largest proportion of new HIV diagnoses, circumcision will be effective as part of a comprehensive prevention program.

Condoms first
Condoms are still the most effective means of HIV prevention. Because high rates of sexually transmitted infections (STIs) are an important contributing factor to the spread of HIV, it is also vital that STIs be controlled [3]. Free STI testing would be an extremely useful weapon in the anti-HIV arsenal. Taking into account regional variations and the special needs of affected populations, health authorities and community-based organizations should promote a global expansion of STI treatment and male circumcision programs as vital components in the prevention of HIV infection.


References:

1. Millett GA, Ding H, Lauby J, Flores S, Stueve A, Bingham T, Carballo-Dieguez A, Murrill C, Liu KL, Wheeler D, Liau A, Marks G. Circumcision Status and HIV Infection Among Black and Latino Men Who Have Sex With Men in 3 US Cities. J Acquir Immune Defic Syndr. 2007 Dec 15;46(5):643-650.

2. Morris BJ. Why circumcision is a biomedical imperative for the 21st century. Bioessays. 2007 Nov;29(11):1147-58.

3. Sahasrabuddhe VV, Vermund SH. The future of HIV prevention: control of sexually transmitted infections and circumcision interventions. Infect Dis Clin North Am. 2007 Mar;21(1):241-57, xi.

4. Sullivan PS, Kilmarx PH, Peterman TA, Taylor AW, Nakashima AK, Kamb ML, Warner L, Mastro TD. Male circumcision for prevention of HIV transmission: what the new data mean for HIV prevention in the United States. PLoS Med. 2007 Jul 24;4(7):e223.

5. UNAIDS. AIDS epidemic update : December 2007 [Internet]. “UNAIDS/07.27E / JC1322E”. Geneva: UNAIDS; 2007. [cited 2007 Dec 24]. 50 p. Available from: http://data.unaids.org/pub/EPISlides/2007/2007_epiupdate_en.pdf

6. Vardi Y, Sadeghi-Nejad H, Pollack S, Aisuodionoe-Shadrach OI, Sharlip ID. Male circumcision and HIV prevention. J Sex Med. 2007 Jul;4(4 Pt 1):838-43.

Grotty cravats and microbial stats: taking aim at "functionless clothing items" in British hospitals

No one has ever had an idea in a dress suit. ~ Sir Frederick G. Banting

His vesture was dabbled in blood — and his broad brow, with all the features of the face, was besprinkled with the scarlet horror. ~ Edgar Allan Poe, The Masque of the Red Death


Nowadays the word "cravat" starts with C. difficile. Undoing centuries of tradition and male privilege, British hospitals are banning neckties (4). Scarcely a civil word can be heard in their defence. In 2006 the British Medical Association called them "functionless clothing items." The BMA went on to say: "Ties are rarely laundered but worn daily, commonly outside the healthcare environment. Ties perform no beneficial function in patient care and have been shown to be colonised by pathogens." Take that, Beau Brummel. Now, along with long sleeves and jewelry, this male fashion staple, first introduced to the court of Louis XIV by Croat mercenaries, will become suddenly highly unfashionable as the UK's National Health Service continues its efforts to stop the spread of deadly hospital-borne infections. Even the hallowed white coat will disappear. Its cuffs can become heavily contaminated (1,10). Acute care hospitals are expected to go "bare below the elbows" by January 2008, according to last September's announcement by Health Secretary Alan Johnson.

A "guidance" document issued by the UK Department of Health, also in September, provides examples of good and poor dress practice for health professionals, expending special reserves of contumely and guile on unwashed coats and cravats. Cascading hair, false nails, open-toed shoes, wristwatches and other hand adornments (22) are also suspect. As a convenient reminder that complete rationality is rarely achieved in bureaucracies, tattoos are to be covered, not because they are a contamination risk, but because tattoo modesty is required to "maintain a professional appearance." Many hospitals have already changed their regulations in accordance with the new guidelines. Bedford Hospital, for example, launched its "bow-tie, no tie" policy in November.

"We think ties only give the baby boys something to take aim at."
Now that the common tie has become the sartorial equivalent of Typhoid Mary, other countries may soon follow Britain's example. Doctors Kei Lui and Danny Challis, from the Royal Women's Hospital at Randwick, Australia, have a wealth of excuses for not wearing neckties and are happy to add another to their list. "It's always too hot in our nurseries for a tie," says Dr Lui, the hospital's director of newborn care. "No tie is more comfortable. I'd only need to take it off when bending down and, most of all, we think ties only give the baby boys something to take aim at." Male pediatricians often wear ties with cartoon themes to entertain their young patients. They may want to think twice about that, now that we know it's more likely the ties that are taking aim at the patients.

Since at least 1972 there has been evidence that things doctors wear or carry around with them, like stethoscopes, may harbour infection (7,21). Computer keyboards also house germs. Studies done in 2000 and 2002 (6,16) demonstrated that neckties were vectors for nosocomial infection. But it wasn't until 2004 that the media picked up on a conference presentation by a medical student which reported on necktie nosology found at a New York teaching hospital (13). Nearly half (47.6%) of neckties worn by medical personnel in that institution were pullulating colonies of dangerous bacteria. Steven Nurkin and his team reported their findings at the 104th General Meeting of the American Society for Microbiology, and the media loved it. Once it was clear that the heraldic regalia of the well-dressed plutocrat had come under attack, every news organization picked up the story. Research on the germ-carrying potential of other types of hospital garb, including white coats, has been given less prominence (1,10,14,15,17,18,23). It was the grotty knotted cravat that attracted popular attention.

