Archive for May, 2011

Meningitis Update

Monday, May 30, 2011 // Uncategorized

Bacterial Meningitis in the U.S.: An Update

Although immunization programs have reduced the incidence of this disease, the case fatality rate has not declined.   THIS MEANS THAT IF YOU GET THE DISEASE, THE LIKELIHOOD THAT YOU WILL DIE OF IT IS UNCHANGED.

Pediatric immunization programs that include the Haemophilus influenzaetype B and heptavalent protein-polysaccharide pneumococcal conjugate vaccines have substantially reduced the incidence of bacterial meningitis. Now, using data from two surveillance systems of the Emerging Infections Programs Network (Active Bacterial Core surveillance and Foodborne Diseases Active Surveillance Network), researchers have studied trends in bacterial meningitis incidence and epidemiology in the U.S. from 1998 through 2007.

Data from eight surveillance areas (~17.4 million people) were analyzed. Bacterial meningitis was defined as the presence of H. influenzae, Streptococcus pneumoniae, group B Streptococcus, Listeria monocytogenes, or Neisseria meningitidisin cerebrospinal fluid or another normally sterile site in conjunction with a clinical diagnosis of meningitis. These five pathogens were selected because they collectively account for most bacterial meningitis cases in the U.S.

Over the entire study period, 3188 meningitis cases were identified, of which 14.8% were fatal. From 2003 through 2007, 1670 cases were identified, with a 13.0% fatality rate. On the basis of these data, the researchers estimated that 4100 cases and 500 deaths occurred annually in the U.S. during these latter years.

Between 1998 and 2007, the incidence of bacterial meningitis caused by these five pathogens decreased by 31% (95% confidence interval, –33 to –29). The median age of patients increased from 30.3 to 41.9 (P<0.001). The case fatality rate did not change during the surveillance period (15.7% in 1998–1999 and 14.3% in 2006–2007; P=0.51). S. pneumoniae was the predominant pathogen identified (56.9% of cases overall).

Comment: The success of vaccination programs in children is laudable and provides impetus for additional vaccine development, as well as for initiation of such programs in developing countries, where they are often lacking. In addition, novel interventions for the management of bacterial meningitis are desperately needed: The case fatality rate has not improved in years. Until that happens, however, empirical antibiotic therapy that includes coverage for resistant strains of S. pneumoniae should be initiated as early as possible in an effort to reduce morbidity and mortality.

Larry M. Baddour, MD

Published in Journal Watch Infectious Diseases May 25, 2011

Citation(s):

Thigpen MC et al. Bacterial meningitis in the United States, 1998–2007. N Engl J Med 2011 May 26; 364:2016.

ACIP Recommends Meningitis Booster for Teens, Pertussis Booster for Adults

The CDC’s Advisory Committee on Immunization Practices has recommended that teens receive an additional shot of the meningitis vaccine at age 16 and that those between 11 and 64 receive a pertussis booster, the New York Times reports.

The vaccine, which was thought to have been effective for 10 years, is only effective for 5, according to the Times‘s account. In a close vote, the ACIP recommended giving the additional shot, rather than moving the age at first vaccination up to 14 or 15 from the currently recommended age of 11 or 12.

Later yesterday, Reuters reported that the committee recommended that people aged 11 to 64 — as well as people aged 65 and older who are regularly around infants — receive a booster vaccine for diphtheria, tetanus, and pertussis because of an outbreak of nearly 6300 pertussis cases in California. Pertussis is also on the rise elsewhere in the nation. Previously, older adults were not in the target group for vaccination.

LINK(S):

New York Times story (Free)

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Limits of New Screen for Heart Disease

Sunday, May 29, 2011 // Uncategorized

There was a lot of interest in coronary CAT scans when they first became available five or six years ago.  It was exciting to be able to directly vizualize the arteries in patients who were thougth to be at increased risk of heart disease.  If detected early, the disease could be treated to prevent heart attacks.  According to this recent article, early detection doesn’t necessarily affect outcomes. 

HEALTH INDUSTRY

  • MAY 24, 2011
  • Limits of New Screen for Heart Disease

    Less-Invasive Test Prompts More Follow-Up Care But Does Little to Stop Heart Attacks, Study Says

     

    Screening patients for heart disease with a heart-imaging test prompted greater follow-up care but had little to no effect on the number of heart attacks and other cardiovascular events in those patients, a new study found.

