Archive for November, 2008

OMNI Postings of 11/30/08

by Paul Rega, MD — published on November 30th, 2008
On this date in 1700, Turkey declares war on Russia.  Claims Russia took more than her share of the white meat!

But I digress…
1)  Take a look at this nose!  It started with a pimple and now even Mom is thinking about leaving the kid alone in the zoo at midnight.
2)  We may not know what this is, but, I think, we would all agree that this baby needs antibiotics and admission.  Anything else?
3)  This study trended acute exacerbations of COPD (AECOPD) between 1993 and 2005.  There was an average annual 0.6 million ED visits for AECOPD, and the visit rates were consistently high (3.2 per 1,000 U.S. population).  The use of systemic corticosteroids increased from 29% in 1993–1994 to 60% in 2005, antibiotics increased from 14% to 42%.
4)  Somebody comes in with definite musculoskeletal pain.  Your analgesic of choice?  Morphine IV or oxycodone PO?  This study showed that it took longer to give MS and the analgesic results were similar after 30 minutes of observation, but patient satisfaction was greater with getting MS.  And after all, isn’t that what really matters!
Bundle up,
Paul R.
Comments Off
categories: Emergency Medicine

What a Nose!

by Paul Rega, MD — published on November 30th, 2008

This 4-year-old boy (http://www.idinchildren.com/200604/spot.asp) presented to the office with a history of crusting and drainage of the surface of the nose for several weeks. His parents said the lesion initially looked like a mosquito bite and then progressed to its appearance at the time of presentation.

Previously, a simple wound culture for bacteria was negative. He had been treated with antibiotics and prednisone with little or no improvement. The lesion has continued to spread slowly. He lives on a farm in Indiana. His family owns a few livestock, chickens and two cats.

                       1

The child’s physician sent fresh tissue from a biopsy for culture and grew Sporothrix schenckii.

S. schenckii is a dimorphic fungus, which grows as an oval or cigar-shaped yeast 98.6°F. It can be found in soil, hay, straw, thorny plants (especially roses), sphagnum moss and decaying vegetation.

Cutaneous sporotrichosis is the most common manifestation of an infection with S. schenckii. Inoculation occurs in the presence of a minor break in the skin. After one to 12 weeks, a painless nodule, which is typically red or violaceous, appears at the site of the inoculation. More nodules develop, and these tend to open, ulcerate and drain. Pulmonary and disseminated forms of sporotrichosis can be seen in immunocompromised patients.

Differential diagnoses for this condition should include herpes, mycetoma, blastomycosis, chromoblastomycosis, mycobacterium infections and discoid lupus.

Our patient was treated for three months with saturated solution of potassium iodide. He healed with scarring. Itraconazole is approved for treatment of cutaneous and lymphocutaneous sporotrichosis in adults; however, the 2003 Red Book states: “Although there are no controlled trials to document the efficacy of itraconazole in pediatric patients, most experts consider itraconazole the preferred treatment”.

Immunocompromised patients with disseminated sporotrichosis often require treatment with amphotericin B.

Recommendations for prevention include wearing gloves and long sleeves when working with materials where the fungus can be found.

Comments Off
categories: Emergency Medicine

Baby with Fever & Rash

by Paul Rega, MD — published on November 30th, 2008

This 11-month-old boy (http://www.idinchildren.com/200603/spot.asp) presented with a four-day history of vesicular rash with erosions and desquamation. The rash initially appeared on his trunk, then progressed to the rest of his body. His review of systems was positive for fever (101.8ºF) and irritability, as well as cough and rhinorrhea one week prior to presentation. He received either acetaminophen (Tylenol, Ortho-McNeil) or ibuprofen for his fever, according to his mother’s history. He has a sister who was seen about two weeks prior for a skin eruption on her arm, which was diagnosed as pityriasis rosea. What do you think is the diagnosis?

                          1

This patient had varicella with superimposed Staphylococcus aureus. An initial Tzanck test was negative. His cultures were positive for methicillin-sensitive S. aureus. He was initially treated with IV acyclovir, clindamycin, oxacillin and vancomycin. Oral acyclovir, linezolid (Zyvox, Pfizer) and cephalexin were administered when the diagnoses of varicella and S. aureus were made.

