TEACHER: Donald, what is the chemical formula for water?
DONALD: H I J K L M N O.
TEACHER: What are you talking about?
DONALD: Yesterday you said it’s H to O.

But I digress….

This abstract in Pediatrics, looked at what empiric antibiotic therapy is best for uncomplicated SSTIs in kids. They looked at beta-lactams, TMP-SMX, and clinda. Bottom line: stick with the beta-lactams. TMP-SMX is the least effective of the 3.
http://omniphysicians.com/2009/05/31/sstis-in-kids/

A couple of cases on meningits in Mary Rutan hospital in Bellefontaine, OH. I patient died. Both were in the maternity ward. Something to keep in mind should you be involved in any transfers.
http://omniphysicians.com/2009/05/31/meningitis-mary-rutan-hospital/

There’s new research concluding that the window to administer TPA in strokes can be expanded to four hours. The new guidelines, published in the same issue of the journal, STROKE, are “expected to increase the number of people who get the treatment.” It’s also expected to increase the number of ER docs who’ll get sued. Who said that???
http://omniphysicians.com/2009/05/31/tpa-in-strokes-up-to-4-hours/

CT scans are responsible for 91% of total radiation exposure in pediatric trauma patients, even though only 32% of imaging done in these patients is computed tomography.

The average radiation dose for each patient was 12.8 milliseverts (mSv), with a high of 73.5 mSv. The average dose from the environment is about 3 mSv per year. Stratified by type of injury, the 178 patients whose trauma resulted from a motor vehicle accident registered the greatest radiation exposure, with an average of 18.6 mSv. Pedestrians struck by cars had the second highest level of radiation, 15.6 mSv. There’s been a greater awareness about how much radiation we are subjecting out patients to. This kind of research is not going away. I can see thrity years from now, someone with CA suing doctors who treated him during an MVA 30 years earlier…all because he had some CTs that diagnosed his ruptured spleen.

Paul R.

Intro: The AP (5/29, Stengle) reports that based on evidence from this study, a “committee for the American Heart Association Stroke Council” is changing their guidelines by “expanding the time that some patients can get clot-busting drugs,” while also stressing “that the earlier the treatment, the better for stroke victims.” The new guidelines, published in the same issue of the journal, are “expected to increase the number of people who get the treatment.” The update, however, also “notes that some patients should still be restricted to treatment within the three-hour period.”

(Stroke. 2009;40:2079.)
© 2009 American Heart Association, Inc.

——————————————————————————–

Original Contributions

Treatment Time-Specific Number Needed to Treat Estimates for Tissue Plasminogen Activator Therapy in Acute Stroke Based on Shifts Over the Entire Range of the Modified Rankin Scale
Maarten G. Lansberg, MD, PhD; Maarten Schrooten, MD; Erich Bluhmki, PhD; Vincent N. Thijs, MD, PhD Jeffrey L. Saver, MD

From the Stanford Stroke Center (M.G.L.), Stanford University Medical Center, Palo Alto, Calif; the Department of Neurology (M.S., V.N.T.), University Hospitals of Leuven, Leuven, Belgium; Vesalius Research Center (V.N.T.), Flemish Institute Biotechnology, Leuven, Belgium; Boehringer Ingelheim Pharma GmbH & Co (E.B.), Ingelheim, Germany; and the Stroke Center and Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA, Los Angeles, Calif.

Correspondence to Maarten G. Lansberg, MD, PhD, Stanford Stroke Center, 701 Welch Road, Suite B325, Palo Alto, CA 94304-9705. E-mail lansberg@stanford.edu

Background and Purpose— To make informed treatment decisions, patients and physicians need to be aware of the benefits and risks of a proposed treatment. The number needed to treat (NNT) for benefit and harm are intuitive and statistically valid measures to describe a treatment effect. The aim of this study is to calculate treatment time-specific NNT estimates based on shifts over the entire spectrum of clinically relevant functional outcomes.

Methods— The pooled data set of the first 6 major randomized acute stroke trials of intravenous tissue plasminogen activator was used for this study. The data were stratified by 90-minute treatment time windows. NNT for benefit and NNT for harm estimates were determined based on expert generation of joint outcome distribution tables. NNT for benefit estimates were also calculated based on joint outcome distribution tables generated by a computer model.

Results— NNT for benefit estimates based on the expert panel were 3.6 for patients treated between 0 and 90 minutes, 4.3 with treatment between 91 and 180 minutes, 5.9 with treatment between 181 and 270 minutes, and 19.3 with treatment between 271 and 360 minutes. The computer simulation yielded very similar results. The NNT for harm estimates for the corresponding time intervals are 65, 38, 30, and 14.

Conclusions— Up to 4 hours after symptom onset, tissue plasminogen activator therapy is associated with more benefit than harm, whereas there is no evidence of a net benefit in the 4- to 6-hour time window. The NNT estimates for each 90-minute epoch provide useful and intuitive information based on which patients may be able to make better informed treatment decisions.

By Denise Napoli
Elsevier Global Medical News
http://www.imng.com

Breaking News (http://www.acep.org/NewsFeed.aspx?id=imn050520091326302067)

BALTIMORE (EGMN) –CT scans are responsible for 91% of total radiation exposure in pediatric trauma patients, even though only 32% of imaging done in these patients is computed tomography, study results showed.

