CDC is requesting that states report all cases of influenza-related pediatric mortality during the 2007-2008 influenza season. This health advisory contains updated information about influenza and bacterial co-infections in children and provides interim testing and treatment recommendations.Background:

Since 2004, the Influenza-Associated Pediatric Mortality Surveillance System, part of the Nationally Notifiable Disease Surveillance System, has collected information on deaths among children due to laboratory-confirmed influenza, including the presence of other medical conditions and bacterial infections at the time of death. From October 1, 2006 through September 30, 2007, 73 deaths from influenza in children were reported to CDC from 39 state health departments and two city health departments. Data on the presence (or absence) of bacterial co-infections were recorded for 69 of these cases; 30 (44%) had a bacterial co-infection, and 22 (73%) of these 30 were infected with Staphylococcus aureus.

The number of pediatric influenza-associated deaths reported during 2006-07 was moderately higher than the number reported during the two previous surveillance years; the number of these deaths in which pneumonia or bacteremia due to S. aureus was noted represents a five-fold increase. Only one S. aureus co-infection among 47influenza deaths was identified in 2004-2005, and 3 co-infections among 46 deaths were identified in 2005-2006. Of the 22 influenza deaths reported with S. aureus in 2006-2007, 15 children had infections with methicillin-resistant S. aureus (MRSA).

The median age of children with S. aureus co-infection was older than children without S. aureus co-infection (10 years versus 5 years, p<.01) and children with co-infection were more likely to have pneumonia and Acute Respiratory Distress Syndrome (ARDS). Influenza strains isolated from these children were not different from common strains circulating in the community, and the MRSA strains have been similar to those associated with MRSA skin infection outbreaks in the United States.

Recommendations:

Health care providers should test persons hospitalized with respiratory illness for influenza, including those with suspected community-acquired pneumonia. Health care providers should be alerted to the possibility of bacterial co-infection among children with influenza, and request bacterial cultures if children are severely ill or when community-acquired pneumonia is suspected. Health care providers should be aware of the prevalence of methicillin-resistant S. aureas strains in their communities when choosing empiric therapy for patients with suspected influenza-related pneumonia. Clinicians, health care providers, and medical examiners are asked to contact their local or state health department as soon as possible when deaths among children associated with laboratory-confirmed influenza are identified.

CDC requests that state health departments report all cases of pediatric influenza-associated deaths to CDC through http://sdn.cdc.gov and that information about bacterial pathogens isolated from sterile sites and/or from sputum or endotracheal aspirates be completed on the Influenza-Associated Pediatric Mortality Surveillance System case report form. If the influenza death was complicated by S. aureus infection, state health departments are asked to please contact the clinical agency that reported the case to determine if the S. aureus isolate is available. CDC will receive S. aureus isolates in order to better characterize those S. aureus isolates from children who have died from influenza.

If you have any questions about this Health Advisory, please call the Influenza Division, Epidemiology and Prevention Branch at 404-639-3747.nass WWE nackt DivasPissing Nahaufnahmencunts reife Wetxxx hentai YugiNaruto Sakura hentai Xxxlisa schibrowski und Bart Sexinterrassisch Kostenlos Sylvia Galerie SaintInterrassisch dpKarton shemalesZeichentrickfilm nackt Batgirl

NuCel Labs and FDA informed consumers and healthcare professionals of a voluntary nationwide recall of all Eye Drops and Eye Wash Products. The products were recalled after testing indicated the presence of bacteria and particulate matter, deeming these products non-sterile. Non-sterile eye drops pose an unacceptable risk of causing eye infections, which in rare cases could lead to blindness. No illnesses or injuries have been reported to date. There are no lot numbers or expiration dates on the products. Consumers who have the product should discontinue use of the product and return it to NuCel Lab. See the manufacturer’s press release for return shipping information.

Read the complete 2008 MedWatch Safety Summary, including a link to the Manufacturer’s Press Release regarding this issue at:
http://www.fda.gov/medwatch/safety/2008/safety08.htm#NuCel

A 15-year-old Hispanic female presented to the clinic with a ‘bump’ on her nose that had been draining pus for three days.

The patient was triaged as a “spider bite.” Examination revealed a papular lesion draining a small amount of pus. She was started on a standard dose of cephalexin for seven days and advised to follow-up if not improving.

