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NEWS: RESEARCH
1112 Mechanical
ventilation for patients with lung damage don't always work
as planned [Toronto ON]--As more Canadians are
diagnosed with H1N1 influenza infection, some will be
admitted to hospital. The most severely affected may be
treated in the intensive care unit (ICU) and placed on a
mechanical ventilator to help them breathe while they
recover from the infection.
While mechanical ventilation clearly saves the lives of many
people felled by serious illness, in some cases, this
supportive measure has been known to damage the lungs, says
Dr. Arthur S. Slutsky, a scientist at St. Michael's Hospital
in Toronto.
"In clinicians' previous zeal to maintain relatively normal
blood gas values, they have ventilated patients using
relatively large tidal volumes," Dr. Slutsky explains. "They
also tended to ventilate patients in the supine
position—that is, while they lay on their backs."
("Tidal volume" refers to the normal volume of air displaced
in the lungs between normal inhalation and exhalation when
extra effort is not applied. Other studies have found that
lowering tidal volumes decreases mortality rates in
ventilated patients.)
"Ventilation is what we call a physiological-based
treatment," he explains. "We look at the patient's current
physiological state, then devise and use treatments aimed at
altering this state, hoping the change will translate into
recovery."
In the case of severe H1N1 infection of the lungs, patients
can develop severe hypoxemia—an abnormally low amount of
oxygen in the arterial blood which is the major result of
respiratory failure.
In an editorial published this week in the Journal of the
American Medical Association (JAMA), Dr. Slutsky comments on
new research published by Fabio S. Taccone and colleagues
from the University of Milan in Milan, Italy.
The researchers looked at whether patients with Acute
Respiratory Distress Syndrome (ARDS) who were mechanically
ventilated in the prone position (lying on their stomachs)
did better than patients ventilated while they were supine
(lying on their backs), as is the standard approach. As in
other studies of this physiological-based treatment, blood
oxygen levels increased in the prone treatment group. But in
the end, the mortality rate among these patients was not
statistically different from that of the control group.
In his editorial, Dr. Slutsky asks the following question:
"Today, 35 years after prone ventilation was suggested and
after hundreds of articles have been published, including
more than 150 review articles and more than 10
meta-analyses, why are more definitive conclusions about
prone ventilation not available?"
Unfortunately, he says, very few large companies have a
commercial interest in this type of intervention—for
example, changing a ventilated patient from a supine to a
prone position. This explains why funding for such research
is hard to obtain and why clear answers about the usefulness
of physiological interventions are often lacking.
In this regard, prone ventilation is similar to other
physiologically-based interventions for which the effect on
important clinical outcomes has not been conclusively
proven. In some cases, these physiological "fixes" do not
always work as planned—interventions that improve one
physiological value may actually worsen another.
In his editorial, Dr. Slutsky says that basing treatments
strictly on physiological endpoints—in this case, increasing
oxygenation in the blood by mechanically increasing volumes
of air in the lungs and changing patients' position during
treatment—is "seductive" for several reasons:
* In many ways, the intensive care unit is a physiology
laboratory in which patients' vital signs and other
functions are monitored and treated around the clock, seven
days a week. By explaining why a patient has a physiological
abnormality such as a decrease in oxygenation or worsening
kidney function, these measurements can suggest therapies to
correct the abnormal physiology.
* Many physiological interventions can be quickly instituted
and monitored at the bedside. They are usually relatively
inexpensive or seen as "free," which makes them attractive
and easy to implement.
"But while physiological insights developed at the bedside
have led to important, lifesaving therapies, it's been
difficult to obtain convincing proof of better clinical
outcomes for many such interventions," Dr. Slutsky says.
One solution would be to design large, simple, generalizable
trials undertaken by a large global network of
investigators. "The time for this may be especially
opportune because the world's critical care community is
coalescing around an initiative to perform large-scale
clinical trials to rapidly address the potential H1N1
pandemic," he says, adding that such trials are necessary to
"separate fact from seduction."
Dr. Art Slutsky is a researcher in the Keenan Research
Centre at the Li Ka Shing Knowledge Institute of St.