“Each provider has to decide: What’s the benefit of getting the pictures that we get?” said Dr. Marissa A. Brunetti, an intensivist at Johns Hopkins Hospital. “Especially with CT … if a patient is critical and the imaging study means the difference between life and death, then by all means get it. But there are times when imaging studies are done out of convenience or in place of other imaging modalities [like ultrasound] that could get pictures that are similar without radiation exposure,” she said.

In a presentation at the annual meeting of the Pediatric Academic Societies on May 5, Dr. Brunetti reported on 729 patients aged 14 years and younger seen in the emergency department at her hospital over a 1-year period. Transfer patients were excluded from the analysis, as were any follow-up imaging studies. In total, 1,457 CT studies and 4,603 radiographic studies were conducted on these patients during that period.

The average radiation dose for each patient was 12.8 milliseverts (mSv), with a high of 73.5 mSv. “The average dose from the environment is about 3 mSv per year, so that’s more than four times the annual dose,” said Dr. Brunetti.

Stratified by type of injury, the 178 patients whose trauma resulted from a motor vehicle accident registered the greatest radiation exposure, with an average of 18.6 mSv. Pedestrians struck by cars had the second highest level of radiation, 15.6 mSv.

Part of the reason possibly unnecessary imaging studies are done, she said, is that “pediatricians and providers don’t know the doses that these images impart.” Education about which studies deliver the highest doses, and emphasis on keeping these studies to a minimum where possible, could lower patients’ total radiation exposure.

Another problem lies with transfer patients. Although the study did not look at transfers to the hospital, an audience member pointed out that “there is this idea that my CT scanner is going to be better than the CT that is done in the community hospital,” and so patients wind up having identical studies repeated.

“For all patients, especially in the very young with long time horizons, the benefit of additional radiation exposure for diagnostic purposes should be weighed against the long-term risks of additional exposure,” concluded Dr. Brunetti.

Dr. Brunetti said that she had no disclosures or conflicts of interest to report in regard to this study.

Date: Wed 27 May 2009
Source: The Columbus Dispatch [edited]

Officials at Mary Rutan Hospital in Bellefontaine [Ohio] say they don’t
know how 2 women in separate rooms of the maternity ward — one of whom
later died — contracted bacterial meningitis late last week. But they say
there is no threat of an outbreak and that expectant mothers ready to
deliver their babies at the Logan County [Ohio] hospital have no cause for
concern. The hospital has pulled batches of any medications the women may
have been given and what remains of any supplies that were used and they
will be tested as a possible source, said hospital spokeswoman Tammy
Allison. She did not know whether hospital employees would be tested for
the bacteria.

The 2 women delivered babies on Thursday [?21 May 2009] and showed signs of
bacterial meningitis on Friday [?22 May, 2009], Allison said. They both
were transferred to Riverside Methodist Hospital in Columbus [Ohio] on
Friday afternoon, and one died, Allison said. She said the other woman
remains in critical condition. Both infants were transferred to Nationwide
Children’s Hospital in Columbus as a precaution, Allison said. She said
federal privacy regulations prevent her from releasing the women’s names or
the condition of the babies.

Riverside spokesman Mark Hopkins said [one of the women], 30, of Huntsville
[Ohio], was transferred from Mary Rutan and died on Friday. Her daughter,
was in good condition yesterday [26 May 2009] at Children’s, a spokeswoman
said.

Allison said the Centers for Disease Control and Prevention, as well as the
local and state health departments, have been contacted and an internal
investigation is under way. The maternity unit is licensed for 12 beds,
according to the Ohio Department of Health. It remains open, though Allison
would not say how many mothers and babies were there yesterday [26 May 2009].

Bacterial meningitis is spread from person to person through respiratory
droplets. It infects the fluid surrounding the brain and spinal cord and
can be fatal without early treatment. If detected early, it can be
successfully treated with strong antibiotics. Serious after-effects can
include brain damage, hearing loss, limb amputation, and learning
disabilities. However, Allison said that Logan County health commissioner
Dr Boyd Hoddinott advised the hospital that the illness is not contagious
and represents no danger to patients. Hoddinott was out of the office late
yesterday [26 May 2009] and could not be reached for comment. Symptoms
include fever, vomiting, an intense headache, and stiffness of the neck.

About 2600 people in the United States contract bacterial meningitis each
year, according to CDC. In 2006, 634 people died of meningitis, according
to the latest data from CDC. There were about 58 cases in Ohio last year
[2008], according to preliminary numbers from the state, said spokesman
Kristopher Weiss. This year [2009], the department has logged 21 cases, not
including the 2 in Logan County. At any given time, an estimated 5 per cent
to 25 per cent of people are carrying the bacteria but have no symptoms.
Those people play a major role in transmitting the disease.

Two vaccines are available for protection against meningitis, and federal
health officials recommend vaccination for young people, especially college
students. The disease is most common in infants, but no vaccine is approved
for use in people younger than 2 years old.

[byline: H Zachariah, M Crane]

A Prospective Comparison of Diaphragmatic Ultrasound and Chest Radiography to Determine Endotracheal Tube Position in a Pediatric Emergency Department
Benjamin Thomas Kerrey, Gary Lee Geis, Andrea Megan Quinn, Richard William Hornung, and Richard Michael Ruddy
Pediatrics 2009; 123: e1039-e1044.

