Link:  http://www.ems1.com/ems-management/articles/604953-Denver-paramedic-gets-12-years-for-attacking-patient/

The Denver Post

DENVER — An ambulance paramedic was sentenced to 12 years in prison Friday for severely beating a patient while transporting him to the Denver Health Medical Center emergency room in January.

Alan Miller, 31, was sentenced after being convicted by a Denver jury last month of second-degree assault and false reporting.

On Jan. 3, Miller and other paramedics picked up Tim Smith, 39, who had suffered a seizure and hit his head. Smith’s wife, Suzanne Lawrence, drove her own car to Denver Health.

When she arrived, her husband had a fractured skull, a broken eye socket and a broken nose. Miller’s partner, Shaunna King, told Lawrence that they had to stop on West Sixth Avenue because her husband had come out of his restraints. The ambulance crew blamed police for Smith’s injuries.

In giving Miller 12 years in prison, the judge noted that not only did Miller injure someone he was supposed to be caring for, he also had tried to avoid responsibility by blaming the assault on an innocent law enforcement officer.

Date: Mon 16 Nov 2009
Source: UT Southwestern Medical Center, press release [edited]
<http://www.eurekalert.org/pub_releases/2009-11/usmc-uss111609.php>

Scientist begins to unravel what makes pandemic H1N1 tick
———————————————————
As the number of deaths related to the pandemic H1N1 virus, commonly 
known as “swine flu,” continues to rise, researchers have been 
scrambling to decipher its inner workings and explain why the 
incidence is lower than expected in older adults. In a study appearing 
online and in a future issue of Proceedings of the National Academy of 
Sciences [see comment below], a UT [University of Texas] Southwestern 
Medical Center researcher and his collaborators in California show 
that the molecular makeup of the current H1N1 flu strain is strikingly 
different from previous H1N1 strains as well as the normal seasonal 
flu, especially in structural parts of the virus normally recognized 
by the immune system.

Prior research has shown that an individual’s immune system is 
triggered to fight off pathogens such as influenza when specific 
components of the immune system — namely antibodies, B-cells, and T 
cells — recognize parts of a virus known as epitopes. An individual’s 
ability to recognize those epitopes — spurred by past infections or 
vaccinations — helps prevent future infections. The challenge is that 
these epitopes vary among flu strains. “We hypothesize that older 
people are somewhat protected because the epitopes present in flu 
strains before 1957 may be similar to those found in the current H1N1 
strain, or at least similar enough that the immune system of the 
previously infected person recognizes the pathogen and knows to 
attack,” said Dr Richard Scheuermann, professor of pathology and 
clinical sciences at UT Southwestern and a co-author of the paper. 
“Those born more recently have virtually no pre-existing immunity to 
this pandemic H1N1 strain because they have never been exposed to 
anything like it.”

Between April and mid-October [2009], the current H1N1 virus sickened 
roughly 22 million Americans and contributed to or caused about 4000 
deaths, according to the figures recently released by the Centers for 
Disease Control and Prevention [CDC]. The deaths included 540 
children. The CDC report also estimates the total number of 
hospitalizations at around 98 000 nationwide, with children accounting 
for 36 000 of the total.

For this study, researchers examined whether epitopes present in the 
seasonal flu strains between 1988 and 2008 also are found in the 
existing H1N1 strain. They used data catalogued in the Immune Epitope 
Database as well as information from the National Center for 
Biotechnology Information (NCBI) and the Global Initiative on Sharing 
Avian Influenza Data’s (GISAID) influenza genetic sequence databases. 
Dr Scheuermann said his team also analyzed the virus genetic data 
using the NIH-sponsored Influenza Research Database 
(<http://www.fludb.org>), which he oversees at UT Southwestern. The 
researchers found major genetic differences between the pandemic H1N1 
strain and seasonal strains, potentially explaining why children and 
young adults are more susceptible to the H1N1 strain now circulating 
worldwide.

“Normally, older adults are generally more susceptible to pathogens 
like influenza, however, for the pandemic H1N1 strain this does not 
seem to be the case,” said Dr Scheuermann, who is also a member of the 
Cancer Immunobiology Center at UT Southwestern. “The antibody 
epitopes, which provide protection against disease, for the pandemic 
H1N1 strain are virtually all different from those present in recent 
seasonal strains, so young people have no built-in protective 
mechanisms. We speculate that older adults may have been exposed to 
viruses in their youth in which the epitopes are more similar.”