She returned in two days with a new complaint of vomiting the night before. The lesion on her nose had improved but she appeared to be developing a new one on her forehead. She was advised to complete the course of cephalexin but if she was not tolerating it, to switch to amoxicillin-clavulanic acid (Augmentin, GlaxoSmithKline) for five days. She was advised to return to the clinic if she was not improving.

The patient returned approximately one month later. She was now wearing a dressing on her nose and the mother requested a referral to an ear, nose and throat specialist.

The patient’s mother was upset because she had been to a local emergency room (ER) five days after her last visit to our clinic. The patient was told that she had a MRSA infection, and she underwent drainage of a nasal abscess. She was discharged home on trimethoprim-sulfamethoxazole. The patient’s mother was angry because the ER had given her a different diagnosis from the diagnosis given to her in the clinic and the patient was still not improving.

The patient now had multiple lesions breaking out all over her body as well as fevers every other day and swelling of her arms and legs. The mother had also tried contacting the ER for further information but could not get anyone to give her follow-up results on the tests performed. Figures 1 and 2 (above) are of the patient’s appearance on third visit.

What is your diagnosis?

Answer

The diagnosis is disseminated Coccidioides immitis.

C. immitis is a dimorphic fungus. It is the causative agent of coccidioidomycosis, or San Joaquin Valley fever, an endemic primary systemic mycosis that is asymptomatic in 95% of cases but also causes life-threatening infections in immunocompetent and immunocompromised hosts.

The infectious forms of this unique fungus are the multinucleate spores arthroconidia, which are thick, barrel-shaped structures that are released from the mold. Coccidioides species are most highly concentrated in the San Joaquin Valley of California and in south-central Arizona. The major burden of coccidioidomycosis falls on Arizona and California, with greater than 95% of all cases reported being from those two states. Kern County, which is located in the San Joaquin Valley, has been recognized as a site for hyperendemic coccidioidomycosis since the 1940s.

Primary infection occurs in the lungs. Primary infection, whether clinically apparent or asymptomatic, is often accompanied by lymphohematogenous dissemination of the fungus. Infection is sub-clinical in about 60% of people who have this illness, and most others have self-limited, primary pulmonary infections. Pulmonary complications occur in less than 5% and disseminated infections in less than 1% of people with this infection. The diagnosis is often belated, because the infection is not considered initially.

Dissemination of the infection to extrapulmonary sites usually occurs within several months after the primary pulmonary infection and rarely after one year. Persistent fever generally accompanies extrapulmonary disease. Individuals at highest risk are neonates and young infants, immunosuppressed patients, Filipinos, blacks, Native Americans and Hispanics.

Most skin infections represent extrapulmonary manifestations arising by spread from a primary pulmonary focus. The skin may be involved by immunologically-induced reactive eruptions or, more rarely, by dissemination of the organisms from the lungs. Lesions begin as papules or pustules that enlarge and can ulcerate. Verrucous plaques, subcutaneous cold abscesses, and wartlike lesions also occur. Lesions occur anywhere and are especially common on the face along the nasolabial folds. Although most skin infections result from dissemination, cutaneous lesions, accompanied by regional adenitis, rarely occur after accidental inoculation.

Symptoms of coccidiodomycosis are not distinctive. The main difficulty in diagnosis is failure to consider coccidioidomycosis. A careful travel history is needed for prompt recognition of the diagnosis, particularly in patients who reside in non-endemic areas. The mainstays of diagnosis are culture and serologic testing.

Less than 5% of people who have C. immitis require antifungal treatment. The decision to treat is based on the specific features and severity of the initial illness and the presence or absence of other risk factors that predict progressive dissemination, a poor outcome, or both. In general, treatment is required for patients who have primary or acquired immunodeficiency, fulminant infections, extrapulmonary manifestations, prolonged symptoms, or any combination of these conditions.

In patients with severe illness or rapid progression of disease, amphotericin B is used initially. In patients with disseminated disease, prolonged chemotherapy is always indicated. Recently, a number of new antifungal agents have been evaluated for their activity against C. immitis. Agents that have been shown to be potentially useful include voriconazole, caspofungin and posaconazole.