BACKGROUND. Investigators report endotracheal tube misplacement in up to 40% of emergent intubations. The standard elements of confirmation have significant limitations. Diaphragmatic ultrasound is a potentially viable addition to the confirmatory process. Our primary hypothesis is that ultrasound is equivalent to chest radiography in determining endotracheal tube position within the airway in emergent pediatric intubations.

METHODS. We enrolled a prospective, convenience sample from all intubated patients in our emergency department. The primary outcome was the agreement between diaphragmatic ultrasound and chest radiography for endotracheal tube position. On ultrasound, tracheal placement equaled bilateral diaphragmatic motion, bronchial placement equaled unilateral diaphragmatic motion, and esophageal placement equaled no or paradoxical diaphragmatic motion during delivery of positive pressure. Study sonographers were blind to radiographic results. Our secondary outcome was the timeliness of ultrasound versus chest radiography results. Our institutional review board approved this study with a waiver of informed consent.

RESULTS. One hundred twenty-seven patients were enrolled. In 24 (19%) patients, the endotracheal tube was in the mainstem bronchus on chest radiography. There were no esophageal intubations in the sample. Ultrasound and chest radiography agreed on endotracheal tube placement in 106 patients (94 tracheal and 12 mainstem), for an overall agreement of 0.83. The sensitivity of ultrasound for tracheal placement was 0.91. The specificity of ultrasound for mainstem intubation was 0.50. Thirty-four patients had a second ultrasound by a separate, blinded sonographer; 33 of 34 of the results of the second sonographer were in agreement with the initial sonogram, for an interrater agreement of 97%. Clinically useful chest radiography results took a median of 8 minutes longer to achieve than ultrasound results.

CONCLUSIONS. Diaphragmatic ultrasound was not equivalent to chest radiography for endotracheal tube placement within the airway. However, ultrasound results were timelier, detected more misplacements than standard confirmation alone, and were highly reproducible between sonographers.

Baseball-Related Injuries to Children Treated in Hospital Emergency Departments in the United States, 1994–2006
Bradley R. Lawson, R. Dawn Comstock, and Gary A. Smith
Pediatrics 2009; 123: e1028-e1034.

OBJECTIVE. To describe the epidemiology of baseball-related injuries among children in the United States.

METHODS. This was a retrospective analysis of data for children younger than 18 years of age from the National Electronic Injury Surveillance System (NEISS) of the Consumer Product Safety Commission from 1994 through 2006. Sample weights provided by the NEISS were used to calculate national estimates of baseball-related injuries. Injury rates were calculated according to age group by using both population and baseball-participation data.

RESULTS. An estimated 1 596 000 (95% confidence interval: 1 330 100–1 861 800) children younger than 18 years were treated in US hospital emergency departments for baseball-related injuries during the 13-year period from 1994 through 2006. During the study period, the annual number of injuries declined by 24.9%, and the annual injury rate for children younger than 18 years decreased significantly (P < .000). The most commonly injured body parts were the face (33.5%) and the upper extremity (32.4%). The most common injury diagnoses were soft tissue injury (34.3%) and fracture (18.4%). The most common mechanism of injury was being hit by the baseball (46.0%). Children in the 9- to 12-year age group had the highest injury rate (2.4 per 1000 population). When injury rates were calculated by using baseball-participation data (2003), children in the 12- to 17-year age group had a higher injury rate (19.8 per 1000 participants) than those in the 6- to 11-year age group (12.1 per 1000 participants).

CONCLUSIONS. Youth baseball is a relatively safe sport for children. Although injury rates and the total number of injuries declined during the study period, our findings indicate that there are opportunities for making baseball an even safer sport for children. We recommend that all youth baseball players wear properly fitted mouth guards, that all leagues, schools, and parks install safety bases, that all batters use helmets with face shields, and that all players use safety baseballs.

Diagnostic Value of Immature Neutrophils (Bands) in the Cerebrospinal Fluid of Children With Cerebrospinal Fluid Pleocytosis
John T. Kanegaye, Lise E. Nigrovic, Richard Malley, Christopher R. Cannavino, Sandra H. Schwab, Jonathan E. Bennett, Michael M. Mohseni, Vincent J. Wang, Yiannis L. Katsogridakis, Martin I. Herman, Nathan Kuppermann for the American Academy of Pediatrics, Pediatric Emergency Medicine Collaborative Research Committee
Pediatrics 2009; 123: e967-e971.

OBJECTIVE. We evaluated the diagnostic utility of the presence and number of cerebrospinal fluid (CSF) bands in distinguishing bacterial from aseptic meningitis among children with CSF pleocytosis.

METHODS. We identified retrospectively a cohort of children 29 days to 19 years of age with CSF pleocytosis (10 x 106 leukocytes per L) who were treated in the emergency departments of 8 pediatric centers between January 2001 and June 2004 and whose CSF was evaluated for the presence of bands. We performed bivariate and multivariate analyses to determine the ability of CSF bands to distinguish bacterial from aseptic meningitis.

