During week 43 (October 19-25, 2008), a low level of influenza activity was reported in the United States. Five (0.4%) specimens tested by U.S. World Health Organization (WHO) and National Respiratory and Enteric Virus Surveillance System (NREVSS) collaborating laboratories, and reported to CDC/Influenza Division, were positive for influenza. The proportion of deaths attributed to pneumonia and influenza (P&I) was below the epidemic threshold. The proportion of outpatient visits for influenza-like illness (ILI) was below national and region-specific baseline levels. Thirteen states and Puerto Rico reported sporadic influenza activity; 36 states and the District of Columbia reported no influenza activity; and one state did not report.

On this date in 1796, John Adams is elected President.  When told of the election results, he was overheard telling Abigail, “Now I can get a beer named after me.  Just like Sam.”

But I digress…

1)  I’m sure you’ve seen this skin condition before.  I know I have.  Now, at least you will know what to call it and what to tell the patient.  It’s better that saying, “I don’t know what the hell it is, but it won’t kill you…That’ll be $255.65.”
http://omniphysicians.com/2008/11/02/bullous-papular-urticaria/

2)  This is an abstract (published in Pediatrics) about the flood of rotavirus gastroenteritis that caused kids to be seen in the ER in 1999-2000.   A noble achievement, but why this was published in 2008 escapes me.  The study is really moot now that we have the rotavirus vaccine and more contemporary studies are showing it’s efficacious (meaning kiddies are not crapping like they used to).
http://omniphysicians.com/2008/11/01/lottsa-rotavirus-in-kids/

3)  There are more kids on chronic medications than ever before.  They are being used to treat diabetes, cholesterol, asthma, attention deficit disorder and hyperactivity.
http://omniphysicians.com/2008/11/03/kids-chronic-meds-2/

4)  Old people fall.  They do it all the time and we treat the repercussions.  But have you ever discussed with them or their healthcare provider ways to minimize the risk?  Sure you do (wink, wink).   Simple things to have them consider:  an eye examination, an exercise program to maintain agility, strength, balance, and coordination,  installing grab bars, handrails and other safety devices in appropriate areas, such as bathrooms and bedrooms, shoes with nonskid soles, and having adequate lighting in the home.
http://omniphysicians.com/2008/11/03/fall-prevention-in-the-elderly/

5)  A panel of experts is saying that the FDA erred big-time when it told the public not to worry about products with BPA in them.  The current margin of safety is 5 mg/kg, but the subcommittee recommended lowering that level by one order of magnitude. The full board stated that there is enough evidence to support a more conservative margin of safety for BPA exposure among infants.  I bet the FDA will backtrack on this one.                                                                                                                   http://omniphysicians.com/2008/11/03/fda-gets-spanked/

MedPage Today, 10/31/08 http://www.medpagetoday.com/PublicHealthPolicy/PublicHealth/11568

The FDA erred when it determined that the use of the common chemical bisphenol A is safe, particularly for infants, the agency’s full science board concluded today.

The full board, made up of independent advisers to the FDA, unanimously endorsed a highly critical report by a special board subcommittee on BPA. The subcommittee concluded that the agency employed faulty science when it determined the BPA is safe as currently used.

The chemical is used in packaging of infant formula, and in molded plastic bottles and sippy cups. The current margin of safety is 5 mg/kg, but the subcommittee recommended lowering that level by one order of magnitude. 

The full board, chaired by Barbara McNeil, M.D., Ph.D., of Harvard, accepted the subcommittee’s report after inserting language to state that enough evidence exists to support a more conservative margin of safety for BPA exposure among infants.

In September, the FDA issued a draft assessment of BPA that said there was insufficient evidence to connect commonly used levels of BPA to some health issues, including those in infants. Canada, meanwhile, recently banned the use of BPA in baby bottles. (See: DA Gives Preliminary Okay to Bisphenol A in Food Packaging)

Some scientists and consumer groups have warned that the chemical might contribute to some cancers, early puberty, alterations of the prostate and urinary tracts, and behavioral problems.

The subcommittee released its assessment of the FDA’s report earlier this week, which charged that the FDA was wrong to dismiss a number of government and academic studies in its assessment for not meeting the standard of “good laboratory practices.”

Toxicologist Martin Philbert, Ph.D., of the University of Michigan School of Public Health, chairman of the science subcommittee, said he understands why the FDA assessment relied so heavily on two studies from a field of many BPA studies, because “good laboratory practice” studies tend to use more animals and readily submit raw data for independent analysis.