Disorders in cellular immunity or therapy with agents that impair cellular immunity are risk factors for aggressive and disseminated infection with C. immitis. Attempts to immunize individuals have been unsuccessful. In endemic regions, immunodeficient patients should be counseled about avoiding infection. All people, particularly those visiting or moving from nonendemic areas, should avoid exposure to activities that may aerosolize spores in contaminated soil. If such activities are unavoidable, respiratory filtration devices should be used.

For more information:

• Sabiha Hussain, MD, works for the pediatrics department at the Family Health Center/Community Action Partnership of Kern.
• Long S, Pickering L, Prober C. Principles and Practice of Pediatric Infectious Diseases. Second Edition.
• Saubolle M, McKellar P and Sussland D. Epidemiologic, clinical and diagnostic aspects of coccidioidomycosis. J Clin Microbiol. 2007; 45(1):26-30.
• Rosenstein N, Emery K, Werner S et al. Risk factors for Severe Pulmonary and Disseminated Coccidioidomycosis: Kern County, California, 1995-1996. CID. 2001; 32: 708-15
• Stevens D. Coccidioidomycosis. N Engl J Med. 332(16): 1077-1082.
• Dicaudo D, Yiannias J, Laman S et al. The exanthem of acute pulmonary coccidioidomycosis; clinical and histopathologic features of 3 cases and review of the literature. Arch Dermatol. 2006; 142: 744-746.
• Park D, Sohn J, Cheong H et al. Combination therapy of disseminated coccidioidomycosis with caspofungin and fluconazole. BMC Infect Dis. 2006;6:26

Source:  Infectious Diseases in Children, 1/08.

MMWR January 31, 2008 / 57 (Early Release);1-3  

On October 29, 2007, the Minnesota Department of Health (MDH) was notified by a tertiary-care provider of unexplained neurologic illnesses among workers in a swine slaughterhouse (plant A) in southeast Minnesota. As a result, MDH initiated a detailed investigation at plant A to characterize the outbreak. This report describes the ongoing investigation and outbreak-control measures undertaken by state public health officials and CDC.

Plant A, located in southeastern Minnesota, employs approximately 1,200 workers and processes 18,000 pigs per day. After being notified of the illnesses, MDH investigators initiated active case finding, interviewed workers at plant A, and reviewed the plant’s occupational health and employment records. As of January 28, 2008, a total of 12 workers at plant A had been identified with confirmed (eight workers), probable (two), or possible (two) progressive inflammatory neuropathy (PIN) (Box). Illness onset ranged from November 2006 through November 2007. Median age of the 12 patients was 31 years (range: 21–51 years); six patients were female. All 12 patients reported being healthy before the onset of neurologic symptoms.

Symptoms ranged from acute paralysis to gradually progressive symmetric weakness over periods ranging from 8 to 213 days. Severity ranged from minor weakness and numbness to paralysis predominantly in the lower extremities affecting mobility. Eleven patients had evidence of axonal or demyelinating peripheral neuropathy by electrodiagnostic testing. Cerebrospinal fluid was obtained from seven patients. All seven had elevated protein levels (median: 125 mg/dL; range: 75–231 mg/dL [normal: 14–45 mg/dL]) with no or minimal pleocytosis (median: 1 cell/dL; range: 1–73 cells/dL in a nontraumatic tap); five patients had evidence of inflammation on spinal magnetic resonance imaging (four patients in peripheral nerves or roots and one patient in the anterior spinal cord).

All 12 patients reported either working at or having regular contact with an area where swine heads were processed (known as the head table), which was located within a larger processing area in plant A known as the warm room. A case-control study was conducted among plant A workers to identify specific risk factors associated with illness. The 10 patients with confirmed or probable cases were included in the study, along with two stratified control groups: 1) a random selection of 48 healthy warm-room workers and 2) all 65 healthy head-table workers. Statistically significant (p<0.05) differences were calculated by chi-square test. Blood samples and throat swabs were collected from all consenting case-patients and controls. As of January 30, laboratory investigations had not identified any infectious agent from the blood and throat-swab specimens that would explain the occurrence of PIN.