Offered his fifteen minutes, Steven Nurkin gave interviews. The IEQ review quoted him as saying, "I watched the doctors come over for a physical exam or procedure and saw the neckties would swing in front of the patient's face, or patients would cough on them. . . . The necktie is important for the doctor-patient relationship, but it's also there on the front lines — dangling in front of patients as the doctor makes his rounds. . . . Almost everything a doctor carries has bacteria — from a cell phone to a stethoscope. You can get to the point where the doctor is completely naked, but then the skin is covered with bacteria too."

Having lived and worked in Israel, where most doctors go about in shirtsleeves, Nurkin had good reason to question the rather stiff dress codes in North America. "This study brings into question whether wearing a necktie is in the best interest of our patients," commented Nurkin. "Being well dressed adds to an aura of professionalism and has been correlated with higher patient confidence. Senior physicians and hospital administrators often encourage staff to wear neckties in order to help promote this valuable relationship; but in so doing, they may also be facilitating the spread of infectious organisms." Nurkin added: "While there is no direct evidence to implicate neckties in the transmission of infection to patients, the link between contaminated neckties and the potential for transmission must be considered."

On this side of the Atlantic?
With a new year about to begin, we now see just how influential Nurkin's research has been. While British clinicians prepare to bare their necks, infection control societies in the U.S. and Canada are not yet recommending similar dress restrictions. Although there have been serious outbreaks of drug-resistant pathogens in North American hospitals, they have not yet reached the state of Prince Prospero's castellated abbey in Poe's The Masque of the Red Death, doomed by pestilence despite the lofty wall that girdles it in. A search of the AMA and CMA websites found no evidence of serious consideration. But it is probably just a matter of time before clothing policies change. As just a small sample of what can be found on the topic of infection control practice, the Canadian Patient Safety Institute has recently announced its Hand Hygiene campaign, aimed at those who are neglectful of soap and hot water. Ontario has produced a best practice manual for C. difficile. The Manitoba Guidelines for the Prevention and Control of Antibiotic Resistant Organisms contain excellent advice on hand hygiene, and mention that false nails and hand jewelry are not acceptable. But so far, no restrictions that I could find on neckties or coat sleeves. However, there is general agreement that doctors and nurses who don't adequately wash their hands pose a serious risk to patients and that hand-washing should be the focus of infection control efforts in hospitals (search PubMed under Handwashing[MAJR]).

Are lanyards as guilty as ties?
According to a 17 Sept 2007 report in Macleans, Dr. Dick Zoutman, physician director on the board of the Community and Hospital Infection Control Association - Canada, says the British decision on neckties has real merit, and Canadians should take a good look at it. Dr. Allison McGeer, director of infection control at Toronto's Mount Sinai Hospital, says she doesn't see many ties in parts of the hospital where patients are cared for. "It's not about ties; it's about things you don't clean," says McGeer. Common items like lanyards, mobile phones and handhelds that medical staff wear or carry with them can spread germs. (One BMJ rapid responder last September — Are lanyards as guilty as ties? — felt that the former were more of a hazard because they are in direct contact with the user’s skin where their tunic has no collar and are unlikely ever to be washed.) "The reason people are picking on ties is they tend not to go into the laundry. If you took them home and washed them the way you do your shirt, there wouldn't be any problem." (Obviously Dr. McGeer has not seen what happens to a pure silk jacquard weave Charvet cravat after being thrown into a washing machine.) It is not clear if anyone has the authority to ban ties from Canadian hospitals. Dr. Zoutman said that CHICA, an organization that represents about 1,200 infection control practitioners in Canada, needs to discuss the developments in Britain.

The controversy has certainly generated interest (4,5,8,11,12,14,15,17,23). Will anyone miss the necktie? As Oscar Wilde observed, "A well-tied tie is the first serious step in life." As an emblem of accomplishment for the upper-class professional male, it will not go quietly. Half of all neckties are purchased by women, according to a Forbes report. So both sexes are responsible for the persistence of this centuries-old carotid constrictor. But after the Beau Brummels and the four-in-hands of the last two hundred years, the belly-warmers and palm-bestrewed horrors of the 1940s, the shagadelic eyesores of the 1960s and 70s, surely the time has come for cravat harm reduction. This seemingly innocent rag has already been shown to contribute to intracranial pressure and glaucoma (2,9,19,20). Now we know that the necktie is a disease carrier too. The current fashion for ties that are long, pink and extremely bloated reflects either very bad taste or unsavoury phallic fixation. There is now a website that sells The Tie Thing, a washable tie restraint that the vendor claims will "keep potentially infectious ties from falling into places they should not." The SafetyTie is an anitmicrobial, stain-resistant necktie for use in the clinical setting. Can we expect to see condoms for ties in the near future?

Quoth the raven, 'Nevermore.'
It is unlikely that its suppression in a few hospitals will affect the universal domination of the Western cravat. However one looks at it, there is no denying its extraordinary endurance and proliferation around the world. This I would attribute not to some intrinsic beauty or comfort, but rather to its close association with power, particularly male power, in our culture. The symbolic significance of the necktie cannot be overstated. Not unlike the barbaric display of clan colours, it is at once a mark of personal style and a sign of belonging to — or at least aspiring to membership in — the ruling class.