Varicella zoster virus is a herpes virus responsible for varicella (chickenpox) and herpes zoster (shingles). Varicella occurs in 90% of U.S. children before age 10 years. The incubation period may last 14 to 16 days, with a one- to three-day prodrome consisting of fever, respiratory symptoms and headache, especially in older patients. The exanthem consists of pruritic red macules that rapidly develop into vesicles with surrounding erythema, giving the characteristic “dew drop on a rose petal” appearance; these then form pustules that scab over. The lesions are typically found on the trunk and face; however, the scalp and mucosal surfaces may also become involved.

The most common complication is secondary bacterial infection (2% to 3% of children) with staphylococci or group A streptococci. Staphylococcal infections may be toxin-mediated (scalded skin syndrome, toxic shock syndrome) or suppurative (impetigo, abscesses). Other complications from varicella include encephalitis, thrombocytopenia, arthritis, hepatitis, cerebellar ataxia, meningitis and glomerulonephritis. Immunocompromised patients may develop varicella pneumonia or hemorrhagic varicella lesions.

Transmission occurs most commonly through respiratory droplets. Infection through direct contact with vesicular fluid is also possible.

Varicella is usually diagnosed clinically from the history and physical. Tzanck smear from an intact vesicle may demonstrate multinucleated giant cells. The diagnosis may also be made from direct fluorescent antibody staining or viral culture of fluid from a fresh vesicle.

The differential diagnosis includes herpes simplex virus, vesicular viral exanthems (coxsackie, enterocytopathic human orphan), impetigo, papular urticaria, scabies, drug eruption, contact dermatitis or folliculitis.

Treatment consists of supportive measures such as antipyretics, antihistamines, calamine lotion and tepid baths. Salicylates should be avoided due to the risk of Reye’s syndrome. Acyclovir given within 24 to 72 hours after onset of rash can result in a modest decrease in duration and symptoms. IV acyclovir is indicated for immunocompromised patients or high-risk neonates. Oral acyclovir should be reserved for immunocompetent patients at increased risk of moderate-to-severe varicella. Famciclovir (Famvir, Novartis) and valacyclovir (Valtrex, GlaxoSmithKline) are other antiviral agents licensed for treatment of adults; safety and efficacy, however, have not been established in children.

The varicella vaccine is more than 95% effective in preventing moderate-to-severe disease, and 70% to 85% effective in preventing mild disease. Recommendations for vaccination are one dose in children 12 years of age or younger, or two doses four to eight weeks apart in patients older than 12. About 1% to 4% of vaccinated children may develop a mild varicellalike reaction consisting of insect bitelike papules, low-grade fever and rapid recovery.

For more information:

  • Bolognia, JL, Jorizzo J, Rupini R. Dermatology. Vol.1. Philadelphia, PA: Mosby; 2003: 1241-1243.
  • Pickering LK, ed. Staphylococcal infections. In: American Academy of Pediatrics. Red Book: 2003 Report of the Committee on Infectious Diseases. 26th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2003: 573-574, 672-683.
  • Pickering LK, ed. Varicella-zoster infections. In: American Academy of Pediatrics. Red Book: 2003 Report of the Committee on Infectious Diseases. 26th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2003: 672-683.
Comments Off
categories: Emergency Medicine

OMNI Postings of 11/29/08

by Paul Rega, MD — published on November 29th, 2008
On March 23, 1994, the medical examiner viewed the body of Ronald Opus and concluded that he died from a shotgun wound to the head. The decedent had jumped from the top of a ten-story building intending to commit suicide.

He left a note to that effect indicating his despondency. As he fell past the ninth floor, his life was interrupted by a shotgun blast passing through a window, which killed him instantly. Neither the shooter nor the decedent was aware that a safety net had been installed just below at the eighth floor level to protect some building workers and that Ronald Opus would not have been able to complete his suicide the way he had planned.

Ordinarily, Dr. Mills continued, “a person who sets out to commit suicide and ultimately succeeds, even though the mechanism might not be what he intended” is still defined as committing suicide. Mr. Opus was shot on the way to certain death nine stories below at street level, but his suicide attempt probably would not have been successful because of the safety net. This caused the medical examiner to feel that he had a homicide on his hands.