Results of the case-control study indicated that case-patients (seven of 10, 70%) were significantly more likely to have worked at the head table than the warm-room controls (12 of 48, 25%) (odds ratio [OR]: 7.0; 95% confidence interval [CI] = 1.3--42.2; p = 0.009). Case-patients also were more likely to have removed brains or remaining skeletal muscle from the pig head (a process known as backing heads) (four of 10, 40%) than controls (two of 46, 4%) (OR: 15.3; CI = 1.8--163.4; p = 0.006). Among head-table workers, case-patients were significantly more likely to have removed brains or skeletal muscle from the head (four of seven, 57%) than head-table controls (eight of 65, 12%) (OR: 9.50; CI = 1.40--70.2; p = 0.01). Illness was not determined to be associated with previous travel outside or within the United States; exposure to chemicals, fertilizers, or insecticides; use of medications; or receipt of previous vaccinations.

An environmental assessment of the plant was conducted on November 28, 2007. Standard personal protective equipment (PPE) used by workers at plant A included hard hats, laboratory coats (including some that were short-sleeved), boots, hearing protection, eye protection, and specialized gloves that varied with the particular task of the worker. A compressed air device was used in the plant to harvest brain tissue from pig heads at the head table. The device was placed into the skull of the pig through the foramen magnum, and the force of the air disrupted the brain material into a liquefied form that made it easier to remove (a technique known as "blowing brains"). This technique caused generation of small droplets and splatter, possibly including aerosolized brain material, to which workers operating the device and others nearby might have been exposed. In response to the investigation, plant A voluntarily suspended harvesting of brains and instituted additional mandatory PPE on November 28, 2007, including face shields and long sleeves, for workers stationed at the head table and other workers who chose to use additional PPE.

Results of Case-Finding Survey

A survey of the 25 federally inspected swine slaughterhouses with >500 employees in the United States indicated that only three plants (plant A in Minnesota and plants in Nebraska and Indiana) reported recent use of compressed air to extract pig brains. To date, no cases of PIN have been identified in association with workers at the Nebraska plant. However, several workers at the Indiana plant have been preliminarily identified with neurologic illnesses and similar histories of exposure to head-processing activities at that slaughterhouse. Further assessments of these patients, and additional measures to identify other workers with illness, are being conducted in Indiana. As a result of this investigation, all three plants have stopped using compressed air to extract brain material.

Editorial Note:

This report summarizes an ongoing investigation of PIN, a syndrome that appears to be associated with swine slaughterhouse workers who process pig heads. Several clinical and laboratory features of this illness and the distinctive epidemiology associated with patients appear unique. Pigs slaughtered at plant A have passed inspection by the U.S. Department of Agriculture Food Safety and Inspection Service, and the investigation has not identified any foodborne risk to the general population.

The investigation in Minnesota indicates that PIN appears associated with having worked at the head table, where a compressed-air device was used to extract pig brains. In the process of blowing compressed air into the pig skull, brain material might have been splattered or even aerosolized, and workers might have been exposed through inhalation or contact with mucous membranes. One hypothesis for development of PIN is that worker exposure to aerosolized pig neural protein might have induced an autoimmune-mediated peripheral neuropathy (1,2). Additional investigation of the characteristics and causes of PIN is under way.

Whether compressed-air devices are being used for pig-brain extraction in other slaughterhouses or processing facilities, in the United States or internationally, is unknown. Clinicians should provide CDC with information regarding swine slaughterhouse workers who might have illnesses similar to PIN, including patients with peripheral neuropathy, myelopathy, or features of both. Clinicians who identify such patients should report the cases to their state health department and contact CDC at 770-488-7100.

References

1. 1. Quattrini A. Inflammatory neuropathies. Neurol Sci 2005;26:S6.
2. 2. Tatsumoto M, Koga M, Gilbert M, et al. Spectrum of neurological diseases associated with antibodies to minor gangliosides GM1b and GalNAc-GD1a. J Neuroimmunol 2006;177:201–8.