At this point, he said, scientists must continue to be vigilant about 
tracking the pandemic H1N1 strain as it continues to evolve. “H1N1 has 
not mutated in such a way as to make people sicker, but it could 
happen,” Dr Scheuermann said. “It is important that individuals follow 
the public health guidelines regarding vaccination as the H1N1 vaccine 
becomes more widely available.”

–
Communicated by:
ProMED-mail Rapporteur Mary Marshall

Link:  http://www.hhs.gov/news/press/2009pres/11/20091118a.html

Secretary Sebelius Statement on New Breast Cancer Recommendations

HHS Secretary Kathleen Sebelius issued the following statement today on new breast cancer screening recommendations from the U.S. Preventive Services Task Force:

“There is no question that the U.S. Preventive Services Task Force Recommendations have caused a great deal of confusion and worry among women and their families across this country. I want to address that confusion head on. The U.S. Preventive Task Force is an outside independent panel of doctors and scientists who make recommendations. They do not set federal policy and they don’t determine what services are covered by the federal government. 

“There has been debate in this country for years about the age at which routine screening mammograms should begin, and how often they should be given. The Task Force has presented some new evidence for consideration but our policies remain unchanged. Indeed, I would be very surprised if any private insurance company changed its mammography coverage decisions as a result of this action.

“What is clear is that there is a great need for more evidence, more research and more scientific innovation to help women prevent, detect, and fight breast cancer, the second leading cause of cancer deaths among women.

“My message to women is simple. Mammograms have always been an important life-saving tool in the fight against breast cancer and they still are today. Keep doing what you have been doing for years — talk to your doctor about your individual history, ask questions, and make the decision that is right for you.”

Link:  http://www.ctv.ca/servlet/ArticleNews/story/CTVNews/20091117/adverse_091117/20091117

CTV.ca News Staff

Date: Tue. Nov. 17 2009 1:10 PM ET

Link:  http://content.nejm.org/cgi/content/full/361/21/e49?query=TOC

NEJM Volume 361:e49

A 77-year-old man presented with a 5-day history of painful swelling of his right elbow, which was also red, warm, and tender. When pressure was applied, a toothpastelike, white, chalky substance was easily expressible (Panel A). Four weeks earlier, palliative therapy with sorafenib had been started for metastatic renal-cell carcinoma. The patient reported that he was not taking any other medications and had no history of joint symptoms other than a compound fracture of the right elbow 30 years earlier. The serum creatinine and uric acid levels were slightly elevated (creatinine, 1.4 mg per deciliter [124 µmol per liter]; normal range, 0.6 to 1.3 [53 to 115]; and uric acid, 7.4 mg per deciliter [440 µmol per liter]; normal range, 3.4 to 7.0 [202 to 416]). Inspection of the entire body revealed one additional red, but painless, area of swelling over the right first distal interphalangeal joint (Panel B), which was associated with subepidermal, yellow–white material. We suspected an acute flare of previously asymptomatic, chronic tophaceous gout. Compensated polarized light microscopy of the expressed white, chalky substance revealed needle-shaped, negatively birefringent urate crystals (Panel C), confirming the diagnosis. The acute symptoms subsided rapidly with the use of allopurinol and prednisolone. No further flares have occurred.

Link:  http://content.nejm.org/cgi/content/full/361/21/2015?query=TOC

NEJM Volume 361:2015-2017

Alexandra M. Stewart, J.D.

Mandatory vaccination of health care workers raises important questions about the limits of a state’s power to compel individuals to engage in particular activities in order to protect the public. In justifying New York State’s regulations requiring health care workers who have direct contact with patients or who may expose patients to disease to be vaccinated against seasonal and H1N1 influenza, New York State Health Commissioner Richard Daines recently argued, “[O]ur overriding concern . . . as health care workers, should be the interests of our patients, not our own sensibilities about mandates. . . . [T]he welfare of patients is . . . best served by . . . very high rates of staff immunity that can only be achieved with mandatory influenza vaccination — not the 40-50% rates of staff immunization historically achieved with even the most vigorous of voluntary programs. Under voluntary standards, institutional outbreaks occur. . . . Medical literature convincingly demonstrates that high levels of staff immunity confer protection on those patients who cannot be or have not been effectively vaccinated . . . while also allowing the institution to remain more fully staffed.”¹

Workers at diagnostic and treatment centers, home health care agencies, and hospices are included in New York’s requirement, although workers who can show that they have a recognized medical contraindication to vaccination are exempt. Each facility will have the discretion to determine the steps that unvaccinated health care workers must take to reduce the risk of transmitting disease to patients (see table).

