Archive for October 27th, 2008

Moving Admitted ER Patients

by Paul Rega, MD — published on October 27th, 2008

AP (10/27, Johnson) reports that study scheduled to be presented at a meeting of the American College of Emergency Physicians “found that no harm was caused by moving” emergency department (ED) “patients to upper-floor hallways when they were ready for admission.”

The research “is based on four years of” one hospital’s “experience with more than 2,000 patients admitted to hallways from the” ED. Prior to “the change, when [the] hospital filled up, patients were admitted but held in the [ED] in a common practice called boarding.” According to the study’s lead author, “on busy days, ‘things would grind to a halt and people would wait to be seen,’” as “infectious patients would wait in the [ED's] hallway for isolation rooms to open up elsewhere in the hospital.” The “study found slightly fewer deaths and intensive care unit admissions in the hallway patients compared to the standard bed patients.”

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categories: Emergency Medicine

Beta-blockers & CV Deaths

by Paul Rega, MD — published on October 27th, 2008

Relation of Beta-Blocker–Induced Heart Rate Lowering and Cardioprotection in Hypertension

Source:  J Am Coll Cardiol, 2008; 52:1482-1489, doi:10.1016/j.jacc.2008.06.048

Sripal Bangalore, MD, MHA, Sabrina Sawhney, MD and Franz H. Messerli, MD*

Department of Medicine, Division of Cardiology, St. Luke’s Roosevelt Hospital and Columbia University College of Physicians and Surgeons, New York, New York

ABSTRACT

Objectives: The purpose of this study was to evaluate the role of heart rate reduction with beta-blockers on the risk of cardiovascular events in patients with hypertension.

Background: Resting heart rate has been shown to be a risk factor for cardiovascular morbidity and mortality in the general population and in patients with heart disease such as hypertension, myocardial infarction, and heart failure. Conversely, pharmacological reduction of heart rate is beneficial for patients with heart disease. However, the role of pharmacological reduction of heart rate using beta-blockers in preventing cardiovascular events in patients with hypertension is not known.

Methods: We conducted a MEDLINE/EMBASE/CENTRAL database search of studies from 1966 to May 2008. We included randomized controlled trials that evaluated beta-blockers as first-line therapy for hypertension with follow-up for at least 1 year and with data on heart rate. We extracted the baseline characteristics, the blood pressure response, heart rate at the baseline and end of trial, and cardiovascular outcomes from each trial.

Results: Of 22 randomized controlled trials evaluating beta-blockers for hypertension, 9 studies reported heart rate data. The 9 studies evaluated 34,096 patients taking beta-blockers against 30,139 patients taking other antihypertensive agents and 3,987 patients receiving placebo. Paradoxically, a lower heart rate (as attained in the beta-blocker group at study end) was associated with a greater risk for the end points of all-cause mortality (r = –0.51; p < 0.0001), cardiovascular mortality (r = –0.61; p < 0.0001), myocardial infarction (r = –0.85; p < 0.0001), stroke (r = –0.20; p = 0.06), or heart failure (r = –0.64; p < 0.0001). The same was true when the heart rate difference between the 2 treatment modalities at the end of the study was compared with the relative risk reduction for cardiovascular events.

Conclusions: In contrast to patients with myocardial infarction and heart failure, beta-blocker–associated reduction in heart rate increased the risk of cardiovascular events and death for hypertensive patients.

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categories: Emergency Medicine

Infections & Football

by Paul Rega, MD — published on October 27th, 2008

NY Times, 10/25/08 (http://www.nytimes.com/2008/10/25/sports/football/25staph.html?_r=3&oref=slogin&partner=rssnyt&emc=rss&pagewanted=print)

The news in football this week often seemed ripped from the pages of a journal on infectious disease.

First there was Kellen Winslow, who received a one-game suspension after accusing the Browns of concealing his staph infection. Then there was the news that Peyton Manning had developed a similar condition in his left knee earlier this year. Finally, there was Tom Brady, whose rehabilitation from knee surgery has reportedly been delayed because of an unidentified infection, also in his left knee.

