Have you heard about those two people who were found dead in one of those cult-like “diaphoresis domiciles” (http://prescottdailycourier.com/main.asp?SectionID=1&SubSectionID=1&ArticleID=73316)?  There were another 20 or so who were hospitalized for varying degrees of unconsciousness, renal failure, and dehydration.  One of the survivors at the hospital asked the doctor, “Am I going to die?”

“No, you’ll be fine.  We’ll fix you right up.”

“You sure, doc?”

“Sure.  No sweat!”

But I digress……

Here is another study showing that booze and biking don’t mix.  Two hundred patients 18 years or older were enrolled from December 2006 through November 2007. Alcohol use showed a strong correlation with head injury. Impaired riders were less experienced, less likely to have medical insurance, rarely wore helmets, were more likely to ride at night and in slower speed zones such as city streets, and their hospital charges were double.  The charges were so expensive, it drove many to drink.

http://omniphysicians.com/2009/10/11/booze-biking-brain-injury/

Vitamin D deficiency has been responsible for everyting from osteoporisis to psoriasis to cancer.  Why don’t we hear it as an adjunct to fight against H1N1?  This is a study contributed by one of our dearest associates suggesting that we should maybe augment our Vitamin D intake for this very reason.  Exactly how much is a question you might ask of your own PCP or one of our local experts.

http://omniphysicians.com/wp-admin/post.php?action=edit&post=6962&message=1

This study looked at predictors of a difficult intubation.  They found that a thyroid to hyoid measurement of less than 2 fingers predicted a difficult airway.  They didn’t care for the Mallampati classification but they liked the Cormack and Lehane classification.  The second post is an abstract discussing the LEMON method to assess intubation difficulties.

http://omniphysicians.com/2009/10/11/predictors-of-difficult-intubation/

http://omniphysicians.com/2009/10/11/lemon/

 Source:  http://www.nda.ox.ac.uk/wfsa/html/u17/u1703_01.htm

Paul R.

MMWR October 9, 2009 / 58(39);1100-1101

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5839a3.htm?s_cid=mm5839a3_e

Update on Influenza A (H1N1) 2009 Monovalent Vaccines

On September 15, 2009, four influenza vaccine manufacturers received approval from the Food and Drug Administration for use of influenza A (H1N1) 2009 monovalent influenza vaccines in the prevention of influenza caused by the 2009 pandemic influenza A (H1N1) virus.* Both live, attenuated and inactivated influenza A (H1N1) 2009 monovalent vaccine formulations are available; each contains the strain A/California/7/2009(H1N1)pdm. None of the approved influenza A 2009 (H1N1) monovalent vaccines or seasonal influenza vaccines contains adjuvants (1–5). CDC’s Advisory Committee on Immunization Practices has made recommendations previously for which persons should be the initial targets for immunization with influenza A (H1N1) 2009 monovalent vaccines and has issued guidelines on decisions for expansion of vaccination efforts to other population groups (6). Children aged 6 months–9 years receiving influenza A (H1N1) 2009 monovalent vaccines should receive 2 doses, with doses separated by approximately 4 weeks; persons aged ≥10 years should receive 1 dose (1–4).

The approved age groups for use of inactivated influenza A (H1N1) monovalent influenza vaccines differ by manufacturer (Table). Three manufacturers that produce inactivated vaccines approved for prevention of seasonal influenza (6) also produce formulations of influenza A (H1N1) 2009 monovalent influenza vaccines. Vaccine produced by CSL Limited is approved for use in persons aged ≥18 years (1), vaccine produced by Novartis Vaccines and Diagnostics Limited is approved for persons aged ≥4 years (2), and vaccine produced by Sanofi Pasteur, Inc. is approved for persons aged ≥6 months (3). A live attenuated influenza vaccine (LAIV) manufactured by MedImmune LLC is approved for persons aged 2–49 years (1). The 2009 (H1N1) monovalent LAIV has the same age range for use as the seasonal LAIV and should not be used to vaccinate children aged <2 years, adults aged >49 years, pregnant women, persons with underlying medical conditions that confer a higher risk for influenza complications, or children aged <5 years old with one or more episodes of wheezing in the past year (5).