Michael's Hospital, and Professor of Medicine, Surgery and
Biomedical Engineering at the University of Toronto. He is
also Director of the Interdepartmental Division of Critical
Care Medicine, University of Toronto.
1112 New polls, reports
highlight the need to update the US food safety system [New
York NY]--Over the next several weeks, the U. S.
Senate has an historic opportunity to take a major step
toward improving food safety for all Americans. That is why
a coalition of public health professionals, consumer
organizations and groups representing victims of foodborne
illness is sending the message that it is time to "Make Our
Food Safe for the Holidays!"
Every year, millions of Americans are sickened from
consuming contaminated food, hundreds of thousands are
hospitalized and thousands die. Multiple outbreaks of
foodborne illness over the last several years – from spinach
to peppers to peanut butter products – have demonstrated
that these outbreaks are not random, unpreventable
occurrences, but are due to widespread problems with food
safety oversight in the United States.
This summer the U.S. House of Representatives passed its
version of a sweeping food safety bill, which includes
increased inspections of domestic food facilities and
greater oversight of imports. The Make Our Food Safe
coalition believes the Senate can take a major step forward
in protecting public health by passing legislation that
gives the U.S. Food and Drug Administration (FDA) enhanced
authority to oversee the safety of the nation's food supply
by the end of this year.
New polls of voters in selected states – Nevada, New
Hampshire, North Carolina and Ohio – show overwhelming
support for measures that would give the FDA these new
powers. The polls, which were conducted in October by a
respected bipartisan team of pollsters at Hart Research
(Democratic) and Public Opinion Strategies (Republican),
were commissioned by coalition member the Pew Health Group.
"Families across America want the government to do more to
ensure their loved ones do not get sick from the food they
serve over the holidays," says Sandra Eskin, director of the
food safety project for the Pew Health Group. "Congress
should enact stronger food safety laws before the end of the
year."
Foodborne illness can significantly impact the health of
children. According to a new fact sheet released today by
the Make Our Food Safe coalition, approximately half of the
reported foodborne illnesses occur in children, with the
majority of these cases occurring in those under 15 years of
age. Data from the Centers for Disease Control & Prevention
(CDC) for five major foodborne pathogens —–Salmonella,
Listeria monocytogenes, Campylobacter, Shigella, E. coli
0157:H7— clearly show the burden that children are carrying
with regard to foodborne disease. The fact sheet also
details the health risks associated with Toxoplasma gondii,
a common parasite. To obtain a copy of the fact sheet, visit
www.MakeOurFoodSafe.org.
In addition, coalition member Center for Foodborne Illness
Research & Prevention (CFI) is releasing a report that looks
in detail at the long-term impacts of foodborne pathogens.
CFI's report, The Long-Term Health Outcomes of Selected
Foodborne Pathogens, provides expert descriptions about some
of the serious long-term health outcomes ranging from
hypertension and diabetes to kidney failure and mental
retardation. The report also calls for a new approach to
foodborne illness research and surveillance.
"Systematic follow-up of foodborne illness cases will
greatly enhance our ability to attribute long-term health
problems to acute foodborne illnesses," says Tanya Roberts,
Ph.D., an author of the report. "Population-based studies,
improved public health surveillance and increased data
sharing will improve our knowledge about the sources, trends
and health outcomes associated with foodborne disease.
Taking this approach will require dedicated funding, but
such an investment is necessary to prevent costly economic,
health and personal losses."
"The polling and reports released today should show our
lawmakers that they need to send food safety legislation to
the president's desk as soon as possible," says Elizabeth
Armstrong of Fishers, IN, whose young daughter Ashley became
seriously ill in 2006 after eating contaminated spinach.
"The new legislation may not help my family, but it could
save lives and spare others from suffering what we have
endured. I want the senators to think about that and heed
the coalition's message: Make Our Food Safe for the
Holidays!"
To obtain a copy of the CFI report, visit
www.foodborneillness.org.