    SPL/Photo Researchers

    Image produced in a CCTA, or CT angiography

    HEARTTEST

    HEARTTEST

    Disease Screening, Revisited

     

    • Prostate cancer: Measuring levels of prostate-specific antigen, or PSA, has been shown to detect early-stage cancer in men. But prostate cancer progresses slowly in many cases, and potentially it can be left untreated. The American Cancer Society’s 2010 guidelines recommend against routine testing for prostate cancer. The group said men should discuss PSA testing’s ‘potential benefits and limitations’ with their physician.
    • Breast cancer: In 2009, the U.S. Preventive Services Task Force made the controversial recommendation that most women should start getting mammograms at age 50 rather than age 40, unless they are considered at high risk of developing cancer. It also said most women from ages 50 to 74 could undergo a mammogram every two years rather than annually. The American Cancer Society disagrees and continues to recommend annual mammograms for women age 40 and older.
    • Colon cancer: American Cancer Society guidelines recommend periodic screening in people age 50- plus, including a colonoscopy every 10 years. In 2008, guidelines were updated to include a less-invasive ‘virtual’ colonoscopy, using CT scans and no sedation, every five years.

    Researchers at Johns Hopkins Hospital in Baltimore led the study, which was published online Monday in the Archives of Internal Medicine.

    John McEvoy, a heart specialist at Johns Hopkins Hospital and the lead author, said doctors are looking for “optimum use” of a non-invasive imaging test called coronary computed tomographic angiography, called a CCTA test and also known as CT angiography.

    Researchers wanted to know whether finding plaque buildup at an early stage slows the progression of heart disease and reduce heart attacks in patients who aren’t showing symptoms of heart disease.

    CT angiography is a rapidly growing technology. Michael Lauer, director of the cardiovascular-sciences division at the National Heart, Lung and Blood Institute, wrote in a commentary accompanying the CCTA study, “We cannot simply assume that just because a screening test predicts clinical outcomes, interventions necessarily will prevent them.”

    The study of CCTA screening comes as medical experts are re-evaluating the frequency and usefulness of other types of health screening, including mammographies for women and PSA testing for prostate cancer in men.

    The CCTA test isn’t currently a common screening test for heart disease, and American Heart Association guidelines recommend against such use of it. Still, Dr. Lauer said such use is likely to grow. The test costs from $600 to $1,000 per patient, researchers say.

    Dr. Lauer said the heart, lung and blood institute is funding separate studies of CCTA involving patients with chest pain and other symptoms of heart disease to better define how to use the test.

    For now, most doctors assess risk for coronary heart disease using blood tests to measure cholesterol and other fats in the blood, and then in some cases prescribe medication to lower cholesterol. Imaging tests often are reserved for patients with chest pain or other heart-disease signs.

    In a CCTA test, patients are injected with dye and then undergo a scan, which creates three-dimensional images of the heart and blood vessels. The images show plaque and other deposits that often build up inside blood vessels and can lead to heart attacks and other cardiovascular problems.

    The test differs from a coronary angiogram or a cardiac catheterization, in which a catheter is inserted into a blood vessel in the arm or leg and then guided into the heart to look for blockages or narrowing of blood vessels.

    In contrast, the CCTA scan isn’t invasive, and for that reason some medical experts say it has potential to be widely used for screening healthy patients for heart disease. Some anecdotal evidence suggests such screening is happening and becoming more common.

    The researchers looked at patients who weren’t considered high risk but did exhibit some risk factors for heart disease. Almost all adults over age 50 likely have some plaque in their arteries, he said.

    The study involved 2,000 patients in South Korea with an average age of 50 taking part in a health-screening program. The study compared 1,000 individuals who underwent a CCTA exam with 1,000 who didn’t undergo the test.

    It found 215 patients who underwent the exam had a positive result, meaning they were found to have plaque in their blood vessels. These patients were 10 times as likely to have been sent for an exercise stress test, a nuclear medicine scan or a cardiac catheterization as patients who didn’t have the CCTA test.

    The patients also were three times as likely to be taking a statin medication, and four times as likely to be on aspirin therapy, both designed to lower risk of heart attack.

    After 18 months, the study showed, one person in the CCTA group developed a heart problem known as unstable angina and one person in the non-testing group had a fatal heart attack.

    “Our findings suggest that low-risk patients without symptoms don’t benefit in the short term from knowing whether or not plaque has been detected using CT angiography,” Dr. McEvoy said. “However, their physicians may be inclined to be more aggressive with prescriptions or follow-up tests.”

    Patients would have to be followed for a longer period to look at whether there’s a true difference in heart events and heart-related deaths between the two groups, Dr. McEvoy said.

    Write to Jennifer Corbett Dooren at [email protected]

    The CAT scans are not without risk.  There is significant radiation exposure and often abnormalities of uncertain significance (“incidentalomas”) are detected which may prompt further scans and biopsies which may actually put the patient at risk.