FDA ALERT [1/31/2008] - The FDA has analyzed reports of suicidality (suicidal behavior or ideation) from placebo-controlled clinical studies of eleven drugs used to treat epilepsy as well as psychiatric disorders, and other conditions. These drugs are commonly referred to as antiepileptic drugs (see the list below). In the FDA’s analysis, patients receiving antiepileptic drugs had approximately twice the risk of suicidal behavior or ideation (0.43%) compared to patients receiving placebo (0.22%). The increased risk of suicidal behavior and suicidal ideation was observed as early as one week after starting the antiepileptic drug and continued through 24 weeks. The results were generally consistent among the eleven drugs. Patients who were treated for epilepsy, psychiatric disorders, and other conditions were all at increased risk for suicidality when compared to placebo, and there did not appear to be a specific demographic subgroup of patients to which the increased risk could be attributed. The relative risk for suicidality was higher in the patients with epilepsy compared to patients who were given one of the drugs in the class for psychiatric or other conditions.  All patients who are currently taking or starting on any antiepileptic drug should be closely monitored for notable changes in behavior that could indicate the emergence or worsening of suicidal thoughts or behavior or depression. 

This information reflects FDA’s current analysis of available data concerning these drugs. Posting this information does not mean that FDA has concluded there is a causal relationship between the drug products and the emerging safety issue. Nor does it mean that FDA is advising health care professionals to discontinue prescribing these products. FDA intends to update this document when additional information or analyses become available.

• Healthcare Professional Information
  • Information for Healthcare Professionals

The following is a list of antiepileptic drugs* included in the analyses:

Labeling and approval history from Drugs@FDA.

• Carbamazepine (marketed as Carbatrol, Equetro, Tegretol, Tegretol XR)
• Felbamate (marketed as Felbatol)
• Gabapentin (marketed as Neurontin)
• Lamotrigine (marketed as Lamictal)
• Levetiracetam (marketed as Keppra)
  • Patient Information Sheet
• Oxcarbazepine (marketed as Trileptal)
• Pregabalin (marketed as Lyrica)
• Tiagabine (marketed as Gabitril)
• Topiramate (marketed as Topamax)
• Valproate (marketed as Depakote, Depakote ER, Depakene, Depacon)
• Zonisamide (marketed as Zonegran)

* Some of these drugs are also available in generic form.

USA Today (1/31, Appleby) reports that Morton Grove Pharmaceuticals, the “sole U.S. maker of an insecticide-based treatment for head lice, has stopped promoting the product after a sharply worded warning from the Food and Drug Administration (FDA) that its marketing misled consumers by downplaying the rare, but serious, risks of the treatments.” Referring to the company’s claim that head lice could be effectively treated with “two applications” of Lindane Sampoo “several days apart,” last December, the FDA said that the claim was “extremely alarming given that retreatment with” the product “can lead to increased exposure and possibly death.” Moreover, “[h]ospitalizations, seizures, and deaths have been reported after the use of Lindane Shampoo and Lindane Lotion, according to the products’ warning label.” In 2006, the Environmental Protection Agency banned lindane as an agricultural insecticide, citing its toxicity,” and the FDA “says lindane products are useful as a last resort against head lice and scabies.” Still, Morton Grove maintains that they did “‘not believe’ that the marketing materials ‘intended to downplay’ the risks associated with the shampoo.”

LA Times (1/31, Chong) reports that a sports fan may be putting his or her heart at risk when watching a favorite team play, according to a study published in the New England Journal of Medicine.

  That made my heart go flitter-flutter.

Senior study author Dr. Gerhard Steinbeck, professor of internal medicine and cardiology at the University of Munich, and colleagues “looked at 4,729 [medical] records” of Munich residents “drawn from the month of the World Cup (June 9 to July 9, 2006), along with control periods before and after the tournament and three summer months in 2003 and 2005.” The researchers found that, “[c]ompared with ordinary summer days, Munich-area residents had 2.66 times more serious heart problems on days that Germany was playing.”

HealthDay (1/31, Preidt) reports that the “benchmark for designation as a high-volume heart transplant hospital” ought to “increase, from 10 transplants to 14 transplants” annually, according to a study presented at the Society of Thoracic Surgeons annual meeting, in Fort Lauderdale, Fla.

This stands in opposition to a recent decision by the Centers for Medicare and Medicaid Services, “which qualifies medical centers for federal reimbursement,” to reduce the “high-volume standard from 12 to 10 heart transplants” annually.