Major public health, consumer and food safety groups have
formed the Make Our Food Safe coalition (www.makeourfoodsafe.org),
which includes the American Public Health Association,
Center for Foodborne Illness Research & Prevention, Center
for Science in the Public Interest, the Consumer Federation
of America, Consumers Union, Food & Water Watch, National
Consumers League, The Pew Charitable Trusts, Safe Tables Our
Priority, and Trust for America's Health.
1112 People entering
their 60s may have more disabilities today than in prior
generations [Los Angeles CA]--In a development
that could have significant ramifications for the nation's
health care system, Baby Boomers may well be entering their
60s suffering far more disabilities than their counterparts
did in previous generations, according to a new UCLA study.
The findings, researchers say, may be due in part to
changing American demographics.
In the study, which will be published in the January 2010
issue of the American Journal of Public Health, researchers
from the division of geriatrics at the David Geffen School
of Medicine at UCLA found that the cohort of individuals
between the ages of 60 and 69 exhibited increases in several
types of disabilities over time. By contrast, those between
the ages of 70 and 79 and those aged 80 and over saw no
significant increases — and in some cases exhibited fewer
disabilities than their previous cohorts.
While the study focused on groups born prior to the
post–World War II Baby Boom, the findings hold "significant
and sobering implications" for health care because they
suggest that people now entering their 60s could have even
more disabilities, putting an added burden on an already
fragile system and boosting health costs for society as a
whole, researchers say.
If this is true, it's something we need to address," said
Teresa Seeman, UCLA professor of medicine and epidemiology
and the study's principal investigator. "If this trend
continues unchecked, it will put increasing pressure on our
society to take care of these disabled individuals. This
would just put more of a burden on the health care system to
address the higher levels of these problems."
The researchers used two sets of data — the National Health
and Nutrition Examination Surveys (NHANES) for 1988 and 1999
— to examine how disabilities for the three groups of adults
aged 60, 70, and 80 and older had changed over time. They
assessed disability trends in four areas: basic activities
associated with daily living, such as walking from room to
room and getting into and out of bed; instrumental
activities, such as performing household chores or preparing
meals; mobility, including walking one-quarter mile or
climbing 10 steps without stopping for rest; and functional
limitations, which include stooping, crouching or kneeling.
The study focused primarily on trends for the more recent 60
age group — those born between 1930 and 1944, just before
the start of the Baby Boom, whose data was included in the
1999� NHANES. In particular, researchers felt this group
could offer insights into the health of the Boomers
following them, who are now entering their 60s.
The researchers found that between the periods 1988 and
1999, disability among those in their 60s increased between
40 and 70 percent in each area studied except functional
limitations, independent of sociodemographic
characteristics, health status and behaviors, and relative
weight. The increases were considerably higher among
non-white and overweight subgroups.
By contrast, the researchers found no significant changes
among the group aged 70 to 79, while the 80-plus group
actually saw a drop in functional limitations.
One reason for this uptick, researchers say, is that
disabilities may be linked with the changing racial and
ethnic makeup of the group that recently reached or will
soon be reaching its 60s, with the most rapid growth
projected to be among African Americans and Hispanics —
groups with significantly higher rates of obesity and lower
socioeconomic status, both of which are associated with
higher risk for functional limitations and disabilities.
The researchers note that their controls for differences in
sociodemographics, health status (such as chronic conditions
and biological risk factors) and health behavior do not
completely explain the increase in disability trends among
the 60- to 69-year olds. Still, the trends within that group
"are disturbing," Seeman said.
"Increases in disability in that group are concerning
because it's a big group," she said. "These may be people
who have longer histories of being overweight, and we may be
seeing the consequences of that. We're not sure why these
disabilities are going up. But if this trend continues, it
could have a major impact on us, due to the resources that
will have to be devoted to those people."
Study co-authors included Arun Karlamangla and Sharon Merkin,
of UCLA's geriatrics division, and Eileen Crimmins, of the
Andrus Gerontology Center at the University of Southern
California.
The National Institute on Aging funded this study.