Bakunin foresaw that attaining universal suffrage without an accompanying social revolution prevented ordinary people from achieving their freedom. Instead it forced the ruling elites to make their own depravity universal. The theme is pursued by Theodor Adorno in his Minima moralia: "This is the state to which the ruling consciousness has come — the shameless avowals of the pursuit of extravagant waste and champagne-sipping good times, which were previously the preserve of bemedalled attachés in Hungarian operettas, are now elevated in deadly earnest to a maxim of right living." Hence our tawdry universe of easy money and bored, vicious distraction: voodoo mortgages, video addiction, ridiculous spectacle, mall-formation, and manipulable political apathy. Hence also the snobbery and pitiless conformism of tight cravats and high heels, lavish vacations, real estate, oenophilia, food fads, and, worst of all, liposuction.

The discomfort of the necktie, or the girdle, as a form of attire, is its very significance. As with snaffle bits and hackamores, light but continuous pressure is applied to a region of the body — a constant reminder of your place in the social hierarchy. Are not such functionless clothing items really just tired symbols that are better undone? The cravat when your luck is good: the slipknot when luck runs out. Perhaps we can hope that the hospital ban on the necktie might be extended to other areas, like the increasing restrictions on smoking. We have had great success undermining the noisome reign of tobacco; and gone are the awful stays, bustles and petticoats once imposed on women. Will the cravat's mystique finally be unravelled? Now there's something to take aim at.

Clothes make the man. Naked people have little or no influence on society. ~ Mark Twain

Dress is at all times a frivolous distinction, and excessive solicitude about it often destroys its own aim. ~ Jane Austen



REFERENCES:

1. The traditional white coat: goodbye, or au revoir? Lancet 2007 Sep 29;370(9593):1102.

2. Tight neckties may increase risk of glaucoma. Geriatr. Aging 2003;6(8):11.

3. Candlin J, Stark S. Plastic apron wear during direct patient care. Nurs.Stand. 2005 Sep 21-27;20(2):41-46

AIM: To identify factors that influence nurses' practice in apron use during direct patient care. METHOD: A small-scale documentary analysis of a purposive sample of 15 journal articles relating to nurses' apron use during patient care was undertaken. The analysis sought to address what factors affect nurses' decisions in relation to apron use. FINDINGS: Nurses' decisions regarding apron use during patient care tend to be ritualistic rather than evidence-based. Their knowledge of infection control is limited. CONCLUSION: Although there is current literature available on infection control, as well as health and safety regulations, if local policy regarding apron use in nursing care is scant this can result in inconsistent and, perhaps, less desirable practices.

4. Day M. Doctors are told to ditch "disease spreading" neckties. BMJ 2006;332(7539):442.

5. Ditchburn I. Should doctors wear ties? J.Hosp.Infect. 2006 Jun;63(2):227-228.

6. Dixon M. Neck ties as vectors for nosocomial infection. Intensive Care Med. 2000 Feb;26(2):250.

This study assessed whether neck ties worn by doctors at an intensive care unit were potential vectors for infection. Heavy growths of coagulase negative staphylococcus on 2/5 ties tested suggest this is possible. Neck ties should be considered a significant potential source of infection. Although this risk can be lessened by wearing plastic aprons when we come into contact with patients maybe we should do without neck ties altogether in critical care areas.

7. Gerken A, Cavanagh S,Winner HI. Infection hazard from stethoscopes in hospital. Lancet. 1972 1/2 i:1214-1215.

8. Jameson M. Dirty ties. Br.J.Perioper.Nurs. 2004 Aug;14(8):332.

9. Jonas JB, Theelen T, Meulendijks CFM. Tight necktie, intraocular pressure, and intracranial pressure [19] (multiple letters). Br. J. Ophthalmol. 2005;89(6):786-787.

10. Loh W, Ng VV, Holton J. Bacterial flora on the white coats of medical students. J.Hosp.Infect. 2000 May;45(1):65-68

This study has demonstrated that the white coats of medical students are more likely to be bacteriologically contaminated at points of frequent contact, such as the sleeve and pocket. The organisms identified were principally skin commensals including Staphylococcus aureus. The cleanliness of the coat as perceived by the student was correlated with bacteriological contamination, yet despite this, a significant proportion of students only laundered their coats occassionally. This study supports the view that the students' white coat is a potential source of cross infection on the ward and its design should be modified in order to facilitate hand washing. Hospitals training medical students should consider taking on the burden of providing freshly laundered white coats for the students.

11. Lomas C. Is your uniform harbouring infection? Nurs.Times 2007 Oct 9-15;103(41):20-21.

12. Magos A, Maclean A, Baker D, Goddard N, Ogunbiyi O. Bare below the elbows: A cheap soundbite. BMJ 2007 Oct 6;335(7622):684.

13. Nurkin S. Is the clinician's necktie a potential fomite for hospital acquired infections? 104th General Meeting of the American Society for Microbiology 2004.

14. Nye KJ, Leggett VA, Watterson L. Provision and decontamination of uniforms in the NHS. Nurs.Stand. 2005 Apr 27-May 3;19(33):41-45

AIM: To ascertain the provision and decontamination of uniforms within a cross-section of NHS trusts in the UK and to compare policies regarding their use. METHOD: A questionnaire was circulated to 170 NHS trust infection control teams in the UK. Eighty-six (51 per cent) responses were received, which represented 101 NHS trusts. RESULTS: Less than half of the trusts (47 per cent) provide adequate numbers of uniforms to allow a clean uniform per shift. Only 26 per cent had adequate on-site staff changing facilities and 65 per cent did not launder uniforms. The majority of nursing staff (91 per cent) were compelled, by a combination of these factors, to launder their uniforms at home. Few were provided with any guidance on how to do this safely. CONCLUSION: There is an urgent need for minimum standards to be set for the provision of uniforms, laundering and changing facilities, to minimise the potential for spread of healthcare-associated infections.