When the researchers, from Johns Hopkins Medical Institutions, looked at “the records of 14,401 people who had heart transplants,” they “found that death rates one month and one year after transplant increased steadily at hospitals that did fewer than 14 transplants” annually.

According to the researchers, “[p]atients at hospitals that did less than 10 heart transplants a year had an 80 percent increased risk of dying within a month, compared to less than one percent for patients at hospitals that did more than 40 heart transplants” annually. lingerie sexygirls ebonybig buttsmasterbating girlhorse cockanal fistingsex interracialpussy eat Map

The Doctor’s Guide (1/30) reports that the FDA “has approved Emend (fosaprepitant dimeglumine)” injections as “a new intravenous therapy for the prevention of chemotherapy-induced nausea and vomiting.” This form of Emend “provides a new option for patients receiving an antiemetic on day 1 of their chemotherapy.” Patients receive the drug 30 minutes before beginning chemotherapy treatment. The FDA’s approval was based on a clinical trial which “showed that 115 mg of intravenous Emend…was biologically equivalent to 125 mg of oral Emend.” Participants reported side effects such as “infusion site pain   (7.6 percent), infusion site induration (1.5 percent), and headache (three percent).” Furthermore, patients who take the Emend injection may experience adverse events similar to those of the oral version, “including tiredness, nausea, hiccups, constipation, diarrhea, loss of appetite, headache, and hair loss.”

UPI (1/30) reports that carbon monoxide can cause “direct damage to the heart muscle, separate from the effects of oxygen deprivation,” according to a study published in Academic Emergency Medicine. The study, by lead author Dr. Selim Suner, director of emergency preparedness and disaster medicine at Rhode Island Hospital in Providence, R.I., and colleagues “suggests heart damage caused by carbon monoxide may have long-lasting effects even after it’s been eliminated from the blood, making the diagnosis of carbon monoxide poisoning even more critical.”

The AP (1/30, Ross) reports that many medical professionals “favor…an alcohol-based hand gel, thinking the quick-acting goo will kill bacteria on their hands and curb the spread of infection.”

Yet, according to a study appearing in the January issue of Infection Control and Hospital Epidemiology, “cleaner hands had no bearing on the rate of infections among patients” — a finding that conflicts with the Centers of Disease Control and Prevention’s (CDC) hospital guidelines.

Over a two year period, researchers at the University of Nebraska Medical Center evaluated the hand hygiene “of nurses and doctors in two comparable intensive care units” for roughly 300 hours. Although researchers “found ‘no significant relationship’ between rates of hand gel use and infections among patients,” the team still suggests that staff “shouldn’t wear rings and should trim their fingernails even more than the CDC recommendation of no longer than a quarter of an inch.”

Reuters, 1/29/08:  Dr. Julius Pham’s stomach churned when he saw a critically ill heart patient getting an antibiotic instead of a drug to support his blood pressure — the kind of mix-up that is increasingly common in the United States, according to a new report.”If you have ever had that sinking feeling that drops to the bottom of your stomach, I had it,” Pham, then a critical care physician at Johns Hopkins University in Baltimore, told reporters. “Unfortunately, the patient did not do well.”

A nurse had confused Levophed, which can boost blood pressure, with the antibiotic Levaquin.

The rate of drug name mix-ups has more than doubled since 2004, the U.S. Pharmacopeia said in a report on Tuesday.

The group, which regulates the generic names of drugs and advises pharmaceutical companies, reviewed more than 26,000 records and identified 1,470 unique drugs involved in errors due to similar brand or generic names.

“Together, these drug names contributed to more than 3,170 pairs — nearly double the 1,750 product pairs appearing on USP’s 2004 list,” the organization said in a statement.

“According to this report’s findings, 1.4 percent of the errors resulted in patient harm, including seven that may have caused or contributed to patient deaths.”

The top 10 drugs sold in the United States in 2006 all made the mix-up list, including cholesterol drug Lipitor, heart drugs Toprol and Norvasc, antidepressant Lexapro, stomach acid pill Nexium and asthma drug Singulair.

The USP researchers said 519 facilities reported on 176,409 errors in 2006. “The percentage of harmful errors has remained above 1 percent for more than seven years,” they said.

Some errors could be easily remedied if pharmacies separated or otherwise differentiated easily confused drugs, said USP patient safety expert Diane Cousins.