Many health care workers believe that the mandate violates fundamental individual rights and public health policy, and some have filed court actions. In response, one judge ordered a delay in implementing the regulation, and New York’s governor, David Paterson, suspended the requirement so that the limited supply of H1N1 vaccine currently available can be distributed to the populations most at risk for serious illness and death.

The workers argue, first, that compulsory vaccination violates the Fourteenth Amendment in depriving them of liberty without due process. But in 1905, in deciding the smallpox-vaccination case Jacobson v. Commonwealth of Massachusetts, the U.S. Supreme Court recognized that the “police powers” granted to states under the Tenth Amendment authorize them to require immunization. Police powers are government’s inherent authority to impose restrictions on private rights for the sake of public welfare. Thus, health administrators may develop measures that compel individuals to accept vaccinations in order to protect the public’s health.

Such measures include immunization requirements for school entry, which have been enacted by all states and the District of Columbia. These mandates have been shown to be the most effective method of increasing rates of coverage among school-age children and have withstood multiple legal challenges. In 1922, in Zucht v. King (a case regarding an immunization requirement for school entry in San Antonio, Texas), the Supreme Court endorsed these ordinances, finding that they “confer not arbitrary power, but only that broad discretion required for the protection of the public health.” Opponents of such requirements argue that they are improper on the grounds that they amount to illegal search and seizure under the Fourth Amendment or that they violate either the equal protection clause of the Fourteenth Amendment (”no state shall . . . deny to any person within its jurisdiction the equal protection of the laws”) or the establishment clause of the First Amendment (”Congress shall make no law respecting an establishment of religion”). Yet on the basis of the principles outlined in Jacobson, the judiciary has consistently affirmed that an individual’s right to refuse immunization is outweighed by the community-wide protection conferred by immunization.

Some health care workers in New York have argued that Jacobson does not apply in the case of influenza because there is no health emergency and because the H1N1 influenza virus is not as serious as smallpox. In 2002, in Boone v. Boozman, an Arkansas court heard from opponents of a school-entry requirement for hepatitis B vaccination, who argued that both Jacobson and Zucht were irrelevant because they were decided during declared smallpox emergencies, whereas hepatitis B presented no “clear and present danger.” The court held that “the Supreme Court did not limit its holding in Jacobson to diseases presenting a clear and present danger.” Furthermore, “even if such a distinction could be made, the Court cannot say that hepatitis B presents no such clear and present danger. Hepatitis B may not be airborne like smallpox; however, this is not the only factor by which a disease could be judged dangerous.” The court concluded that “immunization of school children against hepatitis B has a real and substantial relation to the protection of the public health and the public safety.”

Health care workers in New York also argue that because the regulation offers no possibility for religious exemptions, it violates the “free exercise” clause of the First Amendment, which guarantees that government may not interfere with a person’s religious beliefs. But individuals may not engage in activities that threaten important societal interests and expect to be shielded by the First Amendment. When reviewing state initiatives that hinder religious expression, courts weigh the importance of a claim of religious exercise against the state interest. Courts have upheld school-entry vaccination requirements against objections that they infringed on individuals’ religious principles. States have the discretion to determine whether to permit religious exemptions, and Arizona, Mississippi, and West Virginia do not permit such exemptions. Thus, in the absence of a Supreme Court ruling, it is unlikely that the exclusion of a religious exemption from the New York regulation will be considered to be unconstitutional.

The health care workers also argue that the regulation violates the right to “freedom of contract” between employer and employee, as guaranteed by the Fifth and Fourteenth Amendments. However, states are obligated to protect the public welfare, even when doing so affects economic liberty. Furthermore, the Supreme Court has held that states may promulgate regulations restricting liberty of contract in order to protect community health or vulnerable populations.^2,3,4 Although New York’s regulation affects employer–employee relationships, it is permissible because promoting patients’ health and safety is a legitimate state interest. Health care workers must receive other vaccinations as a condition of employment, yet they have not challenged those requirements.

The health care workers further claim that the regulation violates the Fourteenth Amendment right of competent adults to bodily autonomy and the right to refuse medical treatment. Yet the right to refuse treatment is not absolute. In determining whether the regulation violates the personal autonomy of health care workers, courts will, once again, balance individual rights against state interests. The state’s power weakens and the individual’s rights strengthen as the degree of bodily invasion increases and the effectiveness of the intervention decreases.⁵ Courts will consider the extent to which health care workers cause illness and death among patients by exposing them to influenza. Vaccinating health care workers is the most effective means of reducing outbreaks; health care workers are required to submit to the limited intrusion of vaccination in order to protect both themselves and the patients in their care. I believe that the state’s right to compel health care workers to receive vaccinations will supersede their individual rights because of the state’s substantial relation to protection of the public health and safety.