15. Shintani H, Hayashi F, Sakakibara Y, Kurosu S, Miki A, Furukawa T. Relationship between the contamination of the nurse's caps and their period of use in terms of microorganism numbers. Biocontrol Sci. 2006 Mar;11(1):11-16

Nosocomial infections are a great problem in the health care facilities. The white uniforms of nurses are often washed to keep them clean, but the nurse's caps are not washed as frequently in comparison. It could be that the importance of these caps is being overlooked. If these caps are providing a residence for microorganisms causing nosocomial infection in the health care facility, then they should be washed as frequently as the uniforms. So far, the relationship between the contamination of the nurse's caps and nosocomial infection has not yet been studied. Therefore, this study was conducted to confirm if relationships exist among factors regarding the number of microorganisms on the nurse's caps, the period in which caps were used without being washed, and the individual characteristics of nurse wearing the caps. Results showed that the degree of contamination of the nurse's caps depended on individual characteristics and the period of use. Finally, results led to the conclusion that the nurse's caps should not be worn if their only purpose is to symbolize female workers in the health care facilities because, in actually, they provide a resistance for microorganisms causing nosocomial infections.

16. Steinlechner C, Wilding G, Cumberland N. Microbes on ties: do they correlate with wound infection? Ann R Coll Surg Eng 2002, (Suppl) 84(9):307-9.

Many measures are taken to reduce the spread of pathogenic micro-organisms within hospitals, particularly MRSA. It is known that they are transferred by direct contact and that simple measures such as hand washing are highly effective in reducing spread. Many woven fabric items within hospitals have been shown to carry pathogens; the possibility of resultant wound infections cannot be ignored and unnecessary potential vectors should be eliminated. Infection in orthopaedic patients is a disaster which may lead to implant removal and multiple surgical procedures. We tested the ties of our orthopaedic department for pathogenic organism carriage and found that all ties were colonised by bacteria that are frequently cultured from swabs taken from discharging wounds of orthopaedic patients.

17. Sundeep S, Allen KD. An audit of the dress code for hospital medical staff. J.Hosp.Infect. 2006 Sep;64(1):92-93.

18. Takashima M, Shirai F, Sageshima M, Ikeda N, Okamoto Y, Dohi Y. Distinctive bacteria-binding property of cloth materials. Am.J.Infect.Control 2004 Feb;32(1):27-30

BACKGROUND: Nosocomial infections may be caused by pathogens that are transmitted from the hands or clothes of hospital personnel. Handwashing has been evaluated as effective against the spread of pathogens, but transmission through clothes has been little investigated. Evaluation of bacterial adherence to clothes is difficult because of the nonuniform amount of water absorbance by cloth. Therefore, we measured binding of bacteria to cloth fibers made of cotton, nylon, polyester, acrylic, or sheep's wool and tried to characterize bacterial binding to cloth. METHODS: We chose to study the opportunistic pathogens Staphylococcus aureus and Pseudomonas aeruginosa. Cloth fibers were incubated with bacterial suspensions in silicone-coated tubes. We evaluated the reduction of numbers of bacteria in solutions incubated with the fibers and calculated binding ratios of bacteria to the fibers. RESULTS: Polyester or acrylic fibers bound S aureus and P aeruginosa at high ratios (>80%), but cotton fibers bound them at low ratios (<10%). Nylon fibers bound S aureus at low ratios, but P aeruginosa at intermediate ratios. CONCLUSION: The results suggested that polyester, acrylic, or wool clothes could be good carriers of S aureus and P aeruginosa and thus should be covered with cotton clothes to minimize the spread of the pathogens.

19. Tally P, O'Brien PD. Does extended wear of a tight necktie cause raised intraocular pressure? J. Glaucoma 2005;14(6):508-510

20. Teng C, Gurses-Ozden R, Liebmann JM, Tello C, Ritch R. Effect of a tight necktie on intraocular pressure. Br. J. Ophthalmol. 2003;87(8):946-948

21. Waghorn DJ. Stethoscopes: a study of contamination and the effectiveness of disinfection procedures. British Journal of Infection Control. 2005;6(1):15-17

Stethoscopes are universally used by healthcare professionals. They can come into contact with numerous patients and may harbour organisms that can be transferred between individuals. Wycombe hospital has a policy that stethoscopes should be disinfected with a 70% isopropyl alcohol swab after each patient use. A study was undertaken to assess the degree of stethoscope contamination and the effectiveness of the disinfection procedure. A randomly chosen group of healthcare professionals submitted their stethoscopes for microbiological analysis. A selection of ward-based stethoscopes were also tested. Personal stethoscopes were then disinfected with an alcohol wipe and re-sampled. All stethoscopes showed bacterial contamination before disinfection, the highest concentration of organisms being seen on doctors' stethoscopes. Skin flora was grown from all samples and 12% grew Staphylococcus aureus. Following decontamination, bacterial levels were greatly reduced, but three contaminated stethoscopes remained heavily colonised even after the disinfection procedure. Staff need to be made more aware of the need to routinely disinfect stethoscopes correctly between each patient use. The increased placement of bed- or ward-specific stethoscopes needs to be considered.

22. Ward DJ. Hand adornment and infection control. Br.J.Nurs. 2007 Jun 14-27;16(11):654-656

Studies have shown that despite infection control guidelines recommending that false fingernails, nail varnish, stoned rings and wrist watches not be worn by clinical staff, a large proportion of them continue to do so. Hand jewellery and false finger nails should be kept short, clean and free from nail polish. This article discusses the bacterial carriage, contributions to outbreaks of infection and interference with proper hand hygiene practices, thereby explaining why these recommendations are made in infection control policies and guidelines.