The room on the ninth floor from whence the shotgun blast emanated was occupied by an elderly man and his wife. They were arguing vigorously, and he was threatening her with a shotgun. The man was so upset that when he pulled the trigger he completely missed his wife and the pellets went through the window striking Mr. Opus.

When one intends to kill subject A, but kills subject B in the attempt, one is guilty of the murder of subject B. When confronted with the murder charge, the old man and his wife were both adamant. They both said they thought the shotgun was unloaded. The old man said it was his long standing habit to threaten his wife with the unloaded shotgun. He had no intention to murder her. Therefore the killing of Mr. Opus appeared to be an accident, that is, the gun had been accidentally loaded.

The continuing investigation turned up a witness who saw the old couple’s son loading the shotgun about six weeks prior to the fatal accident. It transpired that the old lady had cut off her son’s financial support and the son, knowing the propensity of his father to use the shotgun threateningly, loaded the gun with the expectation that his father would shoot his mother.

The case now becomes one of murder on the part of the son for the death of Ronald Opus.

Now comes the exquisite twist. Further investigation revealed that the son was in fact Ronald Opus. He had become increasingly despondent over both the loss of his financial support and the failure of his attempt to engineer his mother’s murder. This led him to jump off the ten-story building on March 23rd, only to be killed by a shotgun blast passing through the ninth-story window. The son had actually murdered himself, so the medical examiner closed the case as a suicide.

But I digress…

1)  This graph trends the decline of lung cancer cases among men over the recent years.  Sadly, the trend is not as impressive among women.  In fact, the trend among women is scary.
2)  This abstract from Acad Emerg Med presents a unique way to teach about the medicolegal issues in emergency medicine.  The first part is a patient simulation that goes horribly wrong.  That’s then followed by a legal deposition simulation.  According to the results, the participants were profoundly affected.  They gave up medicine and became monks in the Swiss Alps.
3)  How many of you add Decadron to your migraine cocktail protocol?  A pooled analysis of seven trials involving 742 patients suggests a modest but significant benefit when dexamethasone is added to standard antimigraine therapy to reduce the rate of patients with moderate or severe headache on 24- to 72-hour follow-up evaluation.
4)  This is a report from the Concern Network.  There was a loud explosion, a window was shattered and on top of the pilot’s helmet were the remains of a freaking, fouled-up fowl.
Au revoir,
Paul R.
Comments Off
categories: Emergency Medicine

Chopper 1 – Bird 0

by Paul Rega, MD — published on November 29th, 2008

Date: 11/20/2008 1926 CST

Program: Vanderbilt LifeFlight

Type: BK117B-2
Tail #: N164AM
Operator/Vendor: Air Methods

Weather: Clear. Not a factor

Team: Pilot, flight nurse and flight nurse. No injuries reported. No patient.

Description:
    While responding to an interfacility transport at cruise flight of
    2000ft MSL, an extremely loud explosion was heard. No change in
    aircraft control with no Master Warning light and all instruments were
    normal. With further assessment the pilots greenhouse was shattered
    and at the top of the pilots helmet was covered with the bird remains.
    Aircraft had just past over a rural uncontrolled airport and aborted
    flight to land at the airport.  Aircraft was put out of service to be
    inspected by maintenance. 

Additional Info:
    Aircraft window is to be replaced.