RESULTS. Among 1116 children whose CSF was evaluated for the presence of bands, 48 children (4% of study patients) had bacterial meningitis. Bacterial meningitis, compared with aseptic meningitis, was associated with a greater CSF band proportion (0.03 vs 0.01; difference: 0.02; 95% confidence interval: 0.00–0.04) and CSF absolute band count (392 x 106 cells per L vs 3 x 106 cells per L; difference: 389 x 106 cells per L; 95% confidence interval: –77 x 106 cells per L to 855 x 106 cells per L). In addition, 29% of patients with bacterial meningitis, compared with 18% of patients with aseptic meningitis, had any bands detected in the CSF. After adjustment for other factors associated with bacterial meningitis, however, CSF band presence, CSF absolute band count, and CSF band proportion were not independently associated with bacterial meningitis.

CONCLUSION. In this multicenter study, neither the presence nor quantity of CSF bands independently predicted bacterial meningitis among children with CSF pleocytosis.

Empiric Antimicrobial Therapy for Pediatric Skin and Soft-Tissue Infections in the Era of Methicillin-Resistant Staphylococcus aureus
Daniel J. Elliott, Theoklis E. Zaoutis, Andrea B. Troxel, Andrew Loh, and Ron Keren
Pediatrics 2009; 123: e959-e966

OBJECTIVE. The goal was to compare the clinical effectiveness of monotherapy with β-lactams, clindamycin, or trimethoprim-sulfamethoxazole in the outpatient management of nondrained noncultured skin and soft-tissue infections (SSTIs), in a methicillin-resistant Staphylococcus aureus (MRSA)-endemic region.

METHODS. A retrospective, nested, case-control trial was conducted with a cohort of patients from 5 urban pediatric practices in a community-acquired MRSA-endemic region. All subjects were treated as outpatients with oral monotherapy for nondrained noncultured SSTIs between January 2004 and March 2007. The primary outcome was treatment failure, defined as a drainage procedure, hospitalization, change in antibiotic, or second antibiotic prescription within 28 days.

RESULTS. Of 2096 children with nondrained noncultured SSTIs, 104 (5.0%) were identified as experiencing treatment failure and were matched to 480 control subjects. Compared with β-lactam therapy, clindamycin was equally effective but trimethoprim-sulfamethoxazole was associated with an increased risk of failure. Other factors independently associated with failure included initial treatment in the emergency department, presence or history of fever, and presence of either induration or a small abscess.

CONCLUSIONS. Compared with β-lactams, clindamycin monotherapy conferred no benefit, whereas trimethoprim-sulfamethoxazole was associated with an increased risk of treatment failure in a cohort of children with nondrained noncultured SSTIs who were treated as outpatients. Even in regions with endemic community-acquired MRSA, β-lactams may still be appropriate, first-line, empiric therapy for children presenting with these infections.

Q: What is the dirtiest thing ever said on television?
A: “Ward, I think you were a little hard on the Beaver last night.”

But I digress….

This is a MMWR article about what happned when that parent brought in a dead bat for show-and-tell at school. Rabies shots soon followed. And the parent was given the choice of being waterboarded or watching back-to-back episodes of The View. What would you choose? Anyway, this is just a reminder that one may not need to have an actual bite to get rabies.
http://omniphysicians.com/2009/05/28/the-dead-bat-the-dead-head-parent-teachers/

FDA has approved a new drug for bactrial conjunctivitis. It’s called Besivance (besifloxacin ophthalmic suspension 0.6%). It’s really named in honor of Sweet Bessie Vance, the classic Blues singer in the meatpacking district of Chicago in the 1920s. A real cool lady…pretty…good voice…but had a constant yellow drip from her eyes. Patients using the drug in clinical trials had a faster rate of resolution of the infection than those treated with a solution containing only a preservative. The drug was shown to be effective in treating patients age one year and older.

Adverse events were reported in less than 3 percent of patients in clinical trials. They included redness of the eyes, blurred vision, eye pain, irritation and itching, and headache.
http://omniphysicians.com/2009/05/28/besivance-to-treat-bacterial-conjunctivitis/

Drinking water for approximately one sixth of US households is obtained from private wells. Since there’s no regulations governing private well water, there is a heigthened risk of contamination with pollutants and organisms. Is this something we should be asking if rural kis come in with GI manifestations or odd rashes?
http://omniphysicians.com/2009/05/26/well-water-kids/

Finally, I’ve attached an article from CHEST that reviews the use of thrombolytics in patients with submassive PE. Anticoagulants are used for routine PE. Thrombolytics are used with PE and hemodynamic instability. However, the appropriate therapy for submassive PE (PE associated with RV dysfunction but preserved systemic arterial BP) remains an area of contention, and definitive data proving mortality benefit in this setting are lacking. Anyway, it’s something to chew over.

Paul R.

Chang Farm Recalls Expired Chang Farm Bean and Soy Sprouts Because of Possible Health Risk

Contact:
Sidney Chang
413-665-3341

FOR IMMEDIATE RELEASE — May 28, 2009 — Chang Farm, River Road, Whatley, MA is issuing a voluntary recall of Bean and Soy sprouts produced from Chang Farms, with specific expired date codes because of the possible presence of Listeria monocytogenes (L. Monocytogenes) contamination. Listeria monocytogenes, an organism which can cause serious and sometimes fatal infections in young children, frail or elderly people, and others with weakened immune systems. Although healthy individuals may suffer only short-term symptoms such as high fever, severe headache, stiffness, nausea, abdominal pain and diarrhea, Listeria infection can cause miscarriages and stillbirths among pregnant women.