1112 Researchers
mobilizing global resources to test new treatments for
severe H1N1 infection [Toronto ON]--An important,
ground-breaking initiative is unfolding in the global
critical care community in response to the H1N1 pandemic.
While front-line health care workers and infectious disease
experts around the world are working round the clock to
control, treat and prevent H1N1 infection, those who deal
with the most severely ill patients—physicians working in
hospital intensive care units (ICUs)—have joined forces to
develop a more coordinated, long-term approach to H1N1.
In a commentary published today in the medical journal the
Lancet, St. Michael's Hospital's Dr. John Marshall describes
this unprecedented initiative, which is called the
International Forum for Acute Care Trialists (InFACT) H1N1
Collaboration. While the coalition against H1N1 is led by
Canadians, dozens of groups whose members are involved in
the care of critically ill influenza patients from every
continent on the planet have already signed on.
"A core element of our initiative is to undertake clinical
trials of simple, readily available and biologically
plausible interventions that can be used to treat patients
with severe H1N1 infection," says Dr. Marshall, a senior
scientist in the Li Ka Shing Knowledge Institute at St.
Michael's Hospital in Toronto who chairs the InFACT
collaboration.
Will the clinical trials and the other initiatives planned
by InFACT—such as a global registry of influenza victims and
a "biobank" of blood samples—benefit people who are already
sick or will fall ill over the next few months?
"Probably not," Dr. Marshall says. "But H1N1 isn't going
away any time soon. We need to take a coordinated,
evidence-based approach to understanding the natural history
of the disease, to cataloguing current resources and gaps,
and to looking for new and better treatments which may
prevent or shorten hospitalization among those most
seriously affected."
Proposed clinical trials to test new treatments
Canadian researchers are organizing several clinical trials
aimed at finding new and more effective treatments for H1N1
infection.
One of these trials—the Collaborative H1N1 Adjuvant
Treatment (CHAT) trial—seeks to enroll 1,400 patients, most
of them Canadians, who are being treated in a hospital ICU
for severe H1N1 infection and are on a ventilator. The
mortality rate for these patients currently ranges from
10% over the first month. On average, those who survive
spend two weeks in the ICU.
Right now H1N1 infection is treated with anti-viral drugs
and other supportive measures. But researchers want to
evaluate two classes of common, readily available drugs
which have shown promise in limiting the severity of H1N1
infection.
"Anecdotal reports and data from animal studies suggest that
corticosteroids and statins may dampen the inflammatory
response that leads to severe illness and death from H1N1,"
says Dr. Marshall. "None of these drugs has been adequately
studied for efficacy."
Even though no specific data show them to be effective,
right now more than half of patients with severe H1N1
infection are treated with corticosteroids—hormones given to
reduce swelling and decrease the body's immune response.
This is based largely on the observation that corticosteroid
drugs have proven useful in treating severe acute lung
injury.
A recent study of patients with seasonal influenza found
that those who were taking statins when they got sick had a
better prognosis than those were not. These drugs are
currently taken by millions of people take to help control
cholesterol levels and prevent heart disease.
This accelerated "bench-to-bedside" approach is key to
success against pandemic influenza and other infectious
diseases, says Dr. Marshall. "Research during a pandemic
poses unique ethical and logistical challenges. It usually
takes years to mount a major clinical trial. But in the case
of H1N1 our goal is to drastically shorten this to a period
of weeks or a few months without compromising scientific and
ethical integrity," he explains.
While funding is needed for the clinical trials to proceed,
that time is too short to achieve this through conventional
means. "Instead, we've adopted an incremental funding
strategy. This means we're seeking money that will allow us
to launch the trials and moving ahead with confidence that
additional funds can be found," he says.
About the InFACT H1N1 Collaboration
The Canadian-led International Forum for Acute Care
Trialists (InFACT) H1N1 Collaboration is a unique and
unprecedented attempt to gain control over a new pandemic
illness (go to
http://www.infactglobal.org).