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    Zombie Apocalypse

    Saturday, May 21, 2011 // Uncategorized

    The following is a blogpost on the CDC’s blog which got a lot of publicity.  It was a tongue in cheek plan the was meant to bring attention to emergency preparedness and the CDC’s response to epidemics.  This deals with a hypothetical Zombie epidemic.

    Social Media: Preparedness 101: Zombie Apocalypse

    The following was originally posted on CDC Public Health Matters Blog on May 16th, 2011 by Ali S. Khan.

    Image of zombie

    There are all kinds of emergencies out there that we can prepare for. Take a zombie apocalypse for example. That’s right, I said z-o-m-b-i-e a-p-o-c-a-l-y-p-s-e. You may laugh now, but when it happens you’ll be happy you read this, and hey, maybe you’ll even learn a thing or two about how to prepare for a real emergency.

    A Brief History of Zombies
    We’ve all seen at least one movie about flesh-eating zombies taking over (my personal favorite is Resident EvilExternal Web Site Icon.), but where do zombies come from and why do they love eating brains so much? The word zombie comes from Haitian and New Orleans voodoo origins. Although its meaning has changed slightly over the years, it refers to a human corpse mysteriously reanimated to serve the undead. Through ancient voodoo and folk-lore traditions, shows like the Walking Dead were born.

    Photo: A couple dressed as zombies - Danny Zucco and Sandy Olsson from the movie Grease walking in the annual Toronto Zombie Walk.A couple dressed as zombies – Danny Zucco and Sandy Olsson from the movie Grease walking in the annual Toronto Zombie Walk.

    In movies, shows, and literature, zombies are often depicted as being created by an infectious virus, which is passed on via bites and contact with bodily fluids. Harvard psychiatrist Steven Schoolman wrote a (fictional) medical paper on the zombies presented in Night of the Living Dead and refers to the condition as Ataxic Neurodegenerative Satiety Deficiency Syndrome caused by an infectious agent. The Zombie Survival Guide identifies the cause of zombies as a virus called solanum. Other zombie origins shown in films include radiation from a destroyed NASA Venus probe (as in Night of the Living Dead), as well as mutations of existing conditions such as prions, mad-cow disease, measles and rabies

    The rise of zombies in pop culture has given credence to the idea that a zombie apocalypse could happen. In such a scenario zombies would take over entire countries, roaming city streets eating anything living that got in their way. The proliferation of this idea has led many people to wonder “How do I prepare for a zombie apocalypse?”

    Well, we’re here to answer that question for you, and hopefully share a few tips about preparing for real emergencies too!

    Better Safe than Sorry

    Photo: Some of the supplies for your emergency kit.Some of the supplies for your emergency kit.

    So what do you need to do before zombies…or hurricanes or pandemics for example, actually happen? First of all, you should have an emergency kit in your house. This includes things like water, food, and other supplies to get you through the first couple of days before you can locate a zombie-free refugee camp (or in the event of a natural disaster, it will buy you some time until you are able to make your way to an evacuation shelter or utility lines are restored). Below are a few items you should include in your kit, for a full list visit the CDC Emergency page

    • Water (1 gallon per person per day)
    • Food (stock up on non-perishable items that you eat regularly)
    • Medications (this includes prescription and non-prescription meds)
    • Tools and Supplies (utility knife, duct tape, battery powered radio, etc.)
    • Sanitation and Hygiene (household bleach, soap, towels, etc.)
    • Clothing and Bedding (a change of clothes for each family member and blankets)
    • Important documents (copies of your driver’s license, passport, and birth certificate to name a few)
    • First Aid supplies (although you’re a goner if a zombie bites you, you can use these supplies to treat basic cuts and lacerations that you might get during a tornado or hurricane)

    Once you’ve made your emergency kit, you should sit down with your family and come up with an emergency plan. This includes where you would go and who you would call if zombies started appearing outside your door step. You can also implement this plan if there is a flood, earthquake, or other emergency.

      Photo: Family members meeting by their mailbox. You should pick two meeting places, one close to your home and one farther away.Family members meeting by their mailbox. You should pick two meeting places, one close to your home and one farther away.
    1. Identify the types of emergencies that are possible in your area. Besides a zombie apocalypse, this may include floods, tornadoes, or earthquakes. If you are unsure contact your local Red Cross chapter for more information.
    2. Pick a meeting place for your family to regroup in case zombies invade your home…or your town evacuates because of a hurricane. Pick one place right outside your home for sudden emergencies and one place outside of your neighborhood in case you are unable to return home right away.
    3. Identify your emergency contacts. Make a list of local contacts like the police, fire department, and your local zombie response team. Also identify an out-of-state contact that you can call during an emergency to let the rest of your family know you are ok.
    4. Plan your evacuation route. When zombies are hungry they won’t stop until they get food (i.e., brains), which means you need to get out of town fast! Plan where you would go and multiple routes you would take ahead of time so that the flesh eaters don’t have a chance! This is also helpful when natural disasters strike and you have to take shelter fast.

