Archive for October, 2006

Diverticulitis Increasingly Diagnosed in Young, Obese Individuals

Posted by Paul Rega, MD — published on October 24th, 2006
The demographics of acute diverticulitis are changing, according to results of a new study.  Radiologists in Baltimore report that the majority of cases treated recently at their institution’s emergency department occurred in patients age 50 and younger. Approximately one in five cases was diagnosed in patients below the age of 40.

“I’ve been doing abdominal and pelvic CT scans for about 12 years, and during the last 5 years, I was seeing a lot more acute diverticulitis cases in young patients who were obese,” Dr. Barry Daly said in an interview with Reuters Health.

To confirm this observation, Dr. Daly and Dr. Eram Zaidi reviewed medical records of 104 adult patients treated at the University of Maryland Medical Center for acute diverticulitis between 1999 and 2003. Their findings appear in the American Journal of Roentgenology for September.

The age of their cohort ranged from 22 to 88 years (median 49.0). The authors observed that 53.8% of patients were no older than 50, and 21.1% were age 40 and younger.

Drs. Daly and Zaidi documented abdominal obesity in 82% of subjects, as determined by a sagittal abdominal diameter of > 25 cm. Patients no older than 50 were more likely to be obese than older patients (p = 0.05). The differential was more pronounced when limiting the analysis to patients aged 40 years or less and those over 70 years (27.7 cm versus 24.9 cm, p = 0.02).

Eighty-nine percent of patients required hospital admission, the investigators report. CT scans revealed complications in 36% of patients, including colon perforation, abscess, fistula formation, and stricture formation or bowel obstruction. Surgery or percutaneous abscess drainage was required by 26.9%.

In their report, the investigators emphasize the importance of CT imaging in determining or confirming a diagnosis of acute diverticulitis, accurate staging of the inflammatory response, identifying serious complications, and guiding clinical management of patients.

Failure to accurately diagnose acute diverticulitis in younger individuals early in the disease process increases the risk of major complication. Moreover, because of their longer remaining lifespan, “young adults are at risk for repeated episodes,” Dr. Daly added. “We’ve seen patients with up to five acute attacks, and we have patients who had three surgeries.”

“Acute diverticulitis is not a trivial disease,” he emphasized.

Acute diverticulitis is associated with fever, malaise, elevated white cell count and other clinical factors, characteristics that should guide physicians when considering referral for a CT scan.

Dr. Daly pointed out that some patients do develop a mild, self-limiting case of diverticulitis involving inflammation of a single diverticulum. “But typically, those who present at the ED have extensive disease, and quite a few of them are going to develop complications,” he added.

In young adults with belly pain, he recommends that acute diverticulitis be included in the differential diagnosis, along with appendicitis, acute colicystitis, acute pancreatitis, and colitis.

Am J Roentgenol. 2006;187:689-694.

Reuters Health Information 2006. © 2006 Reuters Ltd.

Learning Objectives for This Educational Activity

Upon completion of this activity, participants will be able to:

  • Describe the epidemiology of diverticulitis.
  • List clinical features of patients with diverticulitis.

Clinical Context

Diverticulosis is a common condition among older adults, affecting approximately 75% of Americans older than the age of 80 years. The authors of the current study note that patients younger than 40 years old are thought to comprise only 2% to 5% of patients with diverticulosis. In addition to age, a diet low in fiber increases the risk for diverticulosis, and, thus, this condition is more common in industrialized countries.

The imaging test of choice for patients presenting with symptoms of acute diverticulitis is computed tomography (CT). The authors of the current study report on the clinical features of a cohort of patients with CT findings suggesting diverticulitis.