According to Dr. John Marshall who chairs the group, it is
currently organized around three core initiatives:
* A common global registry listing all patients critically
ill due to H1N1 infection. The registry, which has been
created out of five existing databases around the world,
will enable real-time study of the epidemiology, clinical
course, and treatment of severe H1N1 disease. In parallel,
the group hopes to develop a "biobank"—a repository of
samples of blood and other material taken from people
infected with H1N1—which will allow for studies of genetic
susceptibility and clinical biology. The registry will also
help scientists understand how H1N1 infection varies around
the world in response to local medical capacity and
treatment approaches.
* A program of accelerated randomized clinical trials aimed
at quickly identifying, testing and delivering new
treatments. The first group of clinical studies will
evaluate inexpensive interventions that are available in
both the developed and the developing world. The research
will use so-called "adaptive designs" which ensures that
positive results can be quickly incorporated into practice
and that ineffective treatments are quickly dropped.
* The first-ever catalogue of critical care capacity around
the world. Any coordinated and effective plan for dealing
with H1N1 or another severe pandemic illness requires a host
of resources—hospital ICU beds and ventilators, a steady
supply of vaccines and medications, and enough health care
providers to use them. The group hopes to catalogue
international critical care capacity, and also to promote,
mentor, and support clinical research activities in
resource-poor areas where the human toll is likely to be the
greatest.
1112 Health care
accounts for 8 percent of US carbon footprint [Chicago IL]--The
American health care sector accounts for nearly a tenth of
the country's carbon dioxide emissions, according to a
first-of-its-kind calculation of health care's carbon
footprint.
Published Wednesday in the Journal of the American Medical
Association, University of Chicago researchers used
expenditures from different parts of the health care sector
to measure the industry's potential effect upon global
warming through the release of carbon dioxide and other
greenhouse gases.
Health care in America, including activities such as
hospital care, scientific research and the production and
distribution of pharmaceutical drugs, was found to produce 8
percent of the country's total carbon dioxide output despite
accounting for 16 percent of the U.S. gross domestic
product. Jeanette Chung, PhD, a Research Associate in the
Section of Hospital Medicine at the University of Chicago
and the study's lead author, said that she hoped the study
would draw the attention of the health care industry to its
environmental impact.
"In this country, the primary focus is on issues surrounding
patient safety, health care quality, and cost containment at
this current point in time. The health care sector, in
general, may be a bit slower than other sectors to put this
on their radar screen," Chung said. "But given the focus on
health care policy and environmental policy, it might be
interesting - if not wise - to start accounting for
environmental externalities in health care."
"The question is, are there large opportunities to improve
efficiency in health care that can also have an impact on
the environment?" said study co-author David Meltzer, MD,
PhD, Chief of the Section of Hospital Medicine, Associate
Professor in the Department of Medicine, the Harris School
of Public Policy and the Department of Economics. "If one
sector is very large, even if it's somewhat less
carbon-intensive than others, simply the fact that it's
large means it's a big target, and that's the case with
health care."
Chung and Meltzer calculated the carbon footprint using 2007
health care spending and a model of environmental impact,
called the environmental input-output life cycle assessment
(EIOLCA) model, developed by the Green Design Institute at
Carnegie-Mellon University.
The study assessed direct environmental effects of health
care activities as well as indirect effects capturing
emissions generated in the production and distribution of
commodities used by the health care sector. The EIOLCA model
was then applied to estimate the carbon intensity of each
dollar of commodity produced by the health care industry,
based on emissions of various greenhouse gases, including
carbon dioxide, methane, nitrous oxide and
chlorofluorocarbons.
The analysis found that hospitals were by far the largest
contributor of carbon emissions in the health care sector,
which the authors attributed to the high energy demands
needed for temperature control, ventilation and lighting in
large hospital buildings. Surprisingly, the second largest
health care contributor to the overall carbon footprint was
the pharmaceutical industry, a finding Meltzer attributed to
the high costs of manufacturing and researching drugs
combined with transportation costs associated with
distribution.
Chung and Meltzer hoped that their analysis, published as a
letter in the prestigious medical journal, would draw the
attention of the health care industry to areas where
environmental improvements can be made.