Influenza A (H1N1) 2009 monovalent vaccine approvals were made on the basis of standards developed for vaccine strain changes for seasonal influenza vaccines, adherence to manufacturing processes, product quality testing, and lot release procedures developed for seasonal vaccines. The age groups, precautions, and contraindications approved for the influenza A (H1N1) 2009 monovalent vaccine are identical to those approved for seasonal vaccines. All influenza vaccines available in the United States for the 2009–10 influenza season are produced using embryonated hen’s eggs and contain residual egg protein.

Preliminary data indicate that the immunogenicity and safety of these vaccines are similar to those of seasonal influenza vaccines. An immunogenicity study of an inactivated influenza A (H1N1) monovalent vaccine manufactured by CSL Limited (Parkville, Victoria, Australia) demonstrated that by day 21 after vaccination, antibody titers of 1:40 or more (hemagglutination-inhibition assay) were observed in 116 (97%) of 120 adults who received the 15 μg dose. Local discomfort (e.g., injection site tenderness or pain) was reported by 46% of subjects, and one or more systemic symptoms (e.g., headache, malaise, or myalgia) by 45% of subjects (7). This safety profile is consistent with results from studies of the seasonal influenza vaccine manufactured by CSL Limited (8). In studies of other seasonal inactivated influenza vaccines, rates of adverse events were not significantly different from placebo injections except for arm soreness and redness at the injection site (9). The National Institute of Allergy and Infectious Diseases (NIAID) reported preliminary results of a study among children aged 6 months–18 years. Among children aged 6–35 months, 3–9 years, and 10–17 years immunized with a 15 μg inactivated influenza A 2009 (H1N1) monovalent vaccine (Sanofi Pasteur, Inc., Swiftwater, PA), 25%, 36% and 76%, respectively, developed antibody titers of 1:40 or more (hemagglutination-inhibition assay) after a single dose of vaccine.† Immunogenicity and safety study results similar to those observed for seasonal vaccines also have been reported by the other manufacturers (MedImmune LLC, Gaithersburg, MD and Novartis Vaccines and Diagnostics, Limited, Liverpool, UK, unpublished data, 2009).

Influenza activity attributed to 2009 H1N1 viruses has increased during September 2009 and is expected to continue through the fall and winter influenza season. Surveillance data indicate that the 2009 H1N1 viruses have not undergone substantial antigenic change since they were first characterized in April 2009 and should be well-matched to the monovalent vaccine strain (10). Influenza A (H1N1) 2009 monovalent vaccines will be available in many areas by mid-October. Vaccines against seasonal influenza are available now, and immunization programs and providers should begin or continue administering seasonal influenza vaccines as recommended (5,6). Additional data from clinical trials will be available over the coming weeks, and immunization providers should periodically look for updates on use of influenza A (2009) H1N1 monovalent vaccines at http://www.cdc.gov/flu.