Study Highlights

  • Patients eligible for the study were adults older than the age of 20 years who had positive CT findings of diverticulitis at one institution between 1999 and 2003. Subjects who were evaluated in the study also had a diagnosis of diverticulitis based on clinical criteria.
  • The authors retrospectively collected demographic, clinical, laboratory, and treatment data on the study cohort. Sagittal abdominal diameter on CT was used as a measure of obesity, as body mass index data were not available.
  • 55 men and 49 women comprised the study cohort. The mean patient age was 52.2 years. 53.8% of subjects were 50 years old or younger, and 21.2% of patients were age 40 years or younger. The youngest subject was 22 years old, and men comprised 63.6% of subjects 50 years of age or younger.
  • 68.3% of subjects had disease in the sigmoid colon. Abdominal pain was the most common presentation, with 89% of subjects complaining of this symptom. Only half of patients with sigmoid disease complained of pain in the left lower quadrant. Approximately one third of subjects presented with fever, leukocytosis, or complications of diverticulitis on CT scan.
  • 26.9% of subjects required surgical therapy. There was no significant difference in the treatment of diverticulitis based on subjects’ ages.
  • Younger patients were significantly more obese than older subjects. The mean sagittal abdominal diameter was 27.7 cm in subjects 40 years old and younger compared with a mean diameter of 24.9 cm among subjects older than 70 years.

Pearls for Practice

  • Age and low intake of dietary fiber are risk factors for diverticulosis, a condition which is more common in industrialized countries.
  • In the current study, 21.2% of participants with diverticulitis were 40 years old or younger. Younger patients with diverticulitis were more likely to be male and obese vs older patients.

News Author: Karla Gale
CME Author: Charles Vega, MD, FAAFP

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categories: Emergency Medicine

Spinach, Carrot Juice, and Egg Salad, oh my!

Posted by Paul Rega, MD — published on October 23rd, 2006

Ballard’s Farm Sausage Company is recalling its egg salad products.  There may be Listeria contamination.  Ohio and Michigan are two states where this is taking place. 

What are the symptoms of listeriosis?

A person with listeriosis has fever, muscle aches, and sometimes gastrintestinal symptoms such as nausea or diarrhea. If infection spreads to the nervous system, symptoms such as headache, stiff neck, confusion, loss of balance, or convulsions can occur.
Infected pregnant women may experience only a mild, flu-like illness; however, infections during pregnancy can lead to miscarraige or stillbirth, premature delivery, or infection of the newborn.
How great is the risk for listeriosis?

In the United States, an estimated 2,500 persons become seriously ill with listeriosis each year. Of these, 500 die. At increased risk are:

Pregnant women - They are about 20 times more likely than other healthy adults to get listeriosis. About one-third of listeriosis cases happen during pregnancy.
 
 Newborns - Newborns rather than the pregnant women themselves suffer the serious effects of infection in pregnancy.
 
 Persons with weakened immune systems
 
 Persons with cancer, diabetes, or kidney disease
 
 Persons with AIDS - They are almost 300 times more likely to get listeriosis than people with normal immune systems.
 
 Persons who take glucocorticosteroid medications
 
 The elderly

Healthy adults and children occasionally get infected with Listeria, but they rarely become seriously ill.
How does Listeria get into food?

Listeria monocytogenes is found in soil and water. Vegetables can become contaminated from the soil or from manure used as fertilizer.
Animals can carry the bacterium without appearing ill and can contaminate foods of animal origin such as meats and dairy products. The bacterium has been found in a variety of raw foods, such as uncooked meats and vegetables, as well as in processed foods that become contaminated after processing, such as soft cheeses and cold cuts at the deli counter. Unpasteurized (raw) milk or foods made from unpasteurized milk may contain the bacterium.

Listeria is killed by pasteurization and cooking; however, in certain ready-to-eat foods such as hot dogs and deli meats, contamination may occur after cooking but before packaging.
How do you get listeriosis?

You get listeriosis by eating food contaminated with Listeria. Babies can be born with listeriosis if their mothers eat contaminated food during pregnancy. Although healthy persons may consume contaminated foods without becoming ill, those at increased risk for infection can probably get listeriosis after eating food contaminated with even a few bacteria. Persons at risk can prevent Listeria infection by avoiding certain high-risk foods and by handling food properly.
Can listeriosis be prevented?

The general guidelines recommended for the prevention of listeriosis are similar to those used to help prevent other foodborne illnesses, such as salmonellosis.
How can you reduce your risk for listeriosis?

General recommendations:

Thoroughly cook raw food from animal sources, such as beef, pork, or poultry.
 
 Wash raw vegetables thoroughly before eating.
 