"Obviously, health care and health is very highly valued;
you're not going to shut down a hospital because of its
environmental impact or not produce a drug that you think is
going to save lives because of carbon output," Meltzer said.
"But this reminds people in health care that we're not a
trivial part of the issue."
Some measures hospitals can use to improve energy efficiency
include creating recycling programs and purchasing goods and
services from environmentally friendly suppliers, Chung
suggested.
At the University of Chicago Medical Center, the
Sustainability program managed by Mark Lestina has
implemented a plastic recycling program that diverts more
than 500 pounds of waste each day from landfills to
recycling plants and ensured that 90 percent of cleaning
supplies used by the hospital have Green Seal certification.
Such efforts have reduced waste costs at the Medical Center
from $55,000 per month to $35,000 per month, Lestina said,
suggesting that reducing environmental impact can go hand in
hand with reducing costs in a hospital setting.
"Sustainability does not necessarily just equal garbage and
minimalization," Lestina said. "You're incorporating energy
efficiencies, saving water, using less, re-using more and so
on, and it almost always leads to lower costs."
Lestina is currently working to attain the prestigious LEED
Silver certification from the U.S. Green Building Council
for the New Hospital Pavilion, scheduled to open in 2012.
The work was funded by grants from the Hospital Medicine and
Economics Center for Education and Research in Therapeutics
and the National Institute of Aging.
1112 Over 2,200
veterans died in 2008 due to lack of health insurance
[Boston MA]--A research team at Harvard Medical
School estimates 2,266 U.S. military veterans under the age
of 65 died last year because they lacked health insurance
and thus had reduced access to care. That figure is more
than 14 times the number of deaths (155) suffered by U.S.
troops in Afghanistan in 2008, and more than twice as many
as have died (911 as of Oct. 31) since the war began in
2001.
The researchers, who released their analysis today
[Tuesday], pointedly say the health reform legislation
pending in the House and Senate will not significantly
affect this grim picture.
The Harvard group analyzed data from the U.S. Census
Bureau’s March 2009 Current Population Survey, which
surveyed Americans about their insurance coverage and
veteran status, and found that 1,461,615 veterans between
the ages of 18 and 64 were uninsured in 2008. Veterans were
only classified as uninsured if they neither had health
insurance nor received ongoing care at Veterans Health
Administration (VA) hospitals or clinics.
Using their recently published findings in the American
Journal of Public Health that show being uninsured raises an
individual’s odds of dying by 40 percent (causing 44,798
deaths in the United States annually among those aged 17 to
64), they arrived at their estimate of 2,266 preventable
deaths of non-elderly veterans in 2008. (See table.)
“Like other uninsured Americans, most uninsured vets are
working people - too poor to afford private coverage but not
poor enough to qualify for Medicaid or means-tested VA
care,” said Dr. Steffie Woolhandler, a professor at Harvard
Medical School who testified before Congress about uninsured
veterans in 2007 and carried out the analysis released today
[Tuesday]. “As a result, veterans go without the care they
need every day in the U.S., and thousands die each year.
It’s a disgrace.”
Dr. David Himmelstein, the co-author of the analysis and
associate professor of medicine at Harvard, commented, “On
this Veterans Day we should not only honor the nearly 500
soldiers who have died this year in Iraq and Afghanistan,
but also the more than 2,200 veterans who were killed by our
broken health insurance system. That’s six preventable
deaths a day.”
He continued: “These unnecessary deaths will continue under
the legislation now before the House and Senate. Those bills
would do virtually nothing for the uninsured until 2013, and
leave at least 17 million uninsured over the long run. We
need a solution that works for all veterans - and for all
Americans - single-payer national health insurance.”
While many Americans believe that all veterans can get care
from the VA, even combat veterans may not be able to obtain
VA care, Woolhandler said. As a rule, VA facilities provide
care for any veteran who is disabled by a condition
connected to his or her military service and care for
specific medical conditions acquired during military
service.
Woolhandler said veterans who pass a means test are eligible
for care in VA facilities, but have lower priority status
(Priority 5 or 7, depending upon income level). Veterans
with higher incomes are classified in the lowest priority
group and are not eligible for VA enrollment.