Labels could be applied that use “tall-man” lettering — for instance the glaucoma drug acetaZOLamide, with the “ZOL” in the middle uppercased, versus acetoHEXamide, a drug used to treat diabetes that has a similar name.

Prescriptions should include simple words such as “for sinus,” “for heart,” “for high blood pressure,” Cousins added.

Some of the mistakes found in the survey:

– A child got schizophrenia drug Zyprexa instead of allergy drug Zyrtec after a visit to the emergency room. “The patient returned to the ER after fainting, at which time the medication error was discovered,” the report reads.

– A patient incorrectly received bipolar drug Lamictal instead of blood pressure drug Labetalol. A few days later, the patient was hospitalized with elevated blood pressure, nausea and vomiting.

in Arch Intern Med.  2007; 167(22):2417-22 

Authors:Wu CM ; McLaughlin K ; Lorenzetti DL ; Hill MD ; Manns BJ ; Ghali WA
Department of Medicine, University of Calgary, Calgary, AB, Canada.

Abstract

BACKGROUND: Recent observational studies suggest that the risk for stroke may be high in the first 90 days after transient ischemic attack (TIA). This finding may, however, not be consistent across existing studies assessing stroke risk after TIA. The objectives of our study were to conduct a systematic review and meta-analysis of observational studies estimating the risk of stroke at 2, 30, and 90 days after TIA and to explore clinical and methodological factors that may explain variability in findings across studies.

METHODS: Articles were obtained by searching the Cochrane Database of Systematic Reviews (1996 to present), MEDLINE (1966 to present), EMBASE (1980 to present), CINAHL (1982 to present), and BIOSIS previews (1980 to present). Searches were supplemented by scanning bibliographies of included articles, review articles, and conference proceedings and by contacting an expert in the field. Abstracts were retained if they reported original data and addressed early risk of stroke in patients with TIA. We identified 51 candidate studies reporting early risk of stroke after TIA. Two reviewers independently extracted information from 11 selected studies. Indicators of study quality were collected and included consecutive enrollment, losses to follow-up, explicit criteria used to define TIA and stroke, and method of ascertainment. Pooled early risk of stroke was estimated using fixed and random effects models, and meta-regression was used to assess the association between clinical and methodological factors and the reported early risk of stroke.

RESULTS: Based on a random effects model, the pooled early risk of stroke was 3.5%, 8.0%, and 9.2% at 2, 30, and 90 days after TIA, respectively. Studies reported higher risks when the methodology involved active ascertainment of stroke outcome compared with passive ascertainment. Early risk of stroke was 9.9%, 13.4%, and 17.3% at 2, 30, and 90 days, respectively, when only studies with active outcome ascertainment were considered.

CONCLUSIONS: Transient ischemic attack is associated with high early risk of stroke. The methodological design of studies accounts for some of the variability seen in previous reports of early stroke risk after TIA.

in Cochrane Database Syst Rev.  2007; (4):CD001832 (ISSN: 1469-493X)

Authors:  Prasad K ; Kumar A ; Gupta PK ; Singhal T
All India Institute of Medical Sciences, Neurosciences Center, Room No. 704, AIIMS, New Delhi, India, 11002. drkameshwarprasad@yahoo.co.in

ABSTRACT

BACKGROUND: Antibiotic therapy for suspected acute bacterial meningitis (ABM) needs to be started immediately, even before the results of cerebrospinal fluid (CSF) culture and antibiotic sensitivity are available. Immediate commencement of effective treatment using the intravenous route may reduce death and disability. Although bacterial meningitis guidelines advise the use of third generation cephalosporins, these drugs are often not available in hospitals in low income countries.

OBJECTIVES: The objective of this review was to compare the effectiveness and safety of third generation cephalosporins and conventional treatment with penicillin or ampicillin-chloramphenicol in patients with community-acquired ABM.

SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 1) which contains the Cochrane Acute Respiratory Infections Group Trials Register, MEDLINE (January 1966 to March 2007), and EMBASE (January 1974 to March 2007). We also searched the reference list of review articles and book chapters, and contacted experts for any unpublished trials.

SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing ceftriaxone or cefotaxime with conventional antibiotics as empirical therapy for acute bacterial meningitis.