Despite the outbreak of headlines, several experts in sports medicine and epidemiology said the news only served to highlight how prevalent infections — especially staph infections — are among professional athletes and in the community at large.

“It seems like most of these are single-case episodes,” said Jeff Hageman, an epidemiologist for the Centers for Disease Control and Prevention. “What we know is that staph is one of the most common causes of skin infection in the community,” he said, accounting for between 12 million to 14 million doctor visits a year.

Like athletes in other contact sports, football players are prone to staph infections because of their sport’s skin-on-skin contact, the frequency of cuts and the warm, moist conditions in locker rooms, which encourage the growth of bacteria. Because they are regulars in surgery wards, athletes are susceptible to infections there, too.

Garden-variety versions of the staphylococcus bacteria are easily treated and have lurked in locker rooms for years, but the problem has received heightened attention in recent years because of the emergence of a strain known as MRSA, or methicillin-resistant Staphylococcus aureus, which is resistant to some types of antibiotics. Serious cases of MRSA have derailed the careers of a handful of N.F.L. players, including Brandon Noble, a former defensive tackle for the Washington Redskins, and Jeff Novak, a guard for the Jacksonville Jaguars who later sued the team doctor for malpractice.

“These things are here, they’re very serious,” said Noble, who had two bouts of MRSA in 2005 and is now the defensive line coach at West Chester University in Pennsylvania. With high-profile players in the news, he said, “maybe it’ll wake some people up and get the ball rolling.”

Winslow has not said whether his staph infection — his second in three years — was MRSA, but Manning’s infection was not, according to a statement the Colts released Friday. Brady, who contracted his infection after surgery, has not categorized it.

Greg Aiello, a spokesman for the National Football League, said the teams’ trainers and doctors met annually to discuss infections and other health concerns. “It’s an issue across the country,” he said. “It’s not an N.F.L. or a football player issue.”

A 2005 survey by the N.F.L. Team Physicians Society found that of the 30 teams that responded, 13 said a player had contracted a MRSA infection in recent years, for a total of 60 infections across the league. Andrew Tucker, the president of the society and the team doctor for the Ravens, said teams had access to information about staph infections through an internal injury reporting database, but the N.F.L. declined to release the data.

Football teams increased their efforts to battle staph after 2003, when a MRSA outbreak among the Rams resulted in eight infections. The Rams invited the C.D.C. to investigate their facility, and a 2005 study revealed some nose-wrinkling results — towels were being shared by as many as three players on the field, trainers did not always wash their hands when treating wounds, and players did not take showers before entering whirlpools. Football players were also taking antimicrobial drugs at 10 times the rate of the general public.

Jim Anderson, the Rams’ head trainer, said he was surprised when MRSA even turned up on ultrasound equipment and in the cold pools. Since then, the Rams have been more diligent about disinfecting surfaces in the locker rooms and other facilities. Like other teams, they speak to players before each season about sanitary practices, imparting common-sense advice like washing one’s hands, treating open cuts, and not sharing drinks.

“The biggest thing was making them aware of it,” Anderson said. Since then, although a handful of Rams players have developed staph, none have been MRSA.

After Winslow criticized the Browns for concealing his illness from teammates — a claim the team denies and that led to his suspension, which he is appealing — several news media reports noted that the Browns have had six cases of staph infections since 2005. Bill Bonsiewicz, a Browns spokesman, said in an e-mail message that Browns players have contracted seven cases of staph since 1999, including two MRSA cases separated by a few years. “Both players were aggressively treated and each returned to the field within a few weeks,” Bonsiewicz said. He declined to name the players, citing privacy reasons.

Tucker and Hageman said the frequency of staph infections among Browns players — spread over so many years — did not appear to be out of the ordinary. “You’re talking about one or two per year,” Tucker said. “That’s not a lot.”