Source: Lis Henley, RN, Chief Flight Nurse, LF3

Comments Off
categories: Emergency Medicine

OMNI Postings of 11/28/08

by Paul Rega, MD — published on November 28th, 2008
How was the turkey?  I mean the fowl, not your  brother-in-law.
But I digress…
1)  Do inhaled corticosteroids have a place in stable COPD?  This meta-analysis published in JAMA concluded that steroids did not affect mortality between those on steroids and controls, but those on steroids had a higher incidence of pneumonia as well as being able to push a car uphill.
2)  Just because your patient is a kid doesn’t mean they don’t have a clot.  It’s rare, but children can have Antiphospholipid Syndrome.  Antiphospholipid antibodies predispose kids, as well as adults, to abnormal clotting.  This abstract talks about when it might show up and the types of pathology.
3)  This is a news article indirectly addressing the nursing shortage.  By 2020, the nursing supply/demand will be -29%.  So, the article discusses ways of keeping nurses happy and avoiding burnout.  Some hospitals help keep nurses happy by recruiting volunteers — unpaid nurses with current licenses who provide an extra set of eyes, ears and hands to the nurses on staff.
4)  You can’t turn the TV on without being inundated with ads on Viagra, Cialis, and Boniva.  It’s so overwhelming.  You see Sally Fields sitting in a hot tub waiting for her bones to strengthen while her mate figures out a way to get her up to the bedroom because he just got “his” prescription refilled!  Now, the FDA is considering whether to invite viewers who buy these drugs to notify them when they get an adverse reaction.  That’s opening up a Pandora’s box, to my way of thinking.  Lady:  “Hello?  FDA?”  FDA:  “Good day, madam.  How may we help you?”   Lady:  “I wish to report a side effect.”    FDA:  “What drug are you on?”   Lady: “Boniva.”  FDA:  “What was the side -effect?”   Lady:  “When I pass gas, it smells like a Flying Nun!”
5)  The incidence of new cancer cases has been on the decline in recent years.  Cancer diagnosis rates decreased by an average of 0.8 percent each year from 1999 to 2005
Bye,
Paul R.
Comments Off
categories: Emergency Medicine

COPD Trends

by Paul Rega, MD — published on November 28th, 2008

National Study of Emergency Department Visits for Acute Exacerbation of Chronic Obstructive Pulmonary Disease, 1993–2005 
Chu-Lin Tsai, Justin A. Sobrino, Carlos A. Camargo Jr
Acad Emerg Med Published Online: Oct 27 2008 1:25PM
DOI: 10.1111/j.1553-2712.2008.00284.x

ABSTRACT

Objectives: Little is known about recent trends in U.S. emergency department (ED) visits for acute exacerbation of chronic obstructive pulmonary disease (AECOPD) or about ED management of AECOPD. This study aimed to describe the epidemiology of ED visits for AECOPD and to evaluate concordance with guideline-recommended care.

Methods: Data were obtained from National Hospital Ambulatory Medical Care Survey (NHAMCS). ED visits for AECOPD, during 1993 to 2005, were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Concordance with guideline recommendations was evaluated using process measures.

Results: Over the 13-year study period, there was an average annual 0.6 million ED visits for AECOPD, and the visit rates for AECOPD were consistently high (3.2 per 1,000 U.S. population; Ptrend = 0.13). The trends in the use of chest radiograph, pulse oximetry, or bronchodilator remained stable (all Ptrend > 0.5). By contrast, the use of systemic corticosteroids increased from 29% in 1993–1994 to 60% in 2005, antibiotics increased from 14% to 42%, and methylxanthines decreased from 15% to <1% (all Ptrend < 0.001). Multivariable analysis showed patients in the South (vs. the Northeast) were less likely to receive systemic corticosteroids (odds ratio [OR] = 0.6; 95% confidence interval [CI] = 0.4 to 0.9).

Conclusions: The high burden of ED visits for AECOPD persisted. Overall concordance with guideline-recommended care for AECOPD was moderate, and some emergency treatments had improved over time.

Comments Off
categories: Emergency Medicine

Migraines & Decadron

by Paul Rega, MD — published on November 28th, 2008

Does the Addition of Dexamethasone to Standard Therapy for Acute Migraine Headache Decrease the Incidence of Recurrent Headache for Patients Treated in the Emergency Department? A Meta-analysis and Systematic Review of the Literature (p )
Amandeep Singh, Harrison J. Alter, Brita Zaia
Acad Emerg Med Published Online: Oct 27 2008 1:26PM
DOI: 10.1111/j.1553-2712.2008.00283.x

ABSTRACT

Objectives: Neurogenic inflammation is thought to play a role in the development and perpetuation of migraine headache. The emergency department (ED) administration of dexamethasone in addition to standard antimigraine therapy has been used to decrease the incidence of recurrent headaches at 24 to 72 hours following evaluation. This systematic review details the completed trials that have evaluated the use of dexamethasone in this role.

Methods: The authors searched MEDLINE, EMBASE, CINAHL, LILACS, recent emergency medicine scientific abstracts, and several prepublication trial registries for potential investigations related to the research question. The authors included studies that incorporated randomized, double-blind, placebo-controlled methodology and that were performed in the ED. A fixed-effects and random-effects model was used to obtain summary risk ratios (RRs) and 95% confidence intervals (CIs) for the self-reported outcome of moderate or severe headache on follow-up evaluation.