23. Wilson JA, Loveday HP, Hoffman PN, Pratt RJ. Uniform: an evidence review of the microbiological significance of uniforms and uniform policy in the prevention and control of healthcare-associated infections. Report to the Department of Health (England). J.Hosp.Infect. 2007 Aug;66(4):301-307

A systematic search and quality assessment of published literature was conducted to establish current knowledge on the role of healthcare workers uniforms' as vehicles for the transfer of healthcare-associated infections. This review comprised a systematic search of national and international guidance, published literature and data on recent advances in laundry technology and processes. We found only a small number of relevant studies that provided limited evidence directly related to the decontamination of uniforms. Studies concerning domestic laundry processes are small scale and largely observational. Current practice and guidance for laundering uniforms is extrapolated from studies of industrial hospital linen processing. Healthcare workers' uniforms, including white coats, become progressively contaminated in use with bacteria of low pathogenicity from the wearer and of mixed pathogenicity from the clinical environment and patients. The hypothesis that uniforms/clothing could be a vehicle for the transmission of infections is not supported by existing evidence. All components of the laundering process contribute to the removal or killing of micro-organisms on fabric. There is no robust evidence of a difference in efficacy of decontamination of uniforms/clothing between industrial and domestic laundry processes, or that the home laundering of uniforms provides inadequate decontamination.

RNAO defends the Canadian Health Network

The Registered Nurses' Association of Ontario has issued a strong statement criticizing the federal government for its announced closure this March of the Canadian Health Network.

In its undated "Action Alert" the RNAO states:

[The CHN] is a trusted service that Ontarians use daily to help navigate an overwhelming amount of conflicting opinion and marketing on the web to get to evidence to inform health and health-care decisions.

Health professionals make up 39 per cent of visitors, with nurses compromising the largest segment of health professional users at 14 per cent. The closure of CHN will mean the loss of a health education tool that nurses find invaluable for our nursing practice.

At a more systemic level, we find it unfathomable that the federal government would decimate a trusted resource that has taken eight years to build up in order to save $7 million just as the final surplus for the 2006-2007 fiscal year was $13.8 billion.

RNAO has sent an open letter to the Minister of Health and urges nurses and everyone concerned to do the same, providing a sample letter for the public, which can be sent via the RNAO website.

Go nurses!

Ask the rubber librarian: what happens to condoms in a cold snap?

Talk of your cold! through the parka's fold it stabbed like a driven nail.
— Robert Service, The Cremation of Sam McGee

It's a bit of a stretch calling myself a rubber librarian, although I feel I can make some modest claim to the title. As a student I once endured an excruciating presentation on "Rubber Librarianship" given with a straight face by the corporate librarian at Goodyear, who was so completely devoid of a sense of humour that she banged on in earnest about "rubber research" and "rubber bibliography" over the unsuppressible tittering of my classmates. As fate would have it, I now find myself acting as the unofficial information specialist for Winnipeg public health workers; so I have to know the latest on latex and other prophylactic materials. One has to be flexible you know. Last August a by-the-way question led me to a lengthy search on the efficacy of plastic wrap for oral sex. The outcome? It isn't and you probably shouldn't, but it's better than nothing, especially if you're in prison. Last week I was given another stumper: Do condoms retain their integrity when shipped or stored in extremely cold temperatures?

This is not a frivolous question. This is Winnipeg in wintertime. Like Bratsk, Irkutsk and Krasnoyarsk, Winnipeg is in the running to be The World's Coldest City. This year I think we're winning. Plunked down on flat parkland at the edge of the boreal vastness, we are a congealed place of block heaters and balaclavas, frost bite and flannel sheets. For nearly a month now we have experienced what is appropriately called an "Arctic outbreak," a dome of fiercely frigid air that squats on the middle of North America like an invisible glacier. The result: intense cold — blubber-cracking, tooth-splitting cold. The slightest breeze is a scimitar slicing through the sinuses, trees crack like gunfire, and the hard snow crunches loudly underfoot. Similes and metaphors barely suffice: So cold the wolves are eating the sheep just for the wool. Cold as a sled-dog's snout. Cold as a cocked trigger. Cold as a cruise missile. Cold as a bailiff's heart. A cold so brutal the liquid crystal displays on parking metres wink out, neon signs fade to a sickly glimmer, iPods sputter and die, and cars start, if they start at all, with a juddering, cranking lurch. Even teenagers are known to zip up their jackets and thrust their hands further into their jeans.

So when we ask about the viability of condoms stored in sub-zero temperatures we're not just whistling Dixie. They are still our best defence against STIs. If leaving condoms in the cold degrades their quality, this is something people should know about. So I started my rubber literature search confident that the answer was out there. Unfortunately, like my fruitless investigations into cling wrap, I found virtually nothing on my topic. I pressed on, plumbing the depths of dube-ology, with little to show for it.

There was much technical analysis of the viscoelastic properties of polymers, time-temperature superposition, inspissation, diffusion-limited oxidation, thermogravimetry, Arrhenius behaviour, degradation parameters, tensile elongation, modulus, density, and decay compressive force. In these forbidding thickets of jargon I think I gained a basic understanding that extreme temperatures are bad for condoms, as is air, especially polluted air (3). Condoms should be packaged in impermeable, flexible aluminium foil packaging with a recommended minimum thickness of 8 micrometres (6,9). There are several studies on condom storage in excessive heat (1,2,5,6,7). Research has demonstrated, so says the World Health Organization, that properly packaged, good-quality condoms do not deteriorate when stored at average temperatures found in tropical climates. Air conditioning is not necessary if the condoms are properly packaged and stored in a clean, dry, well-ventilated environment. They must not come into contact with oil, petrol, water or ultraviolet light (9).