Noble said that although teams were making an effort to prevent MRSA, eradicating the bacteria was nearly impossible. Locker rooms, after all, are filthy places. “There’s mud, there’s blood, there’s sweat, there’s spit,” he said. “It’s just a bunch of big, gross guys in a room together.”

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categories: Emergency Medicine

Nationwide 911 under stress

by Paul Rega, MD — published on October 27th, 2008

Washington Post, 10/26/08 (http://www.washingtonpost.com/wp-dyn/content/article/2008/10/25/AR2008102502052.html?nav=rss_health)

Widespread cellphone use and the need for time-consuming language translation have caused workloads and costs to jump for emergency 911 dispatch centers across the nation at a time when the economic downturn is pinching tax receipts and local and state governments are looking for ways to trim spending.

The trend is evident across the country and is particularly acute in the Washington area, where dozens of cellphone users have called to report a single accident on the Capital Beltway and where an ethnically diverse population requires dispatch centers to translate as many as 60 languages in a year.

“Commonly we see one single accident can generate 100 calls, and that’s not an exaggeration,” said Steve Souder, director of the Fairfax County Department of Public Safety Communications. “Everybody’s calling. And those calls have to be fielded. Each one has to be queried so that it is confirmed. We just can’t blow them off or treat any one less intensely than the one before.”

Fairfax, the region’s largest jurisdiction with almost 1.1 million people, is a case in point. Heavy traffic at the Springfield interchange, on Interstate 395, in Tysons Corner and along other major thoroughfares have helped fuel a jump in 911 calls from motorists who can now report a fender bender from behind the wheel rather than pull off the highway and find a pay phone.

Since 2000, annual wireless 911 calls in Fairfax have risen from 180,000 to 268,000, an almost 50 percent increase. That, in turn, has prompted the county to increase the call center staff from 154 to 204 and to increase local spending on 911 services from almost $2 million to more than $10 million (in Virginia, 911 services are funded in part with telephone tax receipts collected by the state). The program is still understaffed, however, so the county also pays police and fire officers overtime — with far higher base salaries than full-time dispatchers — to moonlight at the call center.

“It’s a terrific incentive to get bodies when you need them, but it’s not very efficient,” Souder said.

Call volumes are up across the nation, with widespread cellphone use to report emergencies causing 911 calling to jump from 150 million calls in 2000 to 240 million last year, according to the Association of Public Safety Communications Officials. In Loudoun County, 911 calls rose from 69,000 in 2000 to 98,000 in 2006. In the District, steadily increasing wireless calls have caused total volume to rise from 819,000 in 2004 to 1.3 million last year, officials said.

Montgomery County, almost as large as Fairfax, bucked the national trend and reported relatively even call volume in recent years. The county’s volume of cellular calls has risen, but land line calls have decreased proportionally, officials there said.

Demand for language translation also is increasing pressure on emergency dispatch centers. For years, governments have relied on a private company that dispatchers can call to find translators of dozens of languages. But use of the service has jumped dramatically this decade with growing diversity. In Fairfax, dispatchers fielded more than 17,000 calls in foreign languages last year, requiring interpretation of 66 different languages. All told, dispatchers spent 2,159 hours on such calls, compared with 384 hours in 1997.

In September alone, dispatchers listened to translations of Amharic, Arabic, Bulgarian, Farsi, French, German, Hindi, Japanese, Korean, Mandarin, Russian, Somali, Tagalog, Thai, Urdu and Vietnamese. In addition, they fielded 1,100 calls in Spanish.

The usage is noteworthy, officials said, because foreign language calls are time-consuming and have contributed to an increase in the average call duration in Fairfax from 79 seconds to 114. That, in turn, requires more staffing and more money, Souder said.

“They’re able to interpret, gosh, I forget how many hundreds of languages,” said Richard Taylor, president of the National Association of State 911 Administrators and the head of North Carolina’s 911 coordinating office. “And that takes time.” Taylor added that translation demands are up across the country.

“Fairfax County 911. What is your emergency?” Ben Andrews, 47, a county dispatcher, said into his headset on a recent weekday evening.

