Wind Ensemble Infectious Disease Risks:A Microbiological Examination of Water Key 

Liquids in Brass Instruments

Cynthia Bridges, PhDChair, Department of Music

Del Mar CollegeCorpus Christi, Texas

James Mobley, MD, MPHMedical Arts ClinicPortland, Texas

Speaker Disclosure

• Dr. Mobley has disclosed that he has no actual or potential conflict of interest in relation to this topic.

Goals and Objectives

By the end of this activity, the participant will be better able to: 1. Determine if there are disease risks associated with wind 

instrument fluid releases.2. Be familiar with bacteria found in wind instruments.3. Be able to determine the ways to address wind ensemble 

medical conditions.

The Question

Clinical Case

• The parent of a junior high clarinet player comes to  you.  Her daughter has cystic fibrosis and plays clarinet in the band.  Her daughter reports that the trumpet players sitting behind her empty their spit valves on the floor behind her chair.

• She asks you if she should be concerned about possible infections from the released liquids.  

Question

Is the liquid stuff dripping from band instruments onto rehearsal hall floors:

1. Saliva2. Liquid condensate from exhaled moisture3. Some of both

Study Questions

• Does fluid released from water keys contain oral bacteria?

• Does fluid released from water keys pose an infection risk?

Study Design  

• Descriptive ecologic study• Culture swabs taken from the water keys of brass instruments

– Trumpet– Trombone– Euphonium  (AKA Baritone)– Tuba– French Horn

Study Design• Del Mar College Wind Ensemble

– Ages 18‐25

• Veterans Band of Corpus Christi– Ages 65 – 90

Study Design

Instruments

4

4

7

12

3 EuphoniumFrench HornTromboneTrumpetTuba

Total: 30 samples

Bacterial Types

23

1

2

11

2

4

1 2

Alcaligenes faecalis

Alpha streptococcus species

Bacillus Species not B. anthracis

Citrobacter koseri

Gram negative bacilli

No Growth

Normal respiratory flora

Staphylococcus aureus

Streptococcus viridans

Alcaligenes faecalis

Alcaligenes faecalis

• Environmental microbe found in soil and water• High moisture environments in hospitals• Not usually a pathogen, but….• Associated with 

– Eye infections– Cystic fibrosis patients– Severely ill hospital patients

CONCLUSION 1

• The liquid from water keys is mostly condensate, not saliva.

CONCLUSION 2

• The liquid from water keys does not pose a health hazard to musicians with normal immune systems.  

BANDS ARE UNIQUE

• Bands are highly inclusive and diversified.  

• Students with mental, physical or emotional disabilities can participate in band.

• Most band students are healthy.

• There may be situations in which players would need to exercise care to prevent the spread of infections.  

A Word from Our Sponsors

There are no outbreaks of infections in bands recorded by the Department of State Health Services or the Centers for Disease Control.

What’s Next?

• Woodwind study (TPHJ 68:4  Fall 2016)• Mold study (In progress)

Thank You

PHILIP LAVERE, CHRISTIAN ALCH, JAMAL ISLAM, MDBREAST AND COLORECTAL SURVEILLANCENOVEMBER 1OTH, 2017

Cancer Survivorship Care at UTMB

Disclosures

None I am a medical student

Learning Objectives

By the end of this educational activity, participants should be better able to:1. Discuss and implement surveillance guidelines for cancer survivors in

primary care.

Acknowledgements

Cancer Prevention Institute of Texas (CPRIT) Subcontract from the MD Anderson Cancer Center

Some Elements of Survivorship Care

Primary recurrence, risk for other malignancy Acquired disability & new limitations Lifestyle, environment, genetic factors and overall health Oncologist to PCP transition Guidelines and evidence

ACS Surveillance Guidelines - Breast

H&P Every 3-6 months for first 3 years Every 6-12 months for next 2 years Annual thereafter

Annual mammography Intact breast tissue

No other imaging or labs indicated

ACS Surveillance Guidelines – Colorectal

H&P Every 3-6 months for first two years Every 6 months for years 3-5

Colonoscopy within year 1 Normal repeat in 3 years Advanced adenoma repeat in 1 year