Results: A pooled analysis of seven trials involving 742 patients suggests a modest but significant benefit when dexamethasone is added to standard antimigraine therapy to reduce the rate of patients with moderate or severe headache on 24- to 72-hour follow-up evaluation (RR = 0.87, 95% CI = 0.80 to 0.95; absolute risk reduction = 9.7%). The treatment of 1,000 patients with acute migraine headache using dexamethasone in addition to standard antimigraine therapy would be expected to prevent 97 patients from experiencing the outcome of moderate or severe headache at 24 to 72 hours after ED evaluation. The sensitivity analysis yielded similar results with sequential trial elimination, indicating that no single trial was responsible for the overall result. Adverse effects related to the administration of a single dose of dexamethasone were infrequent, mild, and transient.

Conclusions: These results suggest that dexamethasone is efficacious in preventing headache recurrence and safe when added to standard treatment for the management of acute migraine headache in the ED.

 

Comments Off
categories: Emergency Medicine

Musculoskeletal Pain & Opioids

by Paul Rega, MD — published on November 28th, 2008

Oral versus Intravenous Opioid Dosing for the Initial Treatment of Acute Musculoskeletal Pain in the Emergency Department
James R. Miner, Johanna Moore, Richard O. Gray, Lisa Skinner, Michelle H. Biros
Acad Emerg Med Published Online: Oct 17 2008 11:04AM
DOI: 10.1111/j.1553-2712.2008.00266.x

ABSTRACT

Objectives: The objective was to compare the time to medication administration, the side effects, and the analgesic effect at sequential time points after medication administration of an oral treatment strategy using oxycodone solution with an intravenous (IV) treatment strategy using morphine sulfate for the initial treatment of musculoskeletal pain in emergency department (ED) patients.

Methods: This was a prospective randomized clinical trial of patients >6 years old who were going to receive IV morphine sulfate for the treatment of musculoskeletal pain but did not yet have an IV. Consenting patients were randomized to have the treating physician order either 0.1 mg/kg morphine sulfate IV or 0.125 mg/kg oxycodone orally in a 5 mg/5 mL suspension as their initial treatment for pain. The time from the placement of the order to the administration of the medication was recorded. Pain was measured using a 100-mm visual analog scale (VAS) and recorded at 0, 10, 20, 30 and 40 minutes after drug administration.

Results: A total of 405 eligible patients were identified during the study period; 328 (81.0%) patients consented to be in the study. A total of 158 patients were randomized to the IV morphine sulfate treatment group, and 162 were randomized to the oral oxycodone treatment group. Of the patients who were randomized to IV therapy, 34 were withdrawn from the study prior to drug administration; leaving 125 patients in the IV group for analysis. Of the patients who randomized to oral therapy, 22 were withdrawn from the study prior to drug administration, leaving 140 patients for analysis. No serious adverse events were detected. There was a 12-minute difference between the median time of the order and the administration of oral oxycodone (8.5 minutes) and IV morphine (20.5 minutes). The mean percent change in VAS score was larger for patients in the IV therapy group than those in the oral therapy group at 10 and 20 minutes. At 30 and 40 minutes, the authors could no longer detect a difference. The satisfaction scale score was higher after treatment for the morphine group (median = 4; interquartile range [IQR] = 4 to 5) than for the oxycodone group (median = 4; IQR = 2 to 5; p = 0.008).

Conclusions: The oral loading strategy was associated with delayed onset of analgesia and decreased patient satisfaction, but a shorter time to administration. The oral loading strategy using an oxycodone solution provided similar pain relief to the IV strategy using morphine 30 minutes after administration of the drug. Oral 0.125 mg/kg oxycodone represents a feasible alternative to 0.1 mg/kg IV morphine in the treatment of severe acute musculoskeletal pain when difficult or delayed IV placement greater than 30 minutes presents a barrier to treatment.