 Keep uncooked meats separate from vegetables and from cooked foods and ready-to-eat foods.
 
 Avoid unpasteurized (raw) milk or foods made from unpasteurized milk.
 
 Wash hands, knives, and cutting boards after handling uncooked foods.
 
 Consume perishable and ready-to-eat foods as soon as possible.

Recommendations for persons at high risk, such as pregnant women and persons with weakened immune systems, in addition to the recommendations listed above:

Do not eat hot dogs, luncheon meats, or deli meats, unless they are reheated until steaming hot.
 
 Avoid getting fluid from hot dog packages on other foods, utensils, and food preparation surfaces, and wash hands after handling hot dogs, luncheon meats, and deli meats.
 
 Do not eat soft cheeses such as feta, Brie, and Camembert, blue-veined cheeses, or Mexican-style cheeses such as queso blanco, queso fresco, and Panela, unless they have labels that clearly state they are made from pastuerized milk.
 
 Do not eat refrigerated pâtés or meat spreads. Canned or shelf-stable pâtés and meat spreads may be eaten.
 
 Do not eat refrigerated smoked seafood, unless it is contained in acooked dish, such as a casserole. Refrigerated smoked seafood, such as salmon, trout, whitefish, cod, tuna or mackerel, is most often labeled as “nova-style,” “lox,” “kippered,” “smoked,” or “jerky.” The fish is found in the refrigerator section or sold at deli counters of grocery stores and delicatessens. Canned or shelf-stable smoked seafood may be eaten.

 

How do you know if you have listeriosis?

There is no routine screening test for susceptibility to listeriosis during pregnancy, as there is for rubella and some other congenital infections. If you have symptoms such as fever or stiff neck, consult your doctor. A blood or spinal fluid test (to cultivate the bacteria) will show if you have listeriosis. During pregnancy, a blood test is the most reliable way to find out if your symptoms are due to listeriosis.
What should you do if you’ve eaten a food recalled because of Listeria contamination?

The risk of an individual person developing Listeria infection after consumption of a contaminated product is very small. If you have eaten a contaminated product and do not have any symptoms, we do not recommend that you have any tests or treatment, even if you are in a high-risk group. However, if you are in a high-risk group, have eaten the contaminated product, and within 2 months become ill with fever or signs of serious illness, you should contact your physician and inform him or her about this exposure.
Can listeriosis be treated?

When infection occurs during pregnancy, antibiotics given promptly to the pregnant woman can often prevent infection of the fetus or newborn.
Babies with listeriosis receive the same antibiotics as adults, although a combination of antibiotics is often used until physicians are certain of the diagnosis. Even with prompt treatment, some infections result in death. This is particularly likely in the elderly and in persons with other serious medical problems.
What is the government doing about listeriosis?

Government agencies and the food industry have taken steps to reduce contamination of food by the Listeria bacterium. The Food and Drug Administration and the U. S. Department of Agriculture monitor food regularly. When a processed food is found to be contaminated, food monitoring and plant inspection are intensified, and if necessary, the implicated food is recalled.

The National Center for Infectious Diseases (NCID) is studying listeriosis in several states to help measure the impact of prevention activities and recognize trends in disease occurrence. NCID also assists local health departments in investigating outbreaks. Early detection and reporting of outbreaks of listeriosis to local and state health departments can help identify sources of infection and prevent more cases of the disease.

Source: www.cdc.gov, accessed 10/23/06

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categories: Emergency Medicine

Community-associated C. difficile Diarrhea

Posted by Paul Rega, MD — published on October 19th, 2006
Cases of community-associated _Clostridium difficile_-associated diarrhea
(CA-CDAD) are increasing, and half of these cases are not attributable to
antibiotic use, finds a study presented here at the annual meeting of the
Infectious Diseases Society of America. In a related study, vancomycin was
found to be superior to metronidazole for the treatment of severe CDAD.

“In the healthcare setting, we know that it (_C. difficile_) is transmitted
from patient to patient,” said L. Clifford McDonald, MD, a medical
epidemiologist at the CDC, and one of the first study’s investigators. “The question is how are patients getting it in the community?”