Certainly, courts must take into account Constitutional guarantees of personal autonomy, freedom of contract, and freedom of religion when reviewing the current lawsuits. These rights, however, have been constrained when they conflict with government measures that are intended to protect the community’s health and safety. Health care workers have a profound effect on patients’ health. Although they have the same rights as all private citizens, it is likely that courts will continue to make the health and safety of patients the priority in permitting exceptions to individual rights.

No potential conflict of interest relevant to this article was reported.
Source Information

From George Washington University Medical Center and George Washington University School of Public Health and Health Services, Washington, DC.

This article (10.1056/NEJMp0910151) was published on November 4, 2009, at NEJM.org.

References

1. Open letter to health care workers from NY State Health Commissioner Richard F. Daines, M.D., September 24, 2009. (Accessed November 2, 2009, at http://www.health.state.ny.us/press/releases/2009/2009-09-24_health_care_worker_vaccine_daines_oped.htm.)
2. Williamson v. Lee Optical Co., 348 U.S. 483 (1955).
3. West Coast Hotel Co. v. Parrish, 300 U.S. 379 (1937).
4. Muller v. Oregon, 208 U.S. 412 (1908).
5. Cruzan v. Director, Missouri Department of Health, 497 U.S. 261 (1990).

Link:  http://www.usatoday.com/news/health/2009-11-17-swine-flue-drug-prices_N.htm

USA Today

Some pharmacies are charging three times what others are for a scarce liquid form of the H1N1 drug Tamiflu used by children, USA TODAY has found. At least two states’ attorneys general are investigating.The out-of-pocket price to fill the same liquid Tamiflu prescription can range from $43 to $130, according to USA TODAY’s phone survey of more than 100 pharmacies in six states.

 ”We’re very concerned because there is a shortage and exploiting a shortage is unconscionable,” said Connecticut Attorney General Richard Blumenthal, who is investigating after finding similar price variations in his state. He’s also probing potential price gouging with seasonal flu vaccine.

 In response to the findings, Sen. Chris Dodd, a Connecticut Democrat, on Wednesday called for a federal investigation into the price discrepancies. Dodd chairs the Senate health subcommittee on children and families.

“Forcing some parents to pay three times the cost for medicine for their sick child during a national health crisis is deplorable,” Dodd said in a written statement.

He applauded Blumenthal and others who are investigating, and called on Attorney General Eric Holder and Health Secretary Kathleen Sebelius to do the same.

“Price gouging is never acceptable — but price gouging on Tamiflu endangers our children,” Dodd said.

Mississippi is investigating, too. “We would ask that anyone who had any reports of overcharging for Tamiflu or the H1N1 vaccine to please call us,” Attorney General Jim Hood said.

Swiss drugmaker Roche has focused on making Tamiflu capsules that are faster to produce. Because of the liquid shortage, some pharmacies make their own, mixing Tamiflu capsules into a sweet syrup. Liquid Tamiflu is mostly taken by children because it’s easier to swallow and comes in lower doses.

About 2.2 million children younger than 6 have no health coverage, reports the Kaiser Family Foundation, a research group. The prices given to USA TODAY for the same liquid dose for children:

•Pennsylvania: $49-$94.

•Louisiana: $43-$110.

•Michigan: $49-$94.

•Kansas: $49-$99.

•Colorado: $65-$120.

•California: $55-$130.

“We’re dealing with a national health epidemic,” said Bruce Schneider, of Hart Pharmacy in Wichita whose price was $49. “If I want to sleep at night, I don’t think I should be taking advantage of the situation.”

Some variation in prices may be due to the cost and dosage of Tamiflu capsules a pharmacy stocks, said Mike DeAngelis, a CVS spokesman. CVS stores gave price quotes of $52 to $83.

Walgreens said it would charge $94.49, and Leanne Trela, director of retail clinical services, expressed surprise at lower prices.

 Even parents with health coverage face delays in getting approval for the medicine, said Douglas Hoey of the National Community Pharmacists Association, which sent letters about coverage problems to some major prescription-benefits firms.