References

1. CSL Biotherapies, Inc. Influenza A (H1N1) 2009 monovalent vaccine [Package insert]. King of Prussia, PA: CSL Biotherapies Inc.; 2009. Available at http://www.fda.gov/downloads/biologicsbloodvaccines/vaccines/approvedproducts/ucm182401.pdf. Accessed October 7, 2009.
2. Novartis Vaccines and Diagnostics, Ltd. Influenza A (H1N1) 2009 monovalent vaccine [Package insert]. Cambridge, MA: Novartis Vaccines and Diagnostics, Ltd.; 2009. Available at http://www.fda.gov/downloads/biologicsbloodvaccines/vaccines/approvedproducts/ucm182242.pdf. Accessed October 7, 2009.
3. Sanofi Pasteur, Inc. Influenza A (H1N1) 2009 monovalent vaccine [Package insert]. Swiftwater, PA: Sanofi Pasteur Inc.; 2009. Available at http://www.fda.gov/downloads/biologicsbloodvaccines/vaccines/approvedproducts/ucm182404.pdf. Accessed October 7, 2009.
4. MedImmune, LLC. Influenza A (H1N1) 2009 monovalent vaccine live, intranasal [Package insert]. Gaithersburg, MD: MedImmune, LLC.; 2009. Available at http://www.fda.gov/downloads/biologicsbloodvaccines/vaccines/approvedproducts/ucm182406.pdf. Accessed October 7, 2009.
5. CDC. Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009. MMWR 2009;58(No. RR-8).
6. CDC. Use of influenza A (H1N1) 2009 monovalent vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009. MMWR 2009;58(No. RR-10).
7. Greenberg ME, Lai MH, Hartel GF, et al. Response after one dose of a monovalent influenza A (H1N1) 2009 vaccine—preliminary report. N Engl J Med 2009 [E-pub]. Available at http://content.nejm.org/cgi/reprint/NEJMoa0907413.pdf?resourcetype=HWCIT. Accessed October 7, 2009.
8. Talbot HK, Keitel W, Cate TR, et al. Immunogenicity, safety and consistency of new trivalent inactivated influenza vaccine. Vaccine 2008;26:4057–61.
9. Nichol KL, Margolis KL, Lind A, et al. Side effects associated with influenza vaccination in healthy working adults: a randomized, placebo-controlled trial. Arch Intern Med 1996;156:1546–50.
10. CDC. Update: influenza activity—United States, April–August 2009. MMWR 2009;58:1009–12.

Link:  http://www.vitamindcouncil.org/PDFs/cannell-et-al-epidemic-influenza-and-vitamin-d.pdf

In Epidemiol. Infect 2006.

Epidemic influenza and vitamin D

2D, a steroid hormone, has profound effects on human2D acts as an immune system modulator, preventing excessive expression   

SUMMARY

In 1981, R. Edgar Hope-Simpson proposed that a ‘seasonal stimulus ’ intimately associated with

solar radiation explained the remarkable seasonality of epidemic influenza. Solar radiation triggers

robust seasonal vitamin D production in the skin; vitamin D deficiency is common in the winter,

and activated vitamin D, 1,25(OH)

immunity. 1,25(OH)

of inflammatory cytokines and increasing the ‘oxidative burst’ potential of macrophages. Perhaps

most importantly, it dramatically stimulates the expression of potent anti-microbial peptides,

which exist in neutrophils, monocytes, natural killer cells, and in epithelial cells lining the

respiratory tract where they play a major role in protecting the lung from infection. Volunteers

inoculated with live attenuated influenza virus are more likely to develop fever and serological

evidence of an immune response in the winter. Vitamin D deficiency predisposes children to

respiratory infections. Ultraviolet radiation (either from artificial sources or from sunlight) reduces

the incidence of viral respiratory infections, as does cod liver oil (which contains vitamin D). An

interventional study showed that vitamin D reduces the incidence of respiratory infections in

children. We conclude that vitamin D, or lack of it, may be Hope-Simpson’s ‘seasonal stimulus ’.

Airway Assessment Using “LEMON” Score Predicts Difficult ED Intubation

Use of this tool can reduce the chance of unexpectedly encountering a difficult airway.

http://emergency-medicine.jwatch.org/cgi/content/full/2005/216/1

 As many as 1% of emergency department intubations end up as a “failed airway” (unable to intubate the patient). One tool developed to determine which patients might pose airway management difficulties is the LEMON method. The authors of this study from Scotland developed an airway assessment score based on this method and determined the score’s utility in predicting difficult airways in the ED. They studied 156 patients who were intubated successfully in a single ED between June 2002 and September 2003.