But he said the subcommittee disagrees that those two studies were the only “acceptable” studies to be used, and said more recent research must be considered, including a study published recently in the Journal of the American Medical Assocation that connected BPA to a number of health problems including cardiovascular disease. (See: Common Chemical Linked to Metabolic and Cardiovascular Disorders)

At today’s science board meeting, Dr. Philbert reiterated the criticisms outlined in the subcommittee’s report and criticized the limited scope of the FDA’s assessment on the impact of BPA, because it examined the use of the chemical only in food applications.

He also criticized the FDA for not including demographic information to determine the likely number of people exposed at each BPA concentration and for relying on too few formula samples — which were from the early 1990s and all from one city — in making a determination about BPA in baby formula.

The board called for future, large-scale studies examining BPA exposure from a wider range of applications.

The report now goes to the FDA, which will likely respond in the next few months, said Stephen F. Sundlof, D.V.M., Ph.D., director of the agency’s Center for Food Safety and Applied Nutrition.

If the FDA accepts the subcommittee’s findings, such as a lower margin of safety for exposure for infants, the agency would likely issue new regulations. But, said Dr. Sundlof, the agency would not issue a public notice out of fear that mothers may stop buying infant formula and attempt to make their own, BPA-free, but less nutritious, formula.

According to Dr. Sundlof, the FDA is already working with manufacturing companies that use BPA in their products to develop alternatives or to figure out how to effectively lower levels of the chemical.

HealthDay, 10/31/08 (http://www.healthday.com/Article.asp?AID=620610)

Sudden cardiac death is the leading cause of death among kidney failure patients, and inflammation and malnutrition are major risk factors for fatal heart attacks in these people, Johns Hopkins researchers report.

The researchers analyzed data from 1,041 end-stage renal disease (ESRD) patients on dialysis. Over 9.5 years, there were 658 deaths, including 146 cases of sudden cardiac death.

The Hopkins team then looked at previously recorded blood test results from 122 of those 146 patients to check levels of high-sensitivity C-reactive protein (hsCRP), interleukin-6 (IL-6) and albumin. Low albumin levels are associated with malnutrition, while the proteins hsCRP and IL-6 are markers of widespread blood vessel and organ inflammation.

Patients with high levels of either hsCRP or IL-6 were twice as likely to experience sudden cardiac death as patients with low levels of the enzymes, the study found. Patients with low albumin levels were 1.35 times more likely to die that way than those with high albumin levels. Patients with both high levels of hsCRP and low levels of albumin were four times more likely to have sudden cardiac death than those with low levels of hsCRP and high albumin levels.

The study was published online and was expected to be in the Nov. 2 print issue of Kidney International.

“This is believed to be the first time anyone has taken a rigorous prospective look at why so many patients on dialysis die from sudden cardiac death, and the results could help doctors identify those at highest risk and potentially save lives,” study author Dr. Rulan S. Parekh, an associate professor in the department of nephrology at the Johns Hopkins University School of Medicine, said in a Hopkins news release.

She noted that the 500,000 people in the United States with ESRD are 10 times to 100 times more likely to die from cardiovascular disease than the general public.

“When people think of heart attacks, they think of cholesterol and obesity, but these are risk factors for hardening of the arteries and are not directly linked to sudden heart death among patients on dialysis,” Parekh said.

HealthDay, 11/2/08 (http://www.healthday.com/Article.asp?AID=620634)

Former first lady Nancy Reagan and Democratic presidential candidate Barack Obama’s grandmother have suffered recent pelvic and hip injuries. And on Friday, author Studs Terkel died, following reports that a fall two weeks ago had hastened his decline.

Such news, experts say, should be a reminder to all about the need to help the elderly protect themselves against their increased risk of falls and bone injuries.

According to the American Academy of Orthopaedic Surgeons, one in every three Americans older than 65 experiences a fall, making it the leading cause of injuries to seniors.

To help prevent falls and bone fractures, the academy recommends that seniors:

• Have an annual physical and eye examination. Make sure any cardiac and blood pressure problems are fully evaluated.
• Consume a diet with adequate dietary calcium and vitamin D for good bone health. Do not smoke, and avoid excessive use of alcohol.
• Participate in an exercise program to maintain agility, strength, balance, and coordination.
• Maintain a clutter-free home with clear walking paths through rooms. Eliminate tripping hazards and install grab bars, handrails and other safety devices in appropriate areas, such as bathrooms and bedrooms.
• Wear properly fitting shoes with nonskid soles. Never walk about with only socks or stockings on your feet.
• Have adequate lighting in the home. Use nightlights between bedrooms and bathrooms. Make sure light switches are easily accessible by doorways.