“Please, Spanish,” the caller replied. Andrews pushed a key on his computer keyboard and after about a minute was connected to a translator.

“Please ask him what is the emergency and where is the emergency,” Andrews said to the translator after identifying himself, giving an identification code and stating the language he needed translated. Andrews listened to the translation and the response, which detailed a domestic situation in an apartment near Seven Corners. “Are there drugs and alcohol present?” He listened to the translation, the response, the translation. “Are there any weapons?” He waited. “An officer will be there shortly.”

Souder recently presented the county Board of Supervisors with a list of cuts amounting to 15 percent of the department’s $12.7 million budget, an exercise that all county agencies have been required to do in the face of a $500 million spending shortfall. Souder told supervisors that because 911 is a core government function, the only way to save that much money would be to cut 17 positions.

It is not an option that supervisors will consider, and Souder hired 19 dispatchers this month who will be ready to field calls after four or five months of training. But the exercise illuminates one more area of local government where supervisors won’t be able to find much savings — and renders the task of finding areas where they will that much harder.

“There’s no way I would jeopardize public safety or diminish our ability to respond to public safety incidents,” said Supervisor Sharon S. Bulova (D-Braddock), who is chairman of the board’s budget committee. “That’s not to say we can’t find savings and efficiencies, and those will add up. We’ll do the best we can.”

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categories: Emergency Medicine

Rotateq seems to be effective

by Paul Rega, MD — published on October 27th, 2008

AP, 10/26/08 (http://ap.google.com/article/ALeqM5jLtdLSWx2w1a4gmTZ5GopJXYpW9AD941M1P00)

A vaccine against rotavirus, the leading cause of diarrhea in infants, has led to a dramatic drop in hospitalization and emergency room visits since it came on the market two years ago, doctors reported Saturday.

A bonus: the vaccine seems to be preventing illness even in unvaccinated children by cutting the number of infections in the community that kids can pick up and spread.

“We’re a little surprised by the degree of impact given the coverage we’ve achieved,” said Jane Seward of the federal Centers for Disease Control and Prevention. Only about half of young children had received the vaccine and very few had received all three doses when the studies were done.

Results were reported Saturday at an infectious diseases conference in Washington.

Before the vaccine, more than 200,000 U.S. children were taken to emergency rooms and more than 55,000 were hospitalized each year with rotavirus, which causes vomiting and diarrhea, mostly from January through May. Worldwide, the virus kills 1,600 young children each day.

Since Merck & Co.’s Rotateq came out in 2006, hospital visits and stays due to the virus have dropped 80 percent to 100 percent, studies by the CDC and several other groups show.

Last winter, rotavirus cases started and peaked two to three months later and were much less extensive than in previous years, CDC scientists report. Hospitals in a network that tracks these cases for the CDC saw more than an 80 percent drop in admissions from them, one study showed.

Another study, by Merck, found a 100 percent drop in hospitalizations and ER visits during the 2007 and 2008 rotavirus seasons compared to previous ones. The study was based on a review of health insurance claims for about 61,000 infants and diagnoses by doctors in routine clinical practice.

Rotateq is an oral vaccine given at two, four and six months of age. In June, a second rotavirus vaccine came on the market — GlaxoSmithKline’s Rotarix. It requires only two doses, completed by four months of age.

Also at the conference, scientists reported that a new version of Wyeth’s Prevnar vaccine seems to better protect kids against germs that cause pneumonia, meningitis and ear infections, but whether it makes it onto the market before dangerous strains become a big problem remains to be seen.

Scientists have been retooling Prevnar, which came on the market in 2000 and is advised for children under age 2. It protects against the seven strains of Strep bacteria that were causing the most serious infections at the time. Since then, new strains have become more of a threat and increasingly are resistant to common antibiotics.

The experimental new vaccine adds six of these to the original seven. Scientists from Wyeth and from Johannes Gutenberg University in Mainz, Germany, compared immune responses to the new vaccine, given to 293 babies, versus those of an equal number of babies given the old one.