The score, with a maximum of 10 points, was calculated by assigning 1 point for each of the following LEMON criteria:

 For each patient, the airway assessment score was compared with the Cormack-Lehane laryngoscopic view seen during intubation (1=full view, 4=glottis not visualized). At intubation, 114 patients were classified as Cormack-Lehane grade 1 (defined by the authors as easy intubation), and 42 were classified as grade 2 or higher (defined by the authors as difficult intubation). Patients in the difficult-intubation group had significantly higher LEMON scores than did those in the easy-intubation group. Of the criteria used to calculate the score, only large incisors, inter-incisor distance <3 fingerbreadths, and thyroid-to-floor-of-mouth distance <2 fingerbreadths were associated significantly with difficult intubation.

Published in Journal Watch Emergency Medicine February 16, 2005

3-3-2 Rule:    

3 fingers fit in mouth

3 fingers fit from mentum to hyoid cartilage

2 fingers fit from mandible to top of thyroid cartilage

Determination of difficult intubation in the ED
Secgin Soyuncu, Cenker Eken, Yildiray Cete, Firat Bektas, Mehmet Akcimen
American Journal of Emergency Medicine – October 2009 (Vol. 27, Issue 8, Pages 905-910, DOI: 10.1016/j.ajem.2008.07.003)

http://www.ajemjournal.com/article/S0735-6757(08)00524-X/abstract

Objective

The aim of this study is to determine the predictors of difficult intubation in the emergency setting.

Methods

This prospective observational clinical study was conducted in the emergency department (ED) of a University Hospital with an annually census of 50 000 visits from May 2005 to May 2007. All patients requiring intubation in the ED were included into the study. During the study period, same airway management protocol was used all intubations. The study form included patient’s demographic and variables according to intubation such as the Cormack-Lehane grade, modified LEMON score, Glasgow Coma Scale score, success rate, and associated complications.

Results

A total of 366 patients were included in the study. The mean age of the study patients was 46.8 ± 22.8, and 68.6% (n = 251) of them were male. A total of 86 (23.5%) patients were classified in the difficult intubation group and 280 (76.5%) patients in easy intubation group. Logistic regression analysis performed by the variables found to be significant in the univariate analysis revealed thyroid-to-hyoid distance less than 2 fingers (odds ratio, 3.34; 95% confidence interval, 1.35-8.27; P = .009) as an independent factor complicating the intubation. Cormack and Lehane classification was strongly related to difficult intubation. Intubation was more difficult from grade 1 to 4 (11% vs 25.2% vs 34% vs 81.8%, respectively; P = .000).

Conclusions

The thyroid-to-hyoid distance less than 2 fingers is the only independent variable in predicting difficult intubation. Mallampati classification is not a useful tool in classifying the difficult intubation in the ED that the “LEMON” acrostic can be modified to “LEON”.

 Source:  http://www.nda.ox.ac.uk/wfsa/html/u17/u1703_01.htm

Termination of drug-induced torsades de pointes with overdrive pacing
Published online: 07 October 2009
Nathan P. Charlton, David T. Lawrence, William J. Brady, Mark A. Kirk,
Christopher P. Holstege
DOI: 10.1016/j.ajem.2008.09.029
American Journal of Emergency Medicine

Link:    http://www.ajemjournal.com/article/S0735-6757%2808%2900668-2/abstract

Drug-induced prolongation of the QT interval is frequently encountered after medication overdose. Such toxicity can result in degeneration to torsades de pointes (TdP) and require overdrive pacing. We present 3 cases in which intentional medication overdose resulted in QTc prolongation with subsequent degeneration to TdP. Despite appropriate care, including magnesium therapy, each case required overdrive pacing for resolution of TdP. Although rarely encountered, patients with drug-induced TdP can be successfully managed with overdrive pacing.