About condoms in the cold, however, the literature is silent, except for a 16-year-old article in German on the safety of condoms in outdoor vending machines (4), which I have not been able to obtain. Even if it turns up, I can't be sure its findings would be relevant to the daunting conditions of a Canadian winter. The best that authorities can say is that research is continuing to find better ways to predict accurately the stability of a condom as it ages (8).

Chapter 5 of the online monograph on latex condoms by McNeill et al. (8) offers a useful description of how variations in temperature might affect condoms:

Latex rubber is known as a "viscoelastic" material; i.e., it has a "viscous" or damping component and an "elastic" or springy component. . . . The response of these components changes with the frequency of vibration and with temperature. For example, the children's toy called Silly Putty, which is a silicone rubber, becomes solid if it is very cold but flows under its own weight in a warm room. If pulled quickly, it fractures; if pulled slowly, it stretches. Analogous phenomena occur in latex rubber.

In Winterpeg, in a cold snap, no one in their right mind is going to try playing with Silly Putty outside. The same goes for condoms. But if you watch the cars creeping through the freezing exhaust fog at Portage and Main, you can bet that many of them will have a few condoms stashed in the glove compartment. Probably not a good idea. But having diligently applied all my rubber learning to the matter of how condoms fare in extreme cold, I regret to say I can produce little more than a few undocumented warnings. Canadiancondom.com advises against prolonged storage of its products in temperatures above or below 15-30 degrees Celsius. Similar instructions can be found on manufacturers' websites and on packages on the store shelf. Here is a piece of advice from Go Ask Alice:

Question: I'm not wrong when I say condoms can freeze, right? I had some condoms in my car when the temperature outside was definitely below freezing. They were only out in the cold for about thirty minutes. Would it be safe to still use them? Or, should I discard the condoms and get new ones. The box says to keep it below 100-degree temperature, but doesn't say anything about keeping them above a certain temperature. Safe or not?

Answer: The condoms in your car are probably okay to use considering the brief period of time (thirty minutes) they were out in the freezing cold. For longer-term condom storage, keep them in a regulated and constant environment. Ideally, condoms need to be kept in a cool, dry storage space, and away from direct sunlight, to prevent deterioration. Think of certain fruits and vegetables — once they are frozen or cooked, their texture and consistency are permanently changed. The same holds true for condoms. If they've been exposed to a very cold or a very hot climate long enough to freeze or heat up, then cut them in half (so that no one else can use them) and throw them away. Why? After spending a considerable amount of time in these temperature extremes, latex can become brittle, weakening it as a form of adequate protection against pregnancy and most sexually transmitted diseases (STDs). When warmed up or cooled down to room temperature, even if they look okay, these condoms will be less resilient and effective than before.

So take it from Alice: don't hide your condoms in the freezer, under the hookah in the back porch, or in your glove compartment during a Winnipeg winter.

In a frosty December on the Canadian Prairies you can almost feel the planet's uncaring tilt away from warmth. The poor sun can barely lift itself past eye level before dropping out of sight behind smoking chimneys and brittle trees. The remorseless winds empty out the streets, leaving only hunched smokers shivering and stomping in doorways. During this festive time of tipsy indiscretions at office parties and family fisticuffs over the placement of decorations, Winnipeggers brave the unreal cold to go shopping, elbowing their way through hangar-sized emporiums for trinkets and treats, while the latest tattooed crooner roasts chestnuts from scratchy loudspeakers. In one of these mega-stores — was it Krazy Keester's, or Frostco, or The Haggle Hutch? — I attracted not a few cold stares as I rummaged through condom packages squinting at the storage instructions. The rubber librarian gets no respect.


References:

1. Bo MC, Gerofi PJ, Visconte LLY, Nunes RCR. Prediction of shelf life of natural rubber male condoms—a necessity. Polymer testing. 2007 May;26(3):306-14.

2. Bo MC, Lopes L, Visconte LLY, Nunes RCR. Thermal degradation of natural rubber male condoms. Macromolecular symposia, 245-246. 2006:668-76.

3. Clark LJ, Sherwin RP, Baker RF. Latex condom deterioration accelerated by environmental factors: I. Ozone. Contraception 1989 Mar;39(3):245-51

4. Dahmen HG. [Storage and safety of condoms with reference to the effect of high and low temperatures—dispensers in the open]. Lagerfähigkeit und Sicherheit von Kondomen im Hinblick auf die Einwirkung hoher und niedriger Temperaturen - Automaten im Freien. Offentl Gesundheitswes. 1991 Feb;53(2):97-8. [Note: Article in German. The title as translated in the Scopus database has "outside slot machines" instead of "dispensers in the open." The term should be translated as "outdoor vending machines." I was unable to review the text of this article.]