DATA COLLECTION AND ANALYSIS: Two review authors independently applied the study selection criteria, assessed methodological quality, and extracted data.

MAIN RESULTS: Nineteen trials that involved 1496 patients were included in the analysis. There was no heterogeneity of results among the studies in any outcome except diarrhoea. There was no statistically significant difference between the groups in the risk of death (risk difference (RD) 0%; 95% confidence interval (CI) -3% to 2%), risk of deafness (RD -4%; 95% CI -9% to 1%), or risk of treatment failure (RD -1%; 95% CI -4% to 2%). However, there were significantly decreased risks of culture positivity of CSF after 10 to 48 hours (RD -6%; 95% CI -11% to 0%) and statistically significant increases in the risk of diarrhoea between the groups (RD 8%; 95% CI 3% to 13%) with the third generation cephalosporins. The risk of neutropaenia and skin rash were not significantly different between the two groups. However, all the studies were conducted in the 1980s except three, which were reported in 1993, 1996, and 2005.

AUTHORS’ CONCLUSIONS: The review shows no clinically important difference between ceftriaxone or cefotaxime and conventional antibiotics. In situations where availability or affordability is an issue, third generation cephalosporins, ampicillin-chloramphenicol combination, or chloramphenicol alone may be used as alternatives. The antimicrobial resistance pattern against various antibiotics needs to be closely monitored in low to middle income countries as well as high income countries.movies toon pornmovies adult xxxwholesale movie movies wholesale dvdmovies amature porn freeclips bondage movie freehomemade free sex movieslesbian free hentai moviessex free pregnant moviesporn sanders georgette moviesgirls movie mean

in JAMA.  2007; 298(23):2743-53.

Authors:  Anderson DR ; Kahn SR ; Rodger MA ; Kovacs MJ ; et al

ABSTRACT

CONTEXT: Ventilation-perfusion (VQ) lung scanning and computed tomographic pulmonary angiography (CTPA) are widely used imaging procedures for the evaluation of patients with suspected pulmonary embolism. Ventilation-perfusion scanning has been largely replaced by CTPA in many centers despite limited comparative formal evaluations and concerns about CTPA’s low sensitivity (ie, chance of missing clinically important pulmonary embuli).

OBJECTIVES: To determine whether CTPA may be relied upon as a safe alternative to VQ scanning as the initial pulmonary imaging procedure for excluding the diagnosis of pulmonary embolism in acutely symptomatic patients.

DESIGN, SETTING, AND PARTICIPANTS: Randomized, single-blinded noninferiority clinical trial performed at 4 Canadian and 1 US tertiary care centers between May 2001 and April 2005 and involving 1417 patients considered likely to have acute pulmonary embolism based on a Wells clinical model score of 4.5 or greater or a positive D-dimer assay result.

INTERVENTION: Patients were randomized to undergo either VQ scanning or CTPA. Patients in whom pulmonary embolism was considered excluded did not receive antithrombotic therapy and were followed up for a 3-month period.

MAIN OUTCOME MEASURE: The primary outcome was the subsequent development of symptomatic pulmonary embolism or proximal deep vein thrombosis in patients in whom pulmonary embolism had initially been excluded.

RESULTS: Seven hundred one patients were randomized to CTPA and 716 to VQ scanning. Of these, 133 patients (19.2%) in the CTPA group vs 101 (14.2%) in the VQ scan group were diagnosed as having pulmonary embolism in the initial evaluation period (difference, 5.0%; 95% confidence interval [CI], 1.1% to 8.9%) and were treated with anticoagulant therapy. Of those in whom pulmonary embolism was considered excluded, 2 of 561 patients (0.4%) randomized to CTPA vs 6 of 611 patients (1.0%) undergoing VQ scanning developed venous thromboembolism in follow-up (difference, -0.6%; 95% CI, -1.6% to 0.3%) including one patient with fatal pulmonary embolism in the VQ group.

CONCLUSIONS: In this study, CTPA was not inferior to VQ scanning in ruling out pulmonary embolism. However, significantly more patients were diagnosed with pulmonary embolism using the CTPA approach. Further research is required to determine whether all pulmonary emboli detected by CTPA should be managed with anticoagulant therapy.