The new vaccine did about as well as the old one on the original strains and well on five of the six new ones.

The company has said it plans to seek federal approval for it in early 2009, and review can take a year or more. British-based GlaxoSmithKline has a similar vaccine in final-phase testing that targets 10 strains common in Europe and other regions.

In the meantime, parents should continue to have their toddlers get the existing Prevnar, and to use antibiotics only when needed because they don’t work against the common cold and overuse worsens the bacteria resistance problem, said Dr. Cynthia Whitney, a pneumonia expert at the CDC.

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categories: Emergency Medicine

Sunscreens

by Paul Rega, MD — published on October 27th, 2008

Intro:  Researchers  say that in the USA, “there is currently no final regulation on testing and labeling of sunscreens for UVA protection.” 

In vitro assessments of UVA protection by popular sunscreens available in the United States
Steven Q. Wang, Joseph W. Stanfield, Uli Osterwalder
Journal of the American Academy of Dermatology – 03 October 2008 (10.1016/j.jaad.2008.07.043)

Background

The importance of adequate ultraviolet A (UVA) protection has become apparent with improved understanding of the mechanism of UVA-induced damage to tissues. Currently in the United States, there is no regulation on testing and labeling of sunscreens for UVA protection. In August 2007, the Food and Drug Administration (FDA) addressed this issue in a proposed rule.

Objectives

We sought to assess in vitro the degree of UVA protection provided by 13 popular sunscreen products that are commercially available in the United States.

Method

Thirteen sunscreen products were purchased. UVA protection of each product was measured and assessed with 3 in vitro UVA labeling indices: (1) the FDA Proposed Amendment of Final Monograph, August 27, 2007; (2) European Commission Recommendation—the Colipa and critical wavelength methods; (3) and United Kingdom’s Boots star rating system.

Results

Based on the new FDA-proposed guidelines, 8 products achieved the medium protection category, and 5 products achieved high protection. The latter 5 products also fulfilled the UVA protection based on the Colipa guideline desired by the European Commission Recommendation. Nine products achieved the desired critical wavelength value of 370 or higher. Based on the United Kingdom’s Boots star rating system, 6 products achieved a rating of 3 stars, and the remaining 7 products achieved no star rating.

Limitations

The study only evaluated a small number of sunscreen products, and only in vitro methods were used to assess the degree of UVA protection.

Conclusions

The majority of the tested sunscreens in this study offered a medium degree of UVA protection. Compared with the sunscreens in the past, this study shows that UVA protection of sunscreens has improved. Sunscreens with avobenzone and octocrylene provided a higher degree of UVA protection. Globally, there is no uniform standard on testing and labeling sunscreens for UVA protection. In the United States, the FDA has just started to create a much-needed standard. This effort is necessary to educate the public better on how to choose products with adequate UVA protection

 

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categories: Emergency Medicine

Botulism Table

by Paul Rega, MD — published on October 27th, 2008

Source: 

CMAJ. 2008 October 21; 179(9): 927–929.

doi: 10.1503/cmaj.080651.

 1

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categories: Emergency Medicine

Botulism Mimicking as SBO

by Paul Rega, MD — published on October 27th, 2008

Source:  CMAJ. 2008 October 21; 179(9): 927–929.

doi: 10.1503/cmaj.080651.

  

 

TITLE:  Bowel loops and eyelid droops

Jamie Spiegelman, MD, David W. Cescon, MD, Yael Friedman, MD, et al.

Abstract: A patient presented with a small-bowel obstruction associated with signs and symptoms of botulism. Fecal cultures were positive for viable Clostridium botulinum. This case emphasizes the importance of a broad differential diagnosis and doing a complete examination to account for all signs and symptoms.