More information

The American Academy of Orthopaedic Surgeons has more about hip fractures and falls prevention.

USA Today (11/3, Szabo) reports, “The number of children who take medication for chronic diseases has jumped dramatically, another troubling sign that many of the youngest Americans are struggling with obesity,” according to a study in Pediatrics.

The study found that “the number of children who take pills for type 2 diabetes — the kind that’s closely linked to obesity — more than doubled from 2002 to 2005, to a rate of six out of 10,000 children. That suggests that at least 23,000 privately insured children in the USA are now taking diabetes medications.”

In addition, “doctors also saw big increases in prescriptions for high cholesterol, asthma, and attention deficit and hyperactivity.” The study was based “on prescription records of nearly four million children a year, ages five to 19, covered by Express Scripts.”

1: Ann Gen Psychiatry. 2008 Oct 23;7(1):21.

TITLE:  Communication between secondary and primary care following self-harm: are National Institute of Clinical Excellence (NICE) guidelines being met?

Medscape 10/31/08 (http://www.medscape.com/viewarticle/582876?src=rss)

After patients are seen in a hospital emergency department (ED) for intentional self-harm, such as a drug overdose or self-imposed cuts, they often fall through the cracks in the healthcare system, a new study suggests.

Information about a patient’s visit to an ED for self-harm is frequently not passed on from providers of secondary care — psychiatrists, ED staff, or a self-harm liaison team — to the patient’s primary-care provider, according to a study from Manchester, United Kingdom.

“Psychiatric services need to improve the rate of communication to the patient’s general practitioner following psychosocial assessment, and ED staff must also have procedures in place to aid communication to primary-care providers,” study author Elizabeth Murphy, from the Manchester Self-Harm Project at the University of Manchester, told Medscape Psychiatry.

Because primary-care providers play a vital role in following patients who have intentionally injured themselves, they need to be made aware of any such episodes as soon as possible, she said.

The study was published online October 23 in the Annals of General Psychiatry.

Self-Harm May Signal Suicide

Self-harm, defined as intentional self-poisoning or self-injury, is a major public-health problem, said Ms. Murphy.

Each year, at least 200,000 cases are seen in EDs in England, and the Manchester Self-Harm Project reports some of the highest rates in the country: 50 per 1000 population.

Although not all acts of self-harm are a suicide attempt, self-harm is a strong risk factor for suicide. An estimated 1 in 100 people die by suicide within a year of presenting to a hospital for self-harm, she added.

The National Institute for Clinical Excellence guidelines for self-harm for the National Health Service in England and Wales, which came into practice in 2004, recommends that all patients presenting with self-harm receive a psychosocial needs assessment, and that this information be transmitted to the patient’s primary-care provider as soon as possible.

Although relaying information from secondary-care providers to primary-care providers is known to improve patient care, it is not known whether these national guidelines for follow-up after an episode of self-harm are being observed, say the researchers.

To assess whether communication from secondary-care providers to primary-care providers meets national guidelines for the short-term management of people who intentionally harm themselves, the investigators audited the medical records of 93 consecutive patients, aged 16 years and older, who presented to the ED at a single center after a self-harm episode over a 1-month period.

Communication Gap Identified

Information about the patient’s self-harm episode was conveyed to 58 of 93 of the patients’ primary-care providers (62%) — 26 cases by psychiatric staff only, 26 cases by the hospital’s self-harm liaison team, 3 cases by ED staff only, and 3 cases by both ED staff and psychiatric staff.

The ED staff completed a psychosocial assessment for about half the patients seen for self-harm. However, of the 26% of patients who were not admitted or seen by a psychiatrist, this assessment was rarely forwarded to a primary-care provider.

Psychiatric staff assessed 60% of the patients, but only about half these assessments were forwarded to the patients’ primary-care provider.

In 26 cases, mainly when patients were only seen in the ED and not admitted or evaluated by a psychiatrist, members of the hospital self-harm liaison service informed a patient’s primary-care provider about the episode, using the information gleaned from ED records, but this information was not very detailed.

Information provided to primary-care providers from psychiatric assessment was the most detailed, and generally included psychiatric history and precipitating circumstances.