The affected product is packaged in 10 lb bags (bulk) and 12 oz plastic bags (retail), labeled under the Chang Farm Brand as Soy Sprouts and have a “Sell By” date of May 23, 2009 or May 24, 2009 and Bean Sprouts with “Use By” date of May 23, 2009 or May 24, 2009.

The product has been distributed to retail stores and restaurants throughout MA, CT, NY and NJ.

No illnesses have been reported to date.

The contamination was discovered after a sample was secured at a retail store in New York which tested positive for L. monocytogenes

All grocery stores, food services, and other retailers who have this lot in MA, CT, NY and NJ should remove this product from their shelves. Consumers should discard this product or return them to the place of purchase for a full refund.

Consumers should contact their healthcare provider with any illness concerns. Consumers with questions about the warning may contact Chang Farm at 413-665-3341.

MMWR May 29, 2009 / 58(20);557-561 (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5820a1.htm?s_cid=mm5820a1_e)

Human Exposures to a Rabid Bat — Montana, 2008
On September 29, 2008, the Ravalli County Public Health Department (RCPHD) notified the Montana Department of Public Health and Human Services (MDPHHS) of a large-scale human exposure to a dead bat at an elementary school. On October 1, the bat was confirmed to be rabid, and on October 4, MDPHHS requested assistance from CDC in evaluating persons for rabies exposure. Of 107 persons assessed, only one person (1%) was recommended for rabies postexposure prophylaxis (PEP) in accordance with guidance from the Advisory Committee on Immunization Practices (ACIP); however, 74 persons (68%) ultimately pursued rabies PEP. This report describes the incident and public health response, and highlights the importance of unified risk communication. After a potential large-scale exposure to rabies virus, guidance from clinicians should be consistent with ACIP recommendations to ensure appropriate use of rabies PEP (1).

Incident Description

On September 28, a parent of two students at a Ravalli County elementary school found a dead bat carried into the house by the family cat. The bat carcass was placed in a jar and stored overnight. On September 29, one parent accompanied the children to school with the bat, and before leaving school premises, removed the carcass from the jar and presented it to eight different classrooms (one kindergarten, four 5th-grade, and three 4th-grade classrooms). Students and teachers in at least five classrooms touched the bat, along with a few other staff members of the school.

Later that morning, the school nurse notified RCPHD after learning of the presentation. RCPHD subsequently advised the parent to submit the bat for rabies diagnosis. That afternoon, the parent took the bat carcass to an off-campus soccer practice attended by students from the school. Some of these children touched the bat. On September 30, the bat was shipped to the Montana Veterinary Diagnostic Laboratory (MVDL). On October 1, MVDL detected the presence of rabies viral antigen in the animal’s brain via direct fluorescent antibody testing. On October 16, CDC identified the implicated virus variant as one associated with the silver-haired bat (Lasionycteris noctivagans).

On September 30, while awaiting the results of the laboratory testing, school officials sent letters home with students enrolled in the five classrooms (kindergarten and 5th grade) where the teacher observed students touching the bat. The letter described concern for potential exposure to the rabies virus. School officials did not send letters home to students enrolled in the three 4th-grade classrooms because teachers did not observe any of these students touching the bat. On the evening of October 1, school officials telephoned households of students in the kindergarten and 5th-grade classes with news of the positive laboratory findings; voice-mail messages were left if no one answered. The cat that had discovered the bat received a rabies booster shot after a veterinarian confirmed its current rabies vaccination status. The cat was observed in the owner’s home for 45 days and was reported to be healthy at the time of this report.

Public Health Response

On October 3, RCPHD held a public meeting in the school. A panel composed of representatives from RCPHD and MDPHHS and two local clinicians (a physician and a veterinarian) provided information and answered questions about rabies, PEP, and vaccine safety. They announced that public health recommendations for PEP would be based on individual risk assessments and that the school would host a vaccination clinic the following week where PEP would be administered. At the meeting, parents raised concerns that students in the three 4th-grade classrooms might also have touched the bat. School officials strongly encouraged that all students, staff, and soccer players suspected of touching the bat be evaluated for PEP. Announcements regarding the starting date and location of the vaccination clinic were made in the local press and on signs posted at the school.

On October 4, MDPHHS requested that CDC assist MDPHHS and RCPHD in evaluating and providing prevaccination counseling to potentially exposed persons. The vaccination clinic was scheduled to start on October 7 and continue on subsequent days for all doses of vaccine in the 5-dose rabies PEP series.

Exposure Risk and Recommendation for PEP

On October 7, a total of 107 students (accompanied by parents or guardians) and faculty were individually interviewed at the school by representatives of RCPHD, MDPHHS, and CDC. All were identified as requiring evaluation for rabies exposure, either because they reported touching the bat at the school or soccer practice or had been recorded as present in a classroom where touching had been observed by a teacher. Of the 107 interviews, 91 were conducted in person and 16 by telephone. For these 107 interviews, 97 (91%) of respondents were students of the school, and the remaining 10 (9%) were faculty or staff members. Median age was 10 years (range: 5–61 years), and 58 (54%) of respondents were male. Most minors evaluated reported touching the bat while at school.