Investigators defined CDAD as diarrhea in a patient with a positive _C.
difficile_ toxin assay. CA-CDAD was defined as CDAD onset in the community
or within 72 hours of hospital admission in a patient who had not had
inpatient health services during the previous 2 months.

Of a total of 1137 cases of CDAD reviewed at 6 North Carolina hospitals between Jan and Dec 2005, nearly one in 5 (209, 18 percent) were acquired in the community, with 50 percent of those cases not originating from prescription of an antimicrobial, stressed Dr. McDonald. The median age of patients was 60 years.

“These are remarkable figures (18 percent and 50 percent),” he said in an interview with Medscape. “Exposure to antibiotics is the most important modifiable risk factor for the development of the condition. If that is not how it is developing, we can only speculate about how they are getting it. Are they getting it from another person in the family, food, or the environment? We don’t know.”

Dr. McDonald and colleagues matched the medical and laboratory records to
case controls of CA-CDAD at 4 Veteran Affairs hospitals (the remaining
institutions were one university hospital, and one regional hospital). In
statistical analysis, they found CA-CDAD cases were more likely to be
prescribed antimicrobials than control cases (adjusted odds ratio, 18.1; 95
percent confidence interval (CI), 6.3 - 51.9; P less than .0001) during the
previous 3 months. Cases were also more likely to to have underlying bowel
disease (adjusted odds ratio, 55.8; 95 percent CI, 5.1 - 6.7; P = .001) as
well as having had an outpatient visit to a healthcare facility (adjusted
odds ratio, 6.3; 95 percent  CI, 1.9 - 20.3; P = .002).

In their initial findings from 2 hospitals, it appeared that the use of
proton pump inhibitors (PPIs) heightened the risk of acquiring CA-CDAD.
From the overall group of 6 hospitals, a total of 36 percent of case
patients were prescribed a PPI within 3 months prior to onset of symptoms.
Of the CA-CDAD cases, 23 percent were prescribed a PPI.

In the analysis of data from all institutions, they found use of a PPI to
not be a risk factor in the development of CA-CDAD (odds ratio, 1.337; 95 percent CI, 0.5 - 3.4; P = .50).

Daniel Musher, MD, an infectious disease specialist and head of infectious
diseases at Houston Veterans Affairs Medical Center in Texas and a
professor of medicine at the Baylor College of Medicine, said the rate of
CA-CDAD in the study raises the issue of spreading infections in the
community.  He added that while the study did not find PPIs to be a risk
factor for developing CA-CDAD, several other studies have found that link.

Source: ProMEDmail, 10/17/06

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categories: Emergency Medicine

Healthcare Pros & Sexual Misconduct: Rules of the Road

Posted by Paul Rega, MD — published on October 12th, 2006

In Washington state, new regulations went into place last week to protect patients from sexual misconduct by health-care professionals. The rules were ordered by Gov. Christine Gregoire after a Seattle Times investigation revealed that the state Department of Health had inadequately addressed complaints. The new rules create a comprehensive set of patient rights and hold practitioners to certain standards, making the new rules some of the toughest in the country. Under the new regulations, patients must be given privacy when undressing; practitioners cannot solicit dates from patients, discuss their own sexual histories or describe fantasies; and practitioners must wear surgical gloves while performing genital exams. The rules expand the definition of “patient” to include any “key party,” such as parents of patients. In its investigation, the Times found that more registered counselors have been disciplined for sexual misconduct than any other health-care profession in the state; the Washington health department is expected to strengthen the current standards for becoming a registered counselor. The rules apply to 27 health-care professions. Fourteen other professions, such as physicians and chiropractors already have sexual-misconduct rules. Dentists and pharmacists are among those professions that do not have uniform rules.
[Editor’s note: To read Washington’s new “Standards of Professional Conduct,” including definitions, visit http://apps.leg.wa.gov/WAC/default.aspx?cite=246-16.]