CEA Every 3-6 months for first two years Every 6 months for years 3-5

Chest/abdomen/pelvis CT Annually if high risk

Goal: Improving Survivorship Care at UTMB

Gathered patient information on: Demographics BMI Smoking status Disease appropriate surveillance

Methods ICD codes for all current PCP patients chart review

Breast Cancer Results

109 survivors Average age = 68 ± 11 years old Survival = 10 ± 8 years Diagnosed stage = 1.6 ± 0.7 Smoking: Never – 51% Former – 39% Current – 10%

49%

Breast (continued)

BMI data: Underweight – 2% Normal weight – 26% Overweight – 34% Obese – 34% Morbidly obese – 4%

Mammograms: 63% received adequate surveillance

72%

Colorectal Results

61 survivors Average age = 72 ± 13 years old Survival = 14 ± 10 years Diagnosed stage = 2.2 ± 0.9 Smoking: Never – 62% Former – 26% Current – 12%

38%

Colorectal (continued)

BMI data: Underweight – 8% Normal weight – 23% Overweight – 29% Obese – 38% Morbidly obese – 2%

Colonoscopies: 53% received adequate surveillance

69%

Next Steps, Conclusions

Bottom line: A sub-optimal % of our patients receive guideline appropriate survival care

Next steps: Provider training

UTMB Family medicine grand rounds Lung, prostate surveillance data Dot-phrase in EPIC

Quick search for survivorship information

Question 1

As a rough estimate, how many cancer survivors live in the US?

1. 8 million2. 15 million3. 22 million4. 29 million

Question 2

Annual chest/abdomen/pelvis CT imaging is indicated for a colorectal cancer survivor who had a stage 3 primary cancer

1. True2. False

Question 3

CEA testing is recommended for colorectal survivors only in the first two years after primary treatment

1. True2. False

Question 4

Your patient received a unilateral mastectomy 4 years ago for stage III breast cancer. What surveillance tools are indicated at this time according to ACS guidelines?

1. Annual H&P only2. Annual mammogram with H&P3. Annual mammogram only4. Biannual H&P and mammogram

Question 5

For a non-high risk breast cancer survivor, annual mammograms are sufficient imaging surveillance

1. True2. False

Thank you!

Questions?

Can We Improve Compliance with the Diabetic Foot Exam?

Maria Munoz, MD

Disclosures:

• Dr. Munoz has no actual or potential conflict of interest in relation to this topic.

Learning Objective

By the end of this educational activity, participants should be better able to:1. Describe and utilize the ADA recommendations for Diabetic 

foot exam screenings. 

The Magnitude of the Problem:

• 1.4 million people diagnosed with Type II DM in 2014• 67,000 Diabetes related lower limb amputations per year• one in four amputees may require contralateral or re‐

amputation• CMS PQRS(physician quality reporting system) Measure #163• Annual cost ascribed to diabetic foot disease is estimated to 

be more than $1 billion dollars 

The Solution?

• Provision of Diabetic foot exams

• Patient education• Resident education

Purpose:

• Is UTRGV DHR‐Family residency clinic following the guidelines?

• Educate residents on how to properly perform a Diabetic foot exam

Methods:

Diabetic Bilateral AKA

50

The EHR Intervention:

• A prompt in the General Complaint note in the EHR.

The EHR Intervention:

The Educational Intervention:

• A lecture was given to the residents on how to perform the foot exam along with a discussion of common foot deformities.

• A pre and post‐test was also given to them to measure knowledge.

Pre/Post‐test Results:

0

20

40

60

80

100

120

Resident 1 Resident 2 Resident 3 Resident 4 Resident 5

Pretest Postest

The Educational Intervention:

• MA’s were instructed to have all Diabetic patients remove their shoes and socks 

• A reminder was developed and placed behind the doors to every room

If you have Diabetes, please take off your shoes and  your socks so your Doctor can examine your feet.

Si tiene Diabetes, favor de remover los zapatos y calcetines para que su medico le examine los pies.  