Based on ACIP guidance, respondents were considered to have been possibly exposed to the rabies virus if they reported a bite or nonbite exposure. A bite exposure was defined as skin penetration from the bat’s teeth. A nonbite exposure was defined as skin contact with the bat’s mouth (i.e., where infectious saliva might have been present) where 1) open wounds were present or 2) the presence of skin breaks could not be excluded, or 3) the respondent reported subsequent hand contact with conjunctiva or other mucous membranes. Touching the bat in the absence of these conditions was not considered an exposure. History of handwashing or hand sanitizer use immediately after touching the bat also was elicited.

PEP was recommended for one student, who reported possibly being pricked by the bat’s teeth after probing its oral cavity with her fingers. The remaining 106 persons either reported touching nonmouth areas (89 [84%]), reported no contact at all (15 [14%]), or declined to be interviewed (two [2%]) and were not recommended for PEP. Of 11 respondents who reported possibly rubbing their eyes after touching the bat, none reported touching the bat’s mouth, and 10 reported immediate hand sanitizer use or handwashing. Because this indirect contact does not meet ACIP criteria for rabies virus exposure, none of these respondents were recommended for PEP.

Risk assessment was communicated orally to the respondents and/or their parent or guardian, together with an explanation for why PEP was or was not recommended. Persons were counseled on possible adverse events associated with rabies vaccine, including mild local reactions and pain at the injection site and very rare but serious reports of Guillain-Barré syndrome or acute disseminated encephalomyelitis (1).

Administration of PEP

After counseling, respondents pursued or declined PEP, a regimen normally composed of 1 dose of human rabies immune globulin (HRIG) infiltrated in the wound (when applicable) or administered intramuscularly on day 0 (day of initiation) and five injections of rabies vaccine administered intramuscularly on days 0, 3, 7, 14, and 28 (in previously unvaccinated persons). Seventy-four (69%) of the 107 respondents, including the one person with the possible bite exposure, pursued rabies PEP, at a total HRIG and vaccine cost exceeding $75,000. The school’s insurance policy covered this expense, and RCPHD assumed the cost of unused PEP ($29,000) procured in advance of the vaccination clinic. At the time of this report, no serious adverse events had been reported to RCPHD in connection to the administered PEP, and no cases of human rabies had been reported in association with the incident.

Decision to Pursue PEP

A written survey was administered to vaccinees to elucidate sources of information used in their decision to pursue PEP. Adult vaccinees and parents/guardians of minor vaccinees returning to the clinic for their second dose of vaccine (on day 3) were asked to indicate the information sources considered.* Of the 73 persons who attended the day-3 vaccination clinic (one person made arrangements to receive vaccine at an alternate clinic location), 59 (81%) returned the questionnaire. These respondents most frequently rated a physician as the most important source of information used to guide decision-making (18 [31%] of 59), followed by family or friends (13 [22%]), the Internet (12 [20%]), and the health department or CDC (nine [15%] (Figure). Anecdotal reports indicated that many of the vaccinees had consulted their primary-care physician for risk assessment and reported to the vaccination clinic with the expectation of receiving PEP.

Reported by: J Griffin, C Calderwood, MD, Ravalli County Health Dept; S Helgerson, MD, K Johnson, DVM, PhD, B Barnard, MPH, Montana Dept of Public Health and Human Svcs. C Rupprecht, VMD, PhD, Div of Viral and Rickettsial Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases; E Kennedy, DVM, K Robertson, DVM, EIS officers, CDC.

Editorial Note:
The rarity of human rabies in the United States is attributed to effective animal control and canine vaccination programs (1), in addition to widely accessible biologics used for rabies PEP in humans. However, the persistence of disease in wildlife reflects its public health relevance. During 2003–2007, an average of 6,927 animal cases were identified annually in the United States and Puerto Rico, with wildlife bearing approximately 90% of the disease burden (2–6). Although rabid bats constitute less than 25% of these cases, nearly all indigenous human rabies cases reported in the United States have been linked to bats in recent decades (1). Prevention of human rabies in the United States largely hinges on an educated public and professional sector that is aware of bat-associated rabies risks.

Large-scale human contact with rabid animals requires mobilization of substantial resources and involvement of public health officials, as demonstrated by this incident, a similar occurrence in New Hampshire during 1994 (7), and a multistate incident in 2007 (8). These incidents typically generate high public anxiety, which can lead to unnecessary rabies PEP. This report differs from accounts of previous large-scale human rabies exposures because it describes the compliance with ACIP recommendations by persons who were evaluated and counseled by public health officials.

During 2007–2009, the human rabies vaccine supply was limited because of temporary suspension of production by one manufacturer. To acquire rabies vaccine during that time, clinicians were required to first consult with state or local public health officials. MDPHHS requested CDC assistance because of the anticipated challenges posed by assessing and counseling so many persons in this incident, especially during a time of limited vaccine supply.

Approximately one third of rabies large-scale exposures occur in school settings (9), which also are ideal sites for educational outreach to promote safe animal practices. Such outreach should include messages that warn against contact with wildlife (both dead and alive) and instructions on what to do if an animal is found on school or home premises. School policies that prohibit bats and other common rabies reservoirs in classrooms are recommended to lessen exposure risks.† All animals suspected of being infected with the rabies virus should be handled carefully and brought promptly to public health officials for testing.