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categories: Emergency Medicine

One in eight ECGs from MI patients are misinterpreted in the ED, data suggest

Posted by Jeff Hugus, MD — published on October 10th, 2006

Steve Stiles Heartwire 2006. © 2006 Medscape

October 6, 2006 (Dallas, TX) – Emergency department (ED) personnel failed to identify important, high-risk features on the electrocardiograms of about one in eight patients presenting with an acute MI in a retrospective analysis based on the two-year experience of five medical centers [1].
The ECG misinterpretations, which often kept the patients from receiving appropriate, evidenced-based treatments, were especially common among patients without chest pain at presentation, “suggesting that the absence of typical historical findings may inordinately reduce clinicians’ level of suspicion for acute MI,” write the authors, Dr Frederick A Masoudi (University of Colorado at Denver and Health Sciences Center) and colleagues.
Their analysis suggests that misinterpreted ECGs are “relatively common” in the ED and “a critical shortfall in the process of caring for patients with acute MI, with important implications for treatment and potential adverse consequences for patient outcomes,” according to the investigators from the retrospective, cohort-based Emergency Department Quality in Myocardial Infarction (EDQMI) study. Their report was published online October 2, 2006 in Circulation and is scheduled to appear in the journal’s October 10 issue.
“To be honest, the results of the study don’t surprise me that much,” Dr Charles V Pollack Jr (Pennsylvania Hospital, Philadelphia) told heartwire. “I think this is a legitimate problem that hasn’t been addressed in the past.” He pointed out, however, that the analysis was limited to a handful of centers and so doesn’t necessarily apply to emergency departments in general–something the authors acknowledge in their report. Pollack chairs the department of emergency medicine at his center and is an investigator with the CRUSADE registry of patients with non-ST-elevation acute coronary syndromes.
Although it’s “conceivable” that some ED physicians would use less care in reading the ECG of a patient with an atypical presentation, he said, more of a problem are patients with presentations “so atypical we may not even get an electrocardiogram.” Such patients are often women, the elderly, diabetics, or those with heart failure, he observed.
Of 1684 patients with acute MI presenting to the ED at five centers in California and Colorado, all members of health-maintenance organizations, about 12% had a high-risk ECG abnormality such as T-wave inversion or an ST-segment shift that wasn’t spotted by ED care providers. Patients with left-bundle branch block had been excluded from the analysis.
After controlling for institution and patient characteristics, according to Masoudi et al, researchers determined that the likelihood of a missed high-risk ECG abnormality was increased by 78% (p=0.005) among patients with heart failure and by 44% (p=0.03) among those with any history of CV disease, and it was reduced by 54% (p<0.001) for patients presenting with chest pain. Patients with a missed high-risk ECG feature, the group observed, were at significantly increased risk of not receiving a treatment with demonstrated clinical value for them.
Risk of not receiving an evidence-based therapy in the event of a missed high-risk ECG feature, among ideal candidates for the therapy*
Evidence-based treatment for acute MI
OR (95% CI)
*Adjusted for demographics, medical history, and admission characteristics
Despite perceptions among ED physicians that they receive adequate training in reading ECGs, write Masoudi et al, their findings “provide strong evidence that additional training in ECG interpretation and the assessment of competence may be a critical component of the education of physicians who care for patients presenting with acute MI.”
The shortfalls displayed in the analysis are partly a training issue, according to Pollack, but are probably more related to “a need for ongoing collaboration and communication between emergency medicine and cardiology.” When that communication isn’t what it should be, he said, it “can contribute to a poorer diagnostic acumen on the part of the emergency physicians.”
One way cardiologists could improve the dialog, according to Pollack, would be to keep emergency physicians apprised on the outcomes of cases. An interventionalist who takes a patient to the cath lab, for example, “could [later] stop by the emergency department or dictate a quick note to the emergency physicians who saw the patient and give a clinical follow-up.”
Or, he added, consultations could go beyond how to read an ECG to discussions on how to better recognize atypical ACS presentations. “That sort of ongoing interaction I think would really address, in large part, the deficits that these authors are pointing out.”
Masoudi reports having served on the speakers’ bureaus for Pfizer and AstraZeneca.
  1. Masoudi FA, Magid DJ, Vinson DR, et al. Implications of the failure to identify high-risk electrocardiogram findings for the quality of care of patients with acute myocardial infarction. Results of the Emergency Department Quality in Myocardial Infarction (EDQMI) study. Circulation 2006; 114:1565-1571.
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categories: Emergency Medicine