The information was passed on to the patient’s primary-care provider within a day in 58% of cases, and within 3 days in 33% of cases.

The British government guidelines for communication from secondary care to primary care for the short-term management of self-harm patients are only partially being met, even in urban hospitals with a self-harm liaison service. Further study is needed to determine whether these findings apply to other populations, the group concludes.

Ann Gen Psychiatry. 2008;7:21. Abstract

Source reference:
Planche T, et al “Diagnosis of Clostridium difficile infection by toxin detection kits: a systematic review” Lancet Infect Dis 2008.
MedPage Today, 10/31/08 (http://www.medpagetoday.com/InfectiousDisease/InfectionControl/11572)

None of the tests commonly used by hospitals to detect Clostridium difficile may be accurate enough on its own, researchers here found.

In a systematic review, commercial assays had average sensitivities ranging from 0.76 to 0.95 and average specificities ranging from 0.93 to 1.00, reported Sanjeev Krishna, Sc.D., of St. George’s University of London, and colleagues online in The Lancet Infectious Diseases.

But every rapid test had unacceptably low positive predictive values given the low 5% to 10% prevalence of the toxin in stool samples at hospitals in Europe and the United States, they wrote.

Accurate diagnosis of C. difficile-associated diarrhea is crucial for infection control in hospitals and evaluation of the efficacy of interventions, but particularly for management of patients, Dr. Krishna’s group said.

“A false-positive result may mean that a patient starts metronidazole (Flagyl), stops other antibiotics, and is made to share a room with patients who do have C. difficile infection,” they noted.

They recommended a two-stage testing strategy for C. difficile toxin to improve diagnosis similar to strategies commonly used in virology clinics.

“An initial, rapid, highly sensitive screening assay done on the day of the receipt of the sample would detect all (or nearly all) positives and mean that confirmed negative results are issued promptly,” they wrote.

A provisional diagnosis based on the initial assay could be immediately managed with isolation measures and therapy as if they had C. difficile-associated diarrhea while waiting for a definitive result from an assay using the reference method.

The reference method for C. difficile detection — cytotoxicity of stool in cell culture — takes two to three days for results. More rapid detection methods have been developed over the past two decades with most commercially available tests now picking up both C. difficile toxins A and B.

The researchers conducted a systematic review to compare the most commonly used rapid assays and found data from studies and abstracts for a total of 28 comparisons of toxin detection kits with reference standards.

The reported sensitivities of these assays in individual studies were 0.69 to 0.99 and specificities were 0.92 to 1.00.

The overall test performance as measured by the diagnostic odds ratio was similar between all of the commercial assay methods (P=0.33).

Sensitivity and specificity did differ, though, with Meridian Premier most likely to give a true positive result and the Techlab Quik Chek was most likely to give a true negative result.

However, none of the tests met criteria for what the researchers deemed an acceptable test with sensitivity of at least 90% and a false-positive rate of 3% or less estimated at the 25% centile.

Median sensitivity of the assays was as follows:

• 83.3% (interquartile range 81.6% to 85.4%) for TechLab Tox A/B II, an enzyme-linked immuno-sorbent assay (ELISA).
• 83.9% (IQR 81.2% to 87.0%) for TechLab Tox A/B Quik Chek, which uses rapid antigen capture.
• 94.8% (IQR 86.4% to 96.8%) for Meridian Premier, an ELISA test.
• 89.6% (IQR 87.4% to 91.8%) for Meridian Immunocard, a rapid enzyme immunoassay.
• 82.0% (IQR 75.3% to 88.7%) for Remel Xpect, a rapid chromatographic immunoassay.
• 75.7% (IQR 32% to 171%) for BioMérieux VIDAS, an enzyme immunoassay.

Estimated false positive rates at the current 10% average prevalence of C. difficile in hospital stool samples included:

• 12% for TechLab Tox A/B II
• 3% for TechLab Tox A/B Quik Chek
• 22% for Meridian Premier
• 7% for Meridian Immunocard
• 29% for Remel Xpect
• 45% for BioMérieux VIDAS

The researchers noted heterogeneity in the results, possibly because of geographic variations in patient populations or in C. difficile isolates as well as differences in reference methods, laboratory processing of samples — especially if the manufacturers’ protocols were not followed or samples were stored improperly.

Also, they said, their review did not include newer detection methods, such as nucleic acid amplification tests, that may prove acceptable as a single test