Risk communication is an integral component of a public health response after potential large-scale exposures (10), including those involving potential exposure to the rabies virus. Many of the persons who pursued PEP in this incident appear to have acted upon advice from community physicians in preference to information provided by public health officials. Clinicians can play an important role in ensuring that only persons with exposure that meet ACIP criteria receive PEP. Coordination among the medical and public health officials involved in a response to a potential large-scale rabies exposure is critical to ensuring the delivery of a unified message to the public regarding the appropriateness of PEP. Timely dissemination of ACIP exposure criteria to local clinicians via the Health Alert Network (HAN) or other communication tools might help ensure that exposed persons receive advice consistent with recommended public health practice.

Acknowledgments
This report is based, in part, on contributions by Stevensville School District, S Dickerson, N Park, S Hamilton, D Parmenter, K Squires, K McKillip, Ravalli County Public Health Dept; M Emett, S McClintick, Aspen Hospice; E Mosher, Montana Dept of Public Health and Human Svcs; K Prokop, B Layton, DVM, Montana Veterinary Diagnostic Laboratory; and A Tumpey, MS, P Yager, L Orciari, MS, J Blanton, MPH, Div of Viral and Rickettsial Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases, CDC.

References
CDC. Human rabies prevention—United States, 2008. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2008;57:1–26, 28.
Blanton JD, Palmer D, Christian KA, Rupprecht CE. Rabies surveillance in the United States during 2007. J Am Vet Med Assoc 2008;233:884–97.
Blanton JD, Hanlon CA, Rupprecht CE. Rabies surveillance in the United States during 2006. J Am Vet Med Assoc 2007;231:540–56.
Blanton JD, Krebs JW, Hanlon CA, Rupprecht CE. Rabies surveillance in the United States during 2005. J Am Vet Med Assoc 2006;229:1897–911.
Krebs JW, Mandel EJ, Swerdlow DL, Rupprecht CE. Rabies surveillance in the United States during 2004. J Am Vet Med Assoc 2005;227:1912–25.
Krebs JW, Mandel EJ, Swerdlow DL, Rupprecht CE. Rabies surveillance in the United States during 2003. J Am Vet Med Assoc 2004;225:1837–49.
CDC. Mass treatment of humans exposed to rabies—New Hampshire, 1994. MMWR 1995;44:484–6.
CDC. Public health response to a rabid kitten—four states, 2007. MMWR 2008;56:1337–40.
Rotz LD, Hensley JA, Rupprecht CE, Childs JE. Large-scale human exposures to rabid or presumed rabid animals in the United States: 22 cases (1990–1996). J Am Vet Med Assoc 1998;212:1198–200.
Tinker TL, Zook E, Chapel TJ. Key challenges and concepts in health risk communication: perspectives of agency practitioners. J Public Health Manag Pract 2001;7:67–75.
*

FOR IMMEDIATE RELEASE
May 28, 2009
Media Inquiries:
Sandy Walsh, 301-796-4669
Consumer Inquiries:
888-INFO-FDA

FDA Approves Besivance to Treat Bacterial Conjunctivitis
The U.S. Food and Drug Administration today approved Besivance (besifloxacin ophthalmic suspension 0.6 percent) for the treatment of bacterial conjunctivitis (non-viral), a contagious condition marked by irritation of the eyes and a discharge from the mucous membranes.

“Bacterial conjunctivitis is a common condition that affects people of all ages,” said Wiley A. Chambers, M.D., acting director of the Division of Anti-Infective and Ophthalmology Products in FDA’s Center for Drug Evaluation and Research. “It is important to have a variety of treatment options available to health care professionals and patients because an effective drug therapy can reduce the duration of the illness and reduce the chances of infecting others.”

Bacterial forms of conjunctivitis are common in childhood, but they can occur in people of any age. Symptoms of bacterial conjunctivitis can include red eyes, swelling, eyelids sticking together, itching, watering and a white or yellow sticky discharge from the eyes. Bacterial conjunctivitis is generally a condition that runs its course in 7-14 days.

Patients using the drug in clinical trials had a faster rate of resolution of the infection than those treated with a solution containing only a preservative. The drug was shown to be effective in treating patients age one year and older.

Adverse events were reported in less than 3 percent of patients in clinical trials. Adverse reactions included redness of the eyes, blurred vision, eye pain, irritation and itching, and headache. Besivance is an eye drop for topical use on the eyes only. It should not be injected into the eye.

Besivance is made by Bausch & Lomb, Rochester, N.Y.

Q: What do Alexander the Great and Kermit the Frog have in common?
A: Their middle name.

But I digress…..

The FDA is concerned that people are abusing acetominophen and becoming hepatotoxic. They are considering better warning labels, limiting the maximum adult daily dose to no more than 3,250 milligrams (the current recommendation stands at 4,000 milligrams per day), limiting tablet strength for immediate release formulations and limiting options in liquid formulations for children. How many times do we prescribe T-3s and forget to tell patients not to take additional tylenol?
http://omniphysicians.com/2009/05/28/fda-wants-stronger-acetaminophen-warnings/

There’s a law that hospitals have to report disciplinary actions taken against a physician to a national database (The Scarlet Stethescope). According to a patient advocacy group nearly half the hospitals have not done so.

Since 1990, hospitals that revoke or suspend a physician’s admitting privileges for at least 31 days have been required to file a report with the National Practitioner Data Bank (NPDB). The authors say hospitals appear to be altering their disciplinary procedures to evade the reporting requirements. Some hospitals avoid reporting by changing their bylaws or by having physicians take a ‘leave of absence’” in place of suspension.