5. Free MJ, Srisamang V, Vail J, Mercer D, Kotz R, Marlowe DE. Latex rubber condoms: predicting and extending shelf life. Contraception 1996 Apr;53(4):221-9

6. Free MJ, Hutchings J, Lubis F, Natakusumah R. An assessment of burst strength distribution data for monitoring quality of condom stocks in developing countries. Contraception 1986 Mar;33(3):285-99

7. Guigon P, Breton D, Mendes-Oustric AC, Pech A, Clair P. [In vitro studies of factors possibly influencing the performance of latex condoms]. Etude en laboratoire de facteurs pouvant influencer la qualité des préservatifs masculins. Med Trop (Mars) 2005 Nov;65(6):575-9

8. McNeill ET, et al. The Latex Condom: Recent Advances, Future Directions [Internet]. Family Health International; 2006. [cited 8 Dec 2007]. Available from: http://fhi.org/en/RH/Pubs/booksReports/latexcondom/index.htm

9. World Health Organization. The male latex condom: specification and guidelines for condom procurement : 2003. Geneva: Dept. of Reproductive Health and Research, Family and Community Health, World Health Organization; 2004.

The "Ah, Tennyson" moment and the postmodern professional

As a young man Alfred Tennyson was afflicted with a painful attack of piles. Accepting advice, he visited a youthful but well-known proctologist and was so successfully treated that for many years he had no further trouble. However, after he had become a famous poet and had been raised to the peerage, he suffered a further attack. Revisiting the proctologist, he expected to be recognized as the former patient who had become the Poet Laureate. The proctologist, however, gave no signs of recognition. It was only when the noble lord had bent over for examination that the proctologist exclaimed, "Ah, Tennyson."

I treasure this little anecdote, not only because it pokes wry fun at poets and proctologists alike, but because, parable-like, it illustrates a truth about the human condition. Part of its humour arises out of the absurdity that the clinician's concentration on his work should be so complete as to preclude his recognizing the great poet until the baronial drawers have been lowered. There is also, of course, the universal human delight in scatological jokes — the more irreverent the better, since everyone, even an aristocrat, has to sit on the throne.

But there is more to it than that. Implicit in this compelling but elusive narrative is a sense of how blind we can be to anything but the piles of work before and behind us, and how neglectful of the clamouring realities staring us in the face. We may laugh at the single-mindedness of Tennyson's doctor, but librarians are no exception. Squirrelling away at technology, too busy to think, obsessed with getting to the bottom of our own specialties, we suffer a sort of mental constipation, thinking that what we do is an end in itself while we miss the obvious. We are all guilty of this. Librarians can be as heedless as the most absent-minded of professionals.

The impending demise of Canada's leading consumer health information website gave me the opportunity to reflect again on professional short-sightedness and anal-retentiveness. What should librarians, particularly health librarians, think about the motivations and predilections behind the Conservative government's decision to cut funding for the Canadian Health Network? "Conservative" hardly seems to be the appropriate word for what is at work in Ottawa. Au contraire, axing CHN is just one part of a broader, quite radical set of imperatives, it seems to me. As Carol Goar puts it in the very first sentence of her Toronto Star article of November 16, "This is how a nation's social infrastructure is dismantled."

What should we do? Simply wring our hands, adjust our blinkers, and continue working on our promotion? Even the bureaucrats were fumbling for excuses. Shutting down the network was a "very difficult decision," said Alain Desroches of the Public Health Agency. "The agency will continue to look for effective and innovative ways to provide Canadians with high quality, credible information through other means." What, pray tell, might those other means be? Given a government whose primary affinity is with the catechisms of the market, I think we know what to expect.

In fact, Health Minister Tony Clement launched a new website, Healthy Canadians, in October, to provide users with "easy access to Government of Canada health-related promotional campaigns" — the government's children's fitness tax credit, its revised Canada Food Guide, its toy safety tips, its latest product recalls, and its healthy pregnancy guide — all designed to promote the government's vision of what constitutes an active, well-balanced lifestyle. Pregnancy OK, the kind of sex that doesn't result in pregnancy unmentionable. The website looks more like an election ad than a serious source of information for the general public, a feel-good exercise that has been hastily thrown together. What's being promoted is not health but the government itself. This reminds me of the ridiculously widespread use by television networks of the "coming up" promotional advertisement. In addition to being subjected to their incessant commercials, we now must endure frequent and detailed announcements of what they will be telling us later, to the point that a program like CNN news feels like one long advertisement for itself, punctuated regularly by lengthy advertisements for corporations which then finance CNN's own self-promotion. Lost in the midst of this tiresome cycle, this hollow, echoing Lotos-land, is any sense of what is actually occurring in the real world.

The centralization of health information in one place is a good thing. That was the vision behind the Canadian Health Network. Healthy Canadians is something different. As Carol Goar remarks, "What's missing from the new database is any reference to the links between health and the environment, disease and poverty, or violence and gun control. Nor does it touch sensitive topics such as abortion, genetically modified foods or sexual abuse. It completely overlooks mental illness. In contrast, the Canadian Health Network is all-encompassing. It looks at controversial questions from all sides. It is constantly updated as new knowledge becomes available."

What will happen after all the effort put into CHN? Inevitably we are drawn to rationalizing. Losing the program won't be the end of the world. Sad, but true. Canadians will make use, as they already do, of the rich resources of MedlinePlus from the United States and the multitudes of consumer health websites in many languages that have emerged on the web. The CHN contributors and sustainers will find other ways to reach their audiences. Somehow we'll cope. But here is the heart of the issue. Carol Goar again: "[T]he idea of a comprehensive, national database, built and maintained by the best people in their fields will wither. The belief that Canadians can work together, with the government providing a common forum, will wane. A promising experiment will die. And the government will look for another non-essential program to cut."