 

Comments Off
categories: Emergency Medicine

IV N-acetylcysteine

by Paul Rega, MD — published on November 28th, 2008

Hepatotoxicity Despite Early Administration of Intravenous N-Acetylcysteine for Acute Acetaminophen Overdose (p )
Suzanne Doyon, Wendy Klein-Schwartz
Acad Emerg Med Published Online: Nov 10 2008 3:02PM
DOI: 10.1111/j.1553-2712.2008.00296.x
 ABSTRACT

Objectives: The objective was to evaluate the effectiveness of intravenous N-acetylcysteine (IV NAC; 300 mg/kg over 21 hours) in early acute acetaminophen (APAP) overdose patients.

Methods: This observational case series included patients hospitalized between 2004 and 2007 for acute APAP overdoses and who were reported to a regional poison center. Inclusion criteria were plasma APAP concentrations on or above the treatment line on the Rumack-Matthew nomogram, administration of IV NAC within 8 hours of ingestion, and follow-up to known outcome. The hospital chart of each patient who received IV NAC for longer than the standard 21 hours was reviewed. Hepatotoxicity was defined as hepatic aminotransferase levels greater than 1,000 IU/L.

Results: Seventy-seven patients met inclusion criteria and received at least 21 hours of IV NAC for an acute APAP overdose. Seven patients received antidotal therapy for greater than 21 hours. These patients tended to have ingested combination preparations, have very high initial plasma APAP concentrations, and had persistently elevated plasma concentrations during their hospital stay. Hepatotoxicity occurred in 4 patients (5.2%, 95% confidence interval [CI] = 0.2% to 10.1%), including 1 death and 1 liver transplantation.

Conclusions: Hepatotoxicity developed in 5.2% of cases, suggesting that the 21-hour IV NAC regimen is suboptimal in some patients. In addition to high initial plasma APAP concentrations, APAP product formulation and persistently elevated plasma APAP concentrations were identified as factors possibly associated with developing hepatotoxicity. The authors propose a tailored approach to the discontinuation of IV NAC and point out the need for reevaluation of optimal doses and duration of therapy.

Comments Off
categories: Emergency Medicine

Unique Way to Teach Medical Malpractice

by Paul Rega, MD — published on November 28th, 2008

Medical Malpractice: Utilization of Layered Simulation for Resident Education (p 1175-1180)
Nathaniel Ryan Schlicher, Raymond P. Ten Eyck
Acad Emerg Med Published Online: Jul 8 2008 4:59PM
DOI: 10.1111/j.1553-2712.2008.00165.x

ABSTRACT

Objectives: The authors present a novel approach to the use of simulation in medical education with a two-event layered simulation. A patient care simulation with an adverse outcome was followed by a simulated deposition.

Methods: Senior residents in an academic emergency medicine (EM) program were solicited as simulation research volunteers. Other than stating that the research involved adverse outcomes, no identifying information was given. Seven volunteers participated in a simulation involving a forced error (nurse confederate gave an incorrect medication dose). Six weeks later based on the initial simulation, one physician completed a simulated deposition in a teaching conference conducted by a licensed attorney with malpractice experience. The audience, consisting of residents, attendings, and students, watched a recording of the patient care, witnessed the deposition, and evaluated the experience using a 17-question survey with 5-point Likert scales.

Results: Participants felt that overall the training program was a useful educational tool (mean ± standard deviation [SD] Likert score = 4.63 ± 0.49) that would change aspects of their practice (3.31 ± 0.85). Participants stated that they would be more careful in their documentation (3.88 ± 0.60), review high-risk situations with staff (4.00 ± 0.71), and monitor more carefully for errors (3.95 ± 0.74). There was increased fear of the litigation process (3.95 ± 1.18), but participants felt the experience would help improve the risk profile of their practices (3.71 ± 0.68).

Conclusions: A novel approach to medical education was successful in changing attitudes and provided an expanded educational experience for participants. Layered simulation can be successfully incorporated into educational programs for numerous issues including medical malpractice.

 

 

Comments Off
categories: Emergency Medicine

Graphic: Lung Cancer Cases

by Paul Rega, MD — published on November 28th, 2008

 

 

                                           1

Comments Off
categories: Emergency Medicine

U.S.: Decline in Cancer Cases

by Paul Rega, MD — published on November 28th, 2008

NY Times, 11/26/08 (http://www.nytimes.com/2008/11/26/health/research/26cancer.html?_r=1&sq=+&st=nyt&%2334;lung%20cancer=&%2334;=&scp=1&pagewanted=print)

The incidence of new cancer cases has been falling in recent years in the United States, the first time such an extended decline has been documented, researchers reported Tuesday.