From eMedicine (http://emedicine.medscape.com/article/760667-treatment)

Torsade de Pointes: Treatment & Medication

Author: Michael J Bessette, MD, FACEP, Director of Emergency Medicine, Jersey City Medical Center
Coauthor(s): Sheldon Jacobson, MD,

Emergency Department Care

Torsade, an inherently unstable rhythm, is prone to revert to more stable rhythms spontaneously and prone to recurrences. Torsade also is subject to degeneration into ventricular fibrillation. Begin therapy as soon as the rhythm clearly fulfills the criteria for torsade.

• Treat hypokalemia if it is the precipitating factor and administer magnesium sulfate in a dose of 2-4 g intravenously (IV) initially.
  • Magnesium is usually very effective, even in the patient with a normal magnesium level.
  • If this fails, repeat the initial dose, but because of the danger of hypermagnesemia (depression of neuromuscular function) the patient requires close monitoring.
  • Other therapies include overdrive pacing and isoproterenol infusion. Most (75-82%) torsade de pointes (TDP) rhythms are started by a pause. Pacing at rates up to 140 bpm may prevent the ventricular pauses that allow TDP to originate.
  • The patient with torsade who is in extremis should be treated with electrical cardioversion or defibrillation. Anecdotal reports cite successful conversion with phenytoin (Dilantin) and lidocaine.
• Patients with congenital long QT syndromes are thought to have an abnormality of sympathetic balance or tone and are treated with beta-blockers. If the patient breaks through this therapy and enters the ED in torsade, a short-acting beta-blocker, such as esmolol, can be tried.
  • A few cases of successful conversion using phenytoin and overdrive pacing have been reported.
  • If patient is unresponsive to conversion with phenytoin and overdrive pacing, attempt electrical cardioversion.
  • Cervical sympathectomy and implantable pacemakers/defibrillators have been used in some cases for long-term management.
• Shortening the action potential decreases the likelihood of immediate recurrence. Pacing or administration of isoproterenol to a rate of 90-100 bpm is effective.
• Withdraw all QT-prolonging drugs………

Magnesium sulfate

DOC for treatment of torsade de pointes. Acts as antiarrhythmic agent and diminishes frequency of PVCs, particularly when secondary to acute ischemia. Deficiency in this electrolyte is associated with sudden cardiac death and can precipitate refractory VF. Magnesium supplementation is used for treatment of torsade de pointes, known or suspected hypomagnesemia, or severe refractory VF.

Alcohol, bicycling, and head and brain injury: a study of impaired cyclists’
riding patterns R1
Published online: 09 October 2009
Patrick Crocker, Omid Zad, Truman Milling, Karla A. Lawson
DOI: 10.1016/j.ajem.2008.09.011
American Journal of Emergency Medicine

 http://www.ajemjournal.com/article/S0735-6757%2808%2900649-9/abstract

Objective

The aim of the study was to examine the interactions between alcohol, bicycle helmet use, experience level, riding environment, head and brain injury, insurance status, and hospital charges in a medium-sized city without an adult helmet law.

Methods

A study of adult bicycle accident victims presenting to a regional trauma center over a 1-year period was undertaken. Data were collected at the bedside regarding helmet use, alcohol use, experience level, location and type of accident and prevailing vehicle speed (for road accidents), and presence and degree of head or brain injury.

Results

Two hundred patients 18 years or older were enrolled from December 2006 through November 2007. Alcohol use showed a strong correlation with head injury (odds ratio, 3.23; 95% confidence interval, 1.57-6.63; P = .001). Impaired riders were less experienced, less likely to have medical insurance, rarely wore helmets, were more likely to ride at night and in slower speed zones such as city streets, and their hospital charges were double (all P values <.05).

Conclusions

Alcohol use leads to a host of unsafe bicycling practices, increased head and brain injuries, and costs to the cyclist and community. The interrelated characteristics of the riding patterns of the cyclists who use alcohol might help target interventions.