The case: A 45-year-old man who was previously healthy presented to the emergency department with acute-onset abdominal distension and mild blurry vision. Despite self-induced vomiting, his abdominal distension worsened. A small-bowel obstruction was diagnosed based on his clinical presentation and the results of radiography. A computed tomography scan of the patient’s abdomen confirmed the obstruction, but did not add any further information. Despite nasogastric suctioning for 12 hours, the patient’s abdomen continued to distend, bowel sounds became diminished and signs of peritonitis (guarding, tenderness) appeared. To avoid bowel perforation, an exploratory laparotomy was performed. No obvious cause of the obstruction was identified.A neurologist was consulted 5 days later to assess the patient’s worsening neurologic symptoms, including ptosis (Figure 1), diplopia, dysphagia, aphonia and dry mouth. On examination, the patient’s vital signs were normal. Performing the Valsalva manoeuvre did not change his heart rate The patient had bilateral paralysis of cranial nerves 3, 4, 6, 7, 9 and 10. The patient’s pupils were initially dilated but they were sluggishly reactive to light. One day later, his pupils were unreactive to light (Figure 2). Neck flexion was weak, but appendicular strength was preserved. A neurophysiological assessment with repetitive nerve stimulation was performed, which showed an electro-incremental response on high-frequency stimulation, which was suggestive of a presynaptic disorder.

1

1

Botulism was highly suspected based on the clinical presentation and the neurophysiological findings. Serum, stool and gastric contents were sent for testing. A detailed history revealed no exposure to suspicious foods, and he had no sick contacts. Public health was notified immediately. We administered antitoxin based on his clinical presentation and the the progression of his pupillary symptoms. There was no subsequent progression of his symptoms. The patient’s bowel sounds returned 6 days after the exploratory laparotomy. The patient received nutrition through a nasogastric tube until his neurologic deficits improved. Speech sounds and other deficits gradually improved over several weeks.

Initial samples of the patient’s serum, feces and gastric contents as well as food sources were all negative for botulinum neurotoxin and viable Clostridium botulinum. Two fecal samples, taken about 2 and 8 weeks after the onset of symptoms, both tested positive for viable C. botulinum type B. Because the results were positive for C. botulinum type B and negative for toxins, we suspected colonization botulism rather than foodborne botulism. The patient received no further therapy because his symptoms were improving. He remained in hospital with supportive care for 1 month until his dysphagia resolved.

Botulism is a rare neuroparalytic illness caused by a neurotoxin produced by C. botulinum. Botulinum neurotoxin causes irreversible inhibition of acetylcholine release, which affects both the autonomic and somatic systems.1 Although rare, it remains an important public health concern. From 2000 to 2005, there was an average of 5.8 cases of botulism reported each year in Canada.2–5 A complete review of the patient’s systems and a physical examination, including cranial nerves, will help to establish the diagnosis.6

There are 4 natural forms of clinical botulism: foodborne, infant, wound and adult intestinal colonization. Foodborne botulism is caused by ingestion of food contaminated with 1 of 4 serotypes of neurotoxin (A, B, E or F). Foodborne illness in adults can be caused by a variety of foods. Symptoms typically begin 12–36 hours after ingestion and include vomiting and diarrhea, followed by 1 or more of ptosis, visual disturbance, dilated and fixed pupils, dysphagia, dry mouth and dysphonia. These symptoms may progress to a descending symmetric flaccid paralysis in an alert afebrile person. Constipation may occur later in the presentation. Infant botulism results from ingestion of spores, followed by germination and colonization in the intestine. Wound botulism may result from contamination of wounds by soil or injection of illicit drugs. The symptoms of wound botulism are similar to that of the foodborne form, however, vomiting and diarrhea do not occur. Adult intestinal colonization botulism is caused by ingestion of spores that germinate in the colon. The risk factors for adult intestinal colonization botulism include bowel abnormality, previous bowel surgery, Meckel diverticulum, Crohn disease and long-term antimicrobial therapy.