As information providers (and supposedly civilization's guardians), librarians are caught up willy-nilly in this ongoing ideological demolition job. Libraries, as a vital part of the civic commons, are not immune to the kind of calculation that is likely to erase the Canadian Health Network. It has been said, tongue lodged firmly in cheek, that nothing is so useless as a general maxim. But let me propose a new axiom that seems to me as firmly based as the laws of thermodynamics. Postmodernism is now driving politics as surely as the desert wind is dry. We are sliding into the postmodern, post-civil world; we're already there actually, but the process is so subtle that, like desertification in the Sahel, we see what's happening only with hindsight.

However, alternatives are still possible. Nothing is completely foreordained. Needless to say, there are many in this country who do not approve of this or other actions of the government that threaten the public good. The "Friends of CHN" have formed, one of their first initiatives being to start a petition, both in English and in French, demanding that the Canadian Health Network's funding cut be rescinded, and that full, stable funding be restored immediately to allow the program to become the kind of national resource it was meant to be. Letters are being addressed to the Prime Minister and the Minister of Health, people are organizing, bloggers are commenting. But librarians need to do more. So far both the Canadian Library Association and the Canadian Health Libraries Association have been silent. I hope to see some mention of this issue appearing on their websites soon.

To many, what is happening with the Canadian Health Network may seem of little consequence. "Let it go," they'll say. "The market will see to our needs. For that matter, let libraries go as well. Don't we have Web 2.0?" To such a glib proposal I would reply in this way. Once the foundations of the civic commons are removed, stone by stone, in a long process of disintegration of which the quiet removal of CHN is just one episode, there will be little left to remind us of the public polity that was. It will have been replaced by another, less polite, reality. Libraries are not exempt from this process. The new facts on the ground, the only essentials, will be commercial ones, such that culture will have become coextensive with the economy, and consumption will have successfully made itself into an immutable law. Civil society, in my apocalyptic vision, thus undergoes a slow dissolution into a wide-open commercial sphere, a jagged, desolate no-man's-land of receding equality, plutocratic machination, anonymous marauding, and deregulated violence — all garishly backlit by vacuous spectacle, the saturating ubiquity of wall-to-wall ideology. Think of the dystopian science fiction of William Gibson. In this new cultural logic, as Fredric Jameson has maintained, Utopia's deepest subject thus turns out to be precisely our inability to conceive it, our incapacity to produce it as a vision, our failure to imagine what could be. Alternatives become unthinkable. Life becomes, in Adorno's words, the ideology of its own absence.

As the Social Justice Librarian puts it:

When a pro-privatization government cuts national funding to social infrastructure and, at the same time, turns a blind (or at least feeble) eye to corporate challenges to public health and social policy regulations … well, I guess that’s where all that information literacy training we librarians are always pushing comes in. Because health information with a profit-motive is clearly not in the public interest. But without a not-for-profit health education, will we recognize it when we see it?

Speaking of the unthinkable, in her new book, The shock doctrine: the rise of disaster capitalism, Naomi Klein offers a revealing anecdote about her experience at a New Orleans hospital in the aftermath of Hurricane Katrina. A car accident leaves her with minor, but painful, injuries. Conveyed by ambulance to Ochsner Medical Center, "the most modern and calm hospital I have ever been in," Klein receives courteous and comprehensive care. She is amazed by the immaculateness of the wards and the quiet efficiency of the staff:

To a veteran of the Canadian public health care system, these were wholly unfamiliar experiences; I usually wait for forty minutes to see my general practitioner. And this was downtown New Orleans — ground zero of the largest public health emergency in recent U.S. history. A polite administrator came into my room and explained that "in America we pay for health care. I am so sorry, dear — it's really terrible. We wish we had your system. Just fill out this form." (p. 489)

Klein strikes up a conversation with an intern who has kindly slipped her some painkillers since the hospital pharmacy is locked up tight for fear of looters. From him she learns that the Charity Hospital, which serves the city's poor, has been heavily damaged. Then comes the "Ah, Tennyson" moment. "They'd better reopen it," the intern says. "We can't treat those people here." Klein comments:

It occurred to me that this affable young doctor, and the spa-like medical care I had just received, were the embodiment of the culture that had made the horrors of Hurricane Katrina possible, the culture that had left New Orleans' poorest residents to drown. As a graduate of a private medical school and then an intern at a private hospital, he had been trained simply not to see New Orleans turned into a giant emergency room: he had sympathy for the evacuees, but that didn't change the fact that he still could not see them as potential patients of his. (p. 490)

It is this inability to "see" something so obvious to others which, for me, characterizes the blinkered postmodern professional. We have here a terrible disconnect between practice and politics. Here is a promising young physician who cannot, or will not, allow himself to think through unacceptable social conditions, who is content, like Tennyson's proctologist, to focus on what he has been programmed to do while missing the obvious — and losing all the compassionate poetry of life. How many librarians, how many health librarians, are also without eyes to see? In what Lotos-land do we live and lie reclined, careless of mankind, attending only to our objects of professional interest? When shall we have our next "Ah, Tennyson" moment?

The Lotos blooms below the barren peak:
The Lotos blows by every winding creek:
All day the wind breathes low with mellower tone:
Thro' every hollow cave and alley lone
Round and round the spicy downs the yellow Lotos-dust is blown.
We have had enough of action, and of motion we,
Roll'd to starboard, roll'd to larboard, when the surge was seething free,
Where the wallowing monster spouted his foam-fountains in the sea.
Let us swear an oath, and keep it with an equal mind,
In the hollow Lotos-land to live and lie reclined
On the hills like Gods together, careless of mankind.

Alfred Lord Tennyson, from The Lotos-Eaters: Choric Song