1112 Ventilation
treatment in prone position for ARDS does not provide
significant survival benefit [Milan Italy]--Despite
a current suggestion that patients with acute respiratory
distress syndrome be positioned lying face down while
receiving mechanical ventilation, study results indicate
that this positioning does not significantly lower the risk
of death compared to similar patients positioned lying face
up during ventilation, according to a study in the November
11 issue of JAMA.
Acute respiratory distress syndrome (ARDS) is a serious lung
condition with a high mortality rate and may be associated
with severe hypoxemia (abnormally low levels of oxygen in
the blood, resulting in shortness of breath). Prone
positioning is currently suggested for patients with ARDS,
for whom various factors makes mechanical ventilation
potentially injurious. "Moreover, prone positioning has been
advocated as a rescue maneuver for severe hypoxemia, owing
to its positive effects on oxygenation, which have been
repeatedly documented since its first description in 1976.
However, no randomized clinical trial has yet demonstrated a
significant reduction in mortality rate associated with
prone positioning," the authors write.
Paolo Taccone, M.D., of Fondazione IRCCS–"Ospedale Maggiore
Policlinico, Mangiagalli, Regina Elena" di Milano, Milan,
Italy, and colleagues conducted a trial to detect the
potential survival benefit of prone positioning in patients
with moderate and severe hypoxemia who are affected by ARDS.
The randomized controlled trial was conducted in 23 centers
in Italy and 2 in Spain. The study included 342 adult
patients with ARDS receiving mechanical ventilation,
enrolled from February 2004 through June 2008 and stratified
into subgroups with moderate (n = 192) and severe (n = 150)
hypoxemia. Patients were randomized to undergo supine (lying
face up; n = 174) or prone (20 hours per day; n = 168)
positioning during ventilation.
The researchers found that prone and supine patients from
the entire study population had similar 28-day (31.0 percent
vs. 32.8 percent) and 6-month (47.0 percent vs. 52.3
percent) mortality rates, despite significantly higher
complication rates in the prone group. "Outcomes were also
similar for patients with moderate hypoxemia in the prone
and supine groups at 28 days (25.5 percent vs. 22.5 percent)
and at 6 months (42.6 percent vs. 43.9 percent). The 28-day
mortality of patients with severe hypoxemia was 37.8 percent
in the prone and 46.1 percent in the supine group, while
their 6-month mortality was 52.7 percent and 63.2 percent,
respectively."
They authors add that median (midpoint) Sequential Organ
Failure Assessment (SOFA) scores, ventilator-free days, and
intensive care unit length of stay were also similar between
the different groups of patients.
"Do the findings of this trial, together with those of
previous studies, represent the end of the prone position
technique? Undoubtedly, the data of the present trial
together with previous results clearly indicate that
prolonged prone positioning, in the unselected ARDS
population, is not indicated as a treatment. However, its
potential role in patients with the most severe hypoxemia,
for whom the possible benefit could outweigh the risk of
complications, must be further investigated, considering the
strong pathophysiological background, the post hoc result of
our previous study, the most recent meta-analysis, and the
favorable trend observed prospectively in this study," the
authors conclude.
Editorial: Improving Outcomes in Critically Ill Patients
Arthur S. Slutsky, M.D., of St. Michael's Hospital, Toronto,
and the University of Toronto, comments on the findings of
this study in an accompanying editorial.
"Based on the findings from the trial by Taccone et al
combined with data from previous published reports, prone
ventilation should not be used routinely in all patients
with ARDS. However, for a patient at imminent risk of death
from hypoxemia, it makes sense to try prone ventilation,
because multiple studies have demonstrated that it can
increase oxygenation."
1112 One in four
hospitalized heart failure patients with Medicare back in
hospital within a month [Dallas TX]--Almost a
quarter of heart failure patients with Medicare are back in
the hospital within a month after discharge, researchers
report in Circulation: Heart Failure, a journal of the
American Heart Association.