Once botulism is suspected, the local public health unit and the Botulism Reference Service for Canada should be notified immediately. Samples of the patient’s feces and gastric contents as well as suspect foods should be tested for botulinum neurotoxin and viable C. botulinum. Serum should be tested for botulinum neurotoxin. After appropriate samples are collected, treatment with antitoxin should be considered. Antitoxin against type A, B and E is typically administered. The benefit of this therapy is greatest within the first 24 hours after the onset of symptoms. Respiratory monitoring and support is essential. If flaccid paralysis occurs, it can not be reversed by antitoxin; however, the antitoxin neutralizes circulating toxins and prevents progression of symptoms.

REFERENCES

 

Brook I. Botulism: the challenge of diagnosis and treatment. Rev Neurol Dis 2006;3:182-9. [PubMed].

2.

Public Health Agency of Canada. Notifiable diseases summary. Can Commun Dis Rep 2002;28:50.

3.

Public Health Agency of Canada. Notifiable diseases summary. Can Commun Dis Rep 2004;30:182. [PubMed].

4.

Public Health Agency of Canada. Notifiable diseases summary. Can Commun Dis Rep 2005;31:238.

5.

Public Health Agency of Canada. Notifiable diseases summary. Can Commun Dis Rep 2006;32:200.

6.

Cai S, Singh BR, Sharma S. Botulism diagnostics: from clinical symptoms to in vitro assays. Crit Rev Microbiol 2007;33:109-25. [PubMed].

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categories: Emergency Medicine

OMNI Postings of 10/27/08

by Paul Rega, MD — published on October 27th, 2008
On Oct. 27, 1904, the first rapid transit subway, the IRT, opened in New York City.  As the invited celebrities and big-wigs exited the train at 42nd Street they were greeted by the Big Apple’s Inaugural Hooker, Pick-Pocket & Mime Society.
But I digress…
1)  How do you work up a child with a seemingly innocuous conjunctivitis who is also on immunosuppressive therapy?  There are photos and everything.
2)  This might make to morning news shows.  Seems that Hong Kong is reporting that eggs they’ve imported from China also contain — you guessed it— melamine.  Might this discovery affect the U.S.?  Not sure.  The FDA says we’re mainly OK except for a few products that may have found their way into Asian grocery stores. It all depends on how much trust you have in an underfinanced, undermanned federal agency.
3)  Thoratec Corporation is initiating a worldwide medical device correction of some of the HeartMate II Left Ventricular Assist Systems. Over time, wear and fatigue of the percutaneous lead connecting the HeartMate II LVAS blood pump with the System Controller may result in damage that could interrupt pump function, require reoperation to replace the pump and potentially result in serious injury or death. The estimated probability of the need for pump replacement due to percutaneous lead damage is 1.3% at 12 months, 6.5% at 24 months and 11.4% at 36 months.  Big ooops there.
4)  There is a movement afoot to compel physicians with direct patient contact to get flu shots.  You can still refuse, but you’ll have to walk around with a Scarlet “F” on your clothes. 

Chinese Eggs Contaminated with Melamine?

by Paul Rega, MD — published on October 27th, 2008

NY Times, 10/27/08 (http://www.nytimes.com/2008/10/27/world/asia/27china.html?_r=1&th&emc=th&oref=slogin)

Hong Kong food inspectors have found eggs imported from northeast China to be contaminated with high levels of melamine, the toxic industrial additive at the heart of an adulteration scandal in Chinese milk products.

The findings, reported over the weekend, have raised new concerns that a far wider array of China-produced foods than previously believed could be contaminated with melamine, which has already sickened more than 50,000 children in China and led to at least four deaths.

Scientists in China worry that in addition to being used to adulterate dairy supplies, melamine may have been intentionally added to animal feed in China, according to a report published on Sunday in South China Morning Post. Tainted chicken and possibly fish and hog feed could result in poisonous meat and seafood, it said.

China is struggling to cope with a milk scandal that has devastated its fast-growing dairy industry and led to a global recall of foods that were made using Chinese dairy products, including pizza, biscuits, yogurt and other goods.

The Chinese government, which first reported melamine-tainted dairy products in mid-September, has vowed to strengthen food safety measures and severely punish those involved in adulterating food.