    Never Fear – CDC is Ready

    Photo: Get a Kit, Make a Plan, Be PreparedGet a Kit, Make a Plan, Be Prepared

    If zombies did start roaming the streets, CDC would conduct an investigation much like any other disease outbreak. CDC would provide technical assistance to cities, states, or international partners dealing with a zombie infestation. This assistance might include consultation, lab testing and analysis, patient management and care, tracking of contacts, and infection control (including isolation and quarantine). It’s likely that an investigation of this scenario would seek to accomplish several goals: determine the cause of the illness, the source of the infection/virus/toxin, learn how it is transmitted and how readily it is spread, how to break the cycle of transmission and thus prevent further cases, and how patients can best be treated. Not only would scientists be working to identify the cause and cure of the zombie outbreak, but CDC and other federal agencies would send medical teams and first responders to help those in affected areas (I will be volunteering the young nameless disease detectives for the field work). 

    To learn more about what CDC does to prepare for and respond to emergencies of all kinds, visit:
    http://emergency.cdc.gov/cdc/orgs_progs.asp

    To learn more about how you can prepare for and stay safe during an emergency visit:
    http://emergency.cdc.gov/

    To download a badge like the one above that you can add to your social networking profile, blog,

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    Medical Students

    Thursday, May 19, 2011 // Uncategorized

    My patients are usually receptive to having medical students in the office.  The students seem to enjoy the experience.  Whether these rotations encourage students to go into Internal Medicine is unknown.  The following article from The ACP Observer suggests that it does not. Sigh.

    Students enjoy internal medicine as a clerkship, not a career
    Medical students enjoy their internal medicine clerkships but are less
    likely than ever to become general internists, citing educational
    debt, perceived workloads and stress as disincentives, according to a
    comparison of students in 1990 and 2007.

    Researchers compared results from two similar national surveys of
    senior medical students from 1990 and 2007 that asked about their
    clerkship experiences and perceptions of internal medicine careers.
    Results appeared in the April 25 Archives of Internal Medicine.

    The two surveys included 1,244 students at 16 schools in 1990
    (response rate, 75%) and 1,177 students at 11 schools in 2007 (82%).
    More students in 2007 reported high satisfaction with their internal
    medicine clerkships (78% vs. 38%, P<0.001) and more students in 2007
    than in 1990 (58% vs. 42%, P<0.001) felt that opportunities for
    meaningful work in internal medicine were greater than in other
    specialties.

    However, while similar numbers of students planned internal medicine
    careers in the two survey years (23% vs. 24%), the percentage
    intending to go into general internal medicine dropped from 9% to 2%
    (P<0.001).

    Students in 2007 were less likely than their 1990 counterparts to say that:

    the appeal of primary care attracted them to internal medicine (33%
    vs. 57%, P<0.001)
    they were attracted to internal medicine by their outpatient rotation
    (31% vs. 35%, P<0.001), and
    their overall internal medicine clerkship made a career in general
    internal medicine more attractive (19% vs. 24%, P<0.001).
    But they were more likely in 2007 to say their clerkship made a career
    in subspecialty internal medicine more attractive (49% vs. 35%,
    P<0.001).

    Educational loans were a deterrent for more students in 2007 (26% vs.
    16%, P<0.001). For the class of 2009, average total educational debt
    was $132,000 ($158,000 for the 86% of students with debt), and one in
    four students owed more than $200,000. Meanwhile, the income gap
    between primary care and subspecialist physicians has grown to nearly
    threefold, or $3.5 million during a 40-year career, the study authors
    said.

    “Bolder payment and practice reform will be required to reduce the
    remuneration gap between primary care and subspecialty physicians and
    to address the adverse work conditions in general internal medicine
    that students identify in clerkships,” the authors wrote. Such
    policies might include:

    expanding scholarships and loans,
    addressing work-life balance through new and more satisfying practice
    models, and
    slowing the “treadmill” pace by replacing fee-for-service reimbursement.

    On a positive note, I received an email from a fourth year medical student who had spent a month in the practice last year.  He matched in an Internal Medicine residency at the UTHSCSA.

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