Cancer diagnosis rates decreased by an average of 0.8 percent each year from 1999 to 2005, the last year for which data are available, according to an annual report by the National Cancer Institute, the American Cancer Society and other scientific organizations.

Death rates from cancer continued to decline as well, a trend that began some 15 years ago, the report also noted. It was published online in The Journal of the National Cancer Institute.

“Each year that you see these steady declines it gives you more confidence that we’re moving in the right direction,” said Dr. John E. Niederhuber, director of the National Cancer Institute, who is not an author of the report. “This is not just a blip on the screen.”

Death rates from cancer fell an average of 1.8 percent each year from 2002 to 2005, according to the new report. Although last year’s report said death rates dropped an average of 2.1 percent each year from 2002 to 2004, a modest 1 percent decline in 2005 lowered the average percentage for the period.

The decline is primarily due to a reduction in death rates from certain common cancers, including prostate cancer and lung cancer in men, breast cancer in women and colorectal cancer in both sexes.

The report attributes the reductions to adoption of healthier lifestyles and improved screening, as well as advances in treatment.

The drop in annual incidence rates is harder to interpret. The data may point to a real decline in the occurrence of some types of cancer, experts said. Alternatively, the decline may reflect inconsistent screening practices, causing some cancers that used to be detected to now go undiagnosed.

Breast cancer incidence rates decreased by 2.2 percent annually from 1999 to 2005, for example, a drop some researchers attributed to large numbers of women quitting hormone replacement therapy after a national study linked it to breast cancer in 2002.

Yet mammography rates have also fluctuated in recent years, meaning that some breast cancer cases may be going undetected, said Ahmedin Jemal, the strategic director for cancer surveillance at the American Cancer Society.

The incidence of prostate cancer declined by 4.4 percent a year from 2001 to 2005, after annual increases of 2.1 percent a year for several years, Dr. Jemal said. Yet prostate screening rates, too, have leveled off in recent years.

“This might not be good news,” Dr. Jemal said. “It’s always difficult to interpret the incidence rate.”

Christine Eheman, chief of the cancer surveillance branch at the federal Centers for Disease Control and Prevention, was more optimistic about the decline in cancer diagnoses.

“I do think it’s a good sign,” Dr. Eheman said, “but I think we need to be very careful not to think we have this problem in any way beaten. We need to continue to do what we know works, and also find out why some cancers are not decreasing and not decreasing in certain populations.”

Some types of cancer are being found more often, the report said. Among men, incidence rates increased for cancers of the liver, kidney and esophagus, and for melanoma and myeloma. Among women, incidence rates increased for cancers of the lung, thyroid, pancreas, brain and nervous system, bladder and kidney, and for melanoma. Rates of leukemia and non-Hodgkin’s lymphoma increased in both sexes.

The incidence of lung cancer has been declining among men for many years but rising among women, though the increase is slowing, according to the report.

“Women, unfortunately, got hooked on the smoking habit in the ’60s and ’70s,” Dr. Eheman said, “so there was a larger increase in smoking later on in time, and the prevention of smoking has been slower. The decrease in lung cancer that we hope will occur has not been happening yet.”

The report found sharp regional differences in lung cancer rates that appeared to be associated with local legislation, like smoking bans, and social attitudes toward tobacco and smoking. Lung cancer is diagnosed least often in Utah and most often in Kentucky, the report said.

State tobacco control policies appear to have had an enormous impact, the researchers said. In California, the first state to establish a comprehensive statewide tobacco control program, lung cancer death rates among men dropped by 2.8 percent annually on average from 1996 to 2005, twice the decline observed in many Southern and Midwestern states. California was the only state where the incidence of lung cancer among women had decreased.

Lung cancer death rates among women increased in 13 states: Alabama, Arkansas, the Carolinas, Indiana, Iowa, Kansas, Kentucky, Louisiana, Michigan, Mississippi, South Dakota and Tennessee. Tobacco taxes are lower than average in many of these states, the report noted.

Comments Off
categories: Emergency Medicine

Pediatric Antiphospholipid Syndrome

by Paul Rega, MD — published on November 28th, 2008


Tadej Avcin, Rolando Cimaz, et al.