Each year, from 2004 through 2006, more than a half million
Medicare recipients over age 65 went to the hospital for
heart failure and were discharged alive. And each year,
about 23 percent returned to the hospital within 30 days –
signaling a need to improve care, researchers said.
Readmission rates for all causes were almost identical all
three years.
“I was hoping for improvement and was disappointed to find
that was not the case,” said Joseph S. Ross, M.D., M.H.S.,
the study’s lead author and an assistant professor of
geriatrics and palliative medicine at Mount Sinai School of
Medicine in New York. “Despite the increased focus on the
need to reduce readmissions, about a quarter of patients are
back into the hospital within 30 days.”
Heart failure occurs when a heart weakened by disease can no
longer pump effectively. Before discharge heart failure
patients should receive written information on:
• Eating a proper diet;
• Engaging in appropriate physical activity;
• Taking medicines correctly;
• Monitoring their weight; and
• Knowing what to do if their symptoms worsen.
However, the current fee system in the United States doesn’t
encourage a focus on prevention researchers said. In their
analysis, they report that doctors and hospitals are
financially awarded more for treating and hospitalizing
patients, not for preventing hospitalizations through such
strategies as disease management.
“Physicians aren’t paid to coordinate care,” Ross said.
“That physician is busy seeing patients and that’s what
they’re paid to do. If we want to deliver better care, this
trend is what we need to address.”
Another barrier to optimal care is a lack of communications
between doctors who care for patients in the hospital and
the patients’ regular physicians who help patients manage
their chronic disease, Ross said. The disruption to the
continuum of care can negatively affect the patient.
The average age of patients in the study was 80 years and
more than half (57 percent) were women. Most patients had
multiple chronic diseases: 60 percent had heart arrhythmias;
73 percent had atherosclerosis or hardening of the arteries;
49 percent had diabetes; and 29 percent had kidney failure.
“Coming back and forth into the hospital isn’t good for
patients, and it isn’t good for the healthcare system,” said
Ross, who plans to research the reasons heart failure
patients are readmitted to the hospital. “This is a
tremendous challenge.”
Findings of the study are important for patients and
hospitals, Ross said.
“Patients should use this information to vet hospitals, to
look at the quality of care delivered there and ask
questions about the care they receive,” he said. “Hospitals
should consider the rehospitalization rate a grade which,
from these findings, needs improvement.”
The Centers for Medicare and Medicaid Services funded the
study. In July 2009, the agency began publicly reporting
information on readmissions for heart failure patients.
Co-authors are: Jersey Chen, M.D., M.P.H.; Zhen Qiu Lin,
Ph.D.; Héctor Bueno, M.D., Ph.D.; Jeptha P. Curtis, M.D.;
Patricia S. Keenan, Ph.D.; Sharon-Lise T. Normand, Ph.D.;
Geoffrey Schreiner, B.A.; John A. Spertus, M.D., M.P.H.;
Maria T. Vidán, M.D., Ph.D.; Yongfei Wang, M.S.; Yun Wang,
Ph.D.; and Harlan M. Krumholz, M.D., S.M. Author disclosures
are on the manuscript.
1112 Using science to
save lives of mothers and children in Africa [Accra Ghana]--The
lives of almost 4 million women, newborns, and children in
sub-Saharan Africa could be saved every year if
well-established, affordable health care interventions
reached 90 percent of families, according to a joint report
by the national science academies of seven African
countries. Many African nations are underutilizing existing
scientific knowledge to save lives, says the report, which
calls on scientists, health care providers, policymakers,
and development agencies to partner on ways to use the
latest evidence to fill the gap between the discovery of new
interventions and their delivery to families most in need.
The report was released today at the annual conference of
the African Science Academy Development Initiative, which
aims to strengthen effective links between African science
academies and national decision makers.
Half of the world's maternal and child deaths each year
occur in sub-Saharan Africa, where 265,000 mothers die
during pregnancy or childbirth, 1.2 million babies die in
their first month of life, and an additional 3.2 million do
not reach their fifth birthday. More than 880,000
stillbirths go largely unnoticed by global researchers and
policymakers. The U.