Results:Number of Patients

AvgAge

Gender Avg A1c CFE VFE

Pre‐Intervention

50 53 30%M70%F

8.3% 12% 22%

30 days after 50 53 36%M    64%F

8.6% 24% 16%

60 days after 50 57 38% M    62%F

8.7% 32% 26%

90 daysafter

50 52 40%M60%F

9.2% 28% 20%

Compliance:

12

24

32

28

22

16

26

20

0

5

10

15

20

25

30

35

Pre‐Intervention 30days after 60 days after 90 days after

CFE VFE

Percentage

Discussion:

• Some improvement in compliance with CFE • National average is approx. 40%• Need to continue screening patients• More training of auxiliary staff• Other studies looking at relationship between performance 

of DFE and Diabetic control including development of complications such as Neuropathy, PVD, amputations and patient education.

Acknowledgements:

• UNTHSC Fort Worth‐GCAM Faculty• Dr. Manusov• Dr. Galke

Questions?

• Thank you for your attention!

1. How often should a Comprehensive Foot Exam be performed?

1. Every year2. Every visit3. At the discretion of the physician4. When the patient complains of foot pain.

2. Diabetic foot exams are:

1. Not required by CMS2. Are a MIPS/PQRS measure3. Not reimbursable4. Can only be done by podiatrists

3. How often should visual foot exams be performed?

1. Every year2. Every visit3. More frequently at the discretion of the physician 4. When the patient complains of foot pain.

References:• www.cdc.gov/diabetes/data/statistics/2014StatisticsReport.html• Gregg, E. W., Li, Y., Wang, J., Rios Burrows, N., Ali, M. K., Rolka, D., Geiss, L. Changes in diabetes‐related complications in the 

united states, 1990‐2010. The New England Journal of Medicine, 370(16) 2014: 1514‐23.• Johannesson, Anton, Gert‐Uno Larsson, Nerrolyn Ramstrand, Aleksandra Turkiewicz, et al. "Incidence of Lower‐limb 

Amputation in the Diabetic and Nondiabetic General Population: A 10‐year Population‐based Cohort Study of Initial Unilateral and Contralateral Amputations and Reamputations." Diabetes Care 32.2 (2009): 275‐80.

• Praxel, Theodore A.  “Improving the Efficiency and Effectiveness of Performing the Diabetic Foot Exam.” Journal of Medical Quality 5/2001, Volume 26, Issue 3: pg 193‐199.

• O’Brien, Kevin E; Chandramohan, Vineeth; Nelson, Douglas A, et al. :  “Effect of a Physician ‐directed Educational Campaign on the Performance of Proper Diabetic Foot Exams in an Outpatient Setting.”

• Journal of General Internal Medicine 04/2003, Volume 18, Issue 4, pg 258‐264.• Giogia de Bernardis; Pellefrinie, Fabio, Francisosi, Monica, et al. “Physician Attitudes Toward Foot Care Education and Foot 

Examination and Their Correlation with Patient Practice.”  Diabetes Care 2004  Vol:  27, pg 286‐287.• Boegel, William A “Expert Diabetic Foot Care for the Primary Care Physician.”  Clinical Diabetes, Volume 17, Issue 1  , January 

1999, pg 37.• Szpunar, Susan M;  Minnick, Steven E; Imhoitsemeh, Dako; Saravolatz, Lous D “Improving Foot Examinations in patients with 

Diabetes: A Performance Improvement Continuing Medical Education (PI‐CME) Project.” The Diabetes Educator ,   May 2014, Volume 40, Issue 3  Pages: 281‐289

• Donnelly, Ann; Kommareddi, Prasad; James, Michael; et al “ Intensified Diabetes Care Monitoring and Physician Education:  Impact on Outcomes and Costs of Care.” Disease Management and Health Outcomes 2008, Volume 16, Issue 2, pages 113‐123.

• Bell, Ronny; Arcury, Thomas; Snively, Beverly, et al “Diabetes Foot Self‐Care : Practices in a Rural Triethnic Population.”  The Diabetes Educator,  January/February 2006, Volume 31, no. 1, pg 75‐88.