Pediatrics 2008; 122: e1100-e1107.

ABSTRACT

OBJECTIVES. The purpose of this study was to obtain data on the association of antiphospholipid antibodies with clinical manifestations in childhood and to enable future studies to determine the impact of treatment and long-term outcome of pediatric antiphospholipid syndrome. PATIENTS AND METHODS. A European registry extended internationally of pediatric patients with antiphospholipid syndrome was established as a collaborative project of the European Antiphospholipid Antibodies Forum and Lupus Working Group of the Pediatric Rheumatology European Society. To be eligible for enrollment the patient must meet the preliminary criteria for the classification of pediatric antiphospholipid syndrome and the onset of antiphospholipid syndrome must have occurred before the patient’s 18th birthday.

RESULTS. As of December 1, 2007, there were 121 confirmed antiphospholipid syndrome cases registered from 14 countries. Fifty-six patients were male, and 65 were female, with a mean age at the onset of antiphospholipid syndrome of 10.7 years. Sixty (49.5%) patients had underlying autoimmune disease. Venous thrombosis occurred in 72 (60%), arterial thrombosis in 39 (32%), small-vessel thrombosis in 7 (6%), and mixed arterial and venous thrombosis in 3 (2%). Associated nonthrombotic clinical manifestations included hematologic manifestations (38%), skin disorders (18%), and nonthrombotic neurologic manifestations (16%). Laboratory investigations revealed positive anticardiolipin antibodies in 81% of the patients, anti-β2-glycoprotein I antibodies in 67%, and lupus anticoagulant in 72%. Comparisons between different subgroups revealed that patients with primary antiphospholipid syndrome were younger and had a higher frequency of arterial thrombotic events, whereas patients with antiphospholipid syndrome associated with underlying autoimmune disease were older and had a higher frequency of venous thrombotic events associated with hematologic and skin manifestations.

CONCLUSIONS. Clinical and laboratory characterization of patients with pediatric antiphospholipid syndrome implies some important differences between antiphospholipid syndrome in pediatric and adult populations. Comparisons between children with primary antiphospholipid syndrome and antiphospholipid syndrome associated with autoimmune disease have revealed certain differences that suggest 2 distinct subgroups.

Comments Off
categories: Emergency Medicine

OMNI Postings of 11/27/08

by Paul Rega, MD — published on November 26th, 2008
On this date in 1926, Italy and Albania signed a peace treaty.  No one knew  until 1987.   No one cared until 2003. 
But I digress…
1)  This is a report stating that we are not doing enough about HIV testing despite CDC’s admonitions.  Just over 1.1 million Americans are estimated to have HIV and 232,000 of them—or one in five—don’t know they have the disease, according to the CDC. Yet, only 50 to 100 of the country’s 5,000 emergency departments routinely test for HIV in patients.
2)  Well, statins continue to remain on the media’s front burner.  Now, Danish researchers have found that statins may have another beneficial effect: lowering the risk of death from pneumonia.  Scientists examined medical records of 29,000 Danish patients hospitalized for pneumonia over a six-year period. Using regional prescription databases, they found 1,372 who had filled prescriptions for statins within four months of being admitted. Then they calculated mortality rates for statin users and nonusers.  After controlling for age, sex, heart disease, stroke, pulmonary illness, diabetes and 15 other disorders, they found that among statin users the odds of death were reduced by 31 percent within the first 30 days after admission and 25 percent within 90 days.  However, it’s NOT true that they also had a lower incidence of hemorrhoids, nose hairs, and belly-button lint.
3)  Interested in a little knowledge about Medicare, but were afraid to ask?  This might help.
4)  This doctor is upset.  Why?  Not enough healthcare professionals are getting flu shots.  In fact, almost 60 percent of American health-care workers do not receive the flu vaccine.  He calls it shameful.  What do you call it?  He presents the 4 top reasons why they don’t get the shot.  None of them is my reason.  http://omniphysicians.com/2008/11/26/flu-shots-for-hcps-1-docs-opinion/
5)  This is an alert from OSMA.  The organization wants us to phone Ohio legislators and tell them to pass a law forbidding kids under 18 from getting into a tanning booth unless the whipper-snapper presents a prescription for receiving ultraviolet radiation treatments written by a physician.
Have a great Thanksgiving!
Paul R.