The government accused rogue dairy producers and middlemen of intentionally spiking dairy supplies with melamine to save money, using the chemical as a cheap filler that can artificially inflate protein readings.

In September, Beijing ordered a huge recall of dairy products and arrested dozens of people suspected of illegally adulterating food with melamine, which is used to make plastic and fertilizer. But the government has not made it clear whether it has been testing a wider variety of food products for contamination by melamine, which can cause kidney stones and other ailments.

There were also indications over the weekend that the contamination may have reached far more children in China than reported. Health officials said Sunday that a broad survey of homes in Beijing had found that nearly a quarter of the 300,000 families with children younger than 3, about 74,000 families, had a child who had been fed melamine-tainted milk.

The government said it was a door-to-door survey conducted between late September and late October but did not say how many children had fallen ill.

At a news conference after an Asian-European summit meeting in Beijing on Saturday, Prime Minister Wen Jiabao pledged to strengthen food safety to meet international standards.

He also said the government was partly to blame for the scandal because of “lax supervision.”

The milk scandal surfaced in September, slightly more than a year after tainted pet food was exported to the United States, sickening cats and dogs and touching off global criticism of China’s food safety controls.

Beijing responded defiantly to some critics of its record, but late last year it also announced a crackdown on shoddy and unsafe food producers and ordered the closing of thousands of slaughterhouses and food factories.

During that time, several Chinese melamine suppliers admitted in newspaper interviews to selling melamine to animal feed operations and fish feed providers in China. The government, however, never reported finding melamine-tainted fish or animal feed in China’s food supply.

The discovery of contaminated eggs in Hong Kong was announced Saturday by the Center for Food Safety, a Hong Kong government agency, which said the eggs had been imported from a farm in the city of Dalian, in northeastern China. The center reported that the melamine level was almost double the legal limit for food sold in Hong Kong.

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categories: Emergency Medicine

A Red Eye in a 2-Year-Old

by Paul Rega, MD — published on October 27th, 2008
by James H. Brien, DO
Special to Infectious Diseases in Children (http://www.idinchildren.com/200810/wyd.asp)

 A 23-month-old girl was admitted for evaluation and treatment of a red left eye. The history of the chief complaint began with the onset of mild swelling of the left eye lids and erythema of the left eye with scant, clear discharge a few days earlier. The swelling seemed worse in the morning on awakening, and has persisted. There is no significant pain or itching associated with the problem, and she has been afebrile. She has no history of trauma to the area.

Her past medical history is complicated by having been diagnosed with biliary atresia as an infant, ultimately requiring a liver transplant eight months ago. As a result, she is on chronic immunosuppressive therapy with prednisone and tacrolimus (Prograf, Astellas). She also receives trimethoprim/sulfamethoxazole prophylaxis.

On review of systems, her mother related that the child had a minor cough and runny nose that began about the same time as the eye problem. There are no known allergies and her immunizations are somewhat delayed.

On examination, her vital signs are normal, with no fever or distress. The pertinent findings include the mild, painless swelling of her left eye lids as shown in figure 2. The left eye also is erythematous with a small amount of discharge (figure 3), and a mucopurulent nasal discharge is also noted (figure 4). Her eye had full range of motion and the fundoscopic exam was normal. The rest of her examination was unremarkable, but because of her immunosuppressed state, she had a computed tomography scan of the orbits (figures 5 and 6), showing some mild preseptal swelling and fluid in the maxillary and ethmoid sinuses.

Lab tests included a normal complete blood count with blood culture pending. Eye swabs were sent for bacterial and viral cultures.

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Answer:  “…This turned out to be  enteroviral conjunctivitis,  that presented in a compromised patient with some elements concerning for possible bacterial cellulitis of the preseptal tissues, which provoked more imaging and lab tests that an otherwise “normal” patient might have had. Because of this, the patient received empiric intravenous antibiotics (ceftriaxone plus clindamycin) and went home 48 hours later on comparable oral therapy, even though all bacterial cultures were negative prior to discharge, which is not an unusual scenario…”

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categories: Emergency Medicine