Hospitals have also kept suspensions under 31 days, the threshold for mandatory reporting. I have included a link to the report in case you’re interested.

http://omniphysicians.com/2009/05/28/hospitals-not-snitching/
Link to report:
http://www.citizen.org/publications/release.cfm?ID=7659

This news article relates to the perils of texting for kids. Experts claim it is leading to anxiety, distraction in school, falling grades, repetitive stress injury and sleep deprivation. American teenagers sent and received an average of 2,272 text messages per month in the fourth quarter of 2008, according to the Nielsen Company — almost 80 messages a day, more than double the average of a year earlier. That’s what happens when you take away beer and cigarettes from them!
http://omniphysicians.com/2009/05/26/texting/

This study shows that parents have no clue as to how to dose their kids with OTC cough/cold preps. They’re the ones who voted for Obama. Just kidding!
http://omniphysicians.com/2009/05/26/otc-coughcold-meds-and-parental-understanding/

Paul R.

Link: http://www.forbes.com/feeds/ap/2009/05/27/ap6472310.html

AP, 5/27/09: A Food and Drug Administration report released Wednesday recommends stronger warnings and dose limits on drugs containing the painkiller acetaminophen, citing an increased risk of liver injury.

The recommendation covers both prescription doses and over-the-counter medication, of which Johnson & Johnson’s Tylenol is the most well-known. Acetaminophen is also widely available as a generic over-the-counter drug.

“There is extensive evidence that hepatotoxicity (liver toxicity) caused by acetaminophen use may result from lack of consumer awareness that acetaminophen can cause severe liver injury,” the working group report said.

The outside advisers will meet in June to discuss the report’s findings. The recommendations include enhanced public information efforts, stronger labels warning of liver side effects, and dose limitations.

“Consumers may not be aware that acetaminophen is present in many over-the-counter combination products, so they may unknowingly exceed the recommended acetaminophen dose if they take more than one acetaminophen product without knowing that both contain acetaminophen,” the report said.

The recommendations also call for limiting the maximum adult daily dose to no more than 3,250 milligrams. The current recommendation stands at 4,000 milligrams per day. Other recommendations include limiting tablet strength for immediate release formulations and limiting options in liquid formulations for children.

Medpage Today, 5/27/09 (http://www.medpagetoday.com/PublicHealthPolicy/GeneralProfessionalIssues/14395)
Link to report: http://www.citizen.org/publications/release.cfm?ID=7659

Almost half of U.S. hospitals have never reported a single physician disciplinary action to a national database as required by law, according to Public Citizen, the consumer advocacy group.

Since 1990, hospitals that revoke or suspend a physician’s admitting privileges for at least 31 days have been required to file a report with the National Practitioner Data Bank (NPDB).

But according to a Public Citizen report, authored by Sidney Wolfe, M.D., and Alan Levine, a former official in the Department of Health and Human Services, 48.9% of the 5,823 hospitals with active registrations have never submitted a report to the database.

No individual hospitals were identified because the NPDB treats such information as confidential, Dr. Wolfe said.

A total of 11,221 physician disciplinary actions were reported through 2007, the last year for which summary data were released from the NPDB.

The average of 650 reports per year has varied little over the years, and contrasts sharply with initial estimates that 5,000 to 10,000 reports would be filed annually, according to Dr. Wolfe and Levine.

On the basis of numerous studies and anecdotal reports — many of which were published in the 1990s — Dr. Wolfe and Levine said hospitals appear to be altering their disciplinary procedures to evade the reporting requirements.

“Some hospitals avoid reporting by changing their bylaws or by having physicians take a ‘leave of absence’” in place of suspension, they said in the report.

Hospitals have also kept suspensions under 31 days, the threshold for mandatory reporting, they charged.

The lack of reports, said Dr. Wolfe at a press briefing Wednesday, “bespeaks the idea that they aren’t doing discipline, and/or the paired problem that they aren’t reporting.”

He said the numbers suggested that “deficient discipline” — that is, declining to act against negligent physicians — was the main issue.

But the practice of crafting disciplinary actions to evade the reporting mandate is also serious, he said.

The American Hospital Association did not respond to repeated requests for comment.

Public Citizen has sent a letter to Health and Human Services Secretary Kathleen Sebelius, calling for tighter regulations and penalties on hospitals that fail to file reports.

Dr. Wolfe said the NPDB data on individual hospitals and physicians should also be made available to the public. Currently, only the government, state medical boards, and hospitals have access to the individual reports.

Much of the group’s study was based on investigations taking place more than 10 years ago.

For example, a report from the Health and Human Services inspector general’s office (where Levine formerly worked) in 1995 showed that half of hospitals had not submitted anything to the NPDB.

In 1999, a study published in the Journal of the American Medical Association confirmed the low level of reporting.

With the change in administration in Washington, Dr. Wolfe said, now is a good time to raise these issues anew.

He said the hospital industry had previously succeeded in “fending off” stricter reporting requirements.

When Levine was still with the Inspector General’s office, he said, he had attended a meeting on proposed legislation to tighten the mandates.

“It was decided that the proposal would be killed because it would have imposed an ‘additional unnecessary regulatory burden’ on hospitals,” he said.