Inflated pharmacy charges are one reason claims are being rejected, said Maria Palumbo, a spokeswoman for Express Scripts, a leading benefits firm. “Unfortunately, we are seeing claims for compounded Tamiflu that are over five times the average costs for this product,” she said.

Link:  http://www.usatoday.com/news/health/2009-11-18-swinefluasthma18_ST_N.htm

USA Today

The day before Halloween, T.J. Berndsen had what his parents believed was a little asthma flare-up. By Halloween night, he felt lousy enough to cut trick-or-treating short.A week later, the 9-year-old was straining to breathe in the emergency room at Cincinnati Children’s Hospital Medical Center because of complications from an H1N1 influenza infection.

 ”By Sunday, Nov. 8, his cough turned into a croupy bark, and he started running a fever. It got to 102.9. I knew it had gotten to be more than we could handle at home,” says his mother, Jennifer Berndsen. She had suspected flu but wasn’t sure. His school had had significant numbers of children out, but his classroom hadn’t seemed to be hit hard, she says.

 While H1N1’s effects in a healthy child can range anywhere from mild congestion and sore throat to serious respiratory illness, and even death, the 7 million American kids who have asthma are at a higher risk for complications and death if they contract the novel flu virus, says Tom Skinner of the Centers for Disease Control and Prevention.

 ”We’re seeing underlying health problems, including asthma, in about two-thirds of the estimated 540 children who have died from H1N1 complications,” he says.

 But the CDC and pediatric asthma experts say there are steps you can take to prevent H1N1, or swine flu, as well as seasonal flu, and ways to treat it if an infection does occur.

 Prevention is best

“In children with asthma, the key issue is anticipation rather than reacting,” says Erwin Gelfand, chair of pediatrics at National Jewish Health in Denver, a hospital that specializes in treating children with respiratory conditions.

 Gelfand says a parent can ensure two things: vaccination and making sure a child’s asthma is in control.

 The advice goes even for children who get asthma only intermittently, says Tyra Bryant-Stephens, medical director of the Community Asthma Prevention Program at Children’s Hospital of Philadelphia.

 ”Children who only get asthma during exercise, with a cold, or during allergy season can also have serious complications from flu,” Bryant-Stephens says.

 T.J.’s parents gave him what asthma experts call “maintenance medications” every day: an oral Zyrtec (cetirizine) for allergies and the inhaled corticosteroid Flovent (fluticasone), which reduces inflammation in the lungs. They knew he needed the H1N1 vaccine, says T.J.’s mom, but it hadn’t become available in their area yet.

 Unlike T.J., many asthmatic children do not take medications as prescribed, sometimes because of cost or parental concerns about side effects,Gelfand says.

 ”I’d say to any parent, this is not a time to relax compliance. The drugs we have for asthma are as a rule not effective if taken on an intermittent basis, except in possibly the mildest of cases,” Gelfand says.

 As for vaccines, the CDC recommends that children with breathing issues get the shot form of the vaccine – two doses spread out by a month in those under age 9 – instead of the nasal mist.

 If a child does get flulike symptoms, there are steps caregivers should take, says Carolyn Kercsmar, director of the Asthma Center at Cincinnati Children’s.

 She says if a child develops a fever, is feeling poorly, has chest pain, a bad cough or extreme fatigue, see a doctor right away.

 Rough night, quick comeback

 T.J.’s parents took the correct steps, Kercsmar says. After additional home albuterol treatments didn’t budge his symptoms, they scooted fast to the pediatrician, who sent him on to the ER. There, Jennifer Berndsen says, “they did three back-to-back albuterol treatments – continuous for about an hour. He was so sick by then, poor thing.”

 He then received a cornucopia of drugs: Motrin to help reduce fever, antibiotics for atypical pneumonia that a chest X-ray revealed, and an intravenous line of magnesium sulfate to help further open up his airways. They dosed him with the steroid prednisone to simmer down inflammation, and he received pure oxygen through a nose mask, Berndsen says.

 After he was moved to a room well after midnight and an H1N1 swab came up positive, he was given Tamiflu (oseltamivir).

 ”These are the children who can benefit from starting Tamiflu right away. It can turn a very nasty disease into one that’s tolerable,” says Kercsmar, who adds that it works best started within 48 hours, but even within 72 hours can help.

 Berndsen reports that though her son’s night in the hospital was rough, the turnaround was fast.

 ”By noon the next day, Tuesday, Nov. 10, T.J. was feeling well enough to eat a chili dog and a pretzel with cheese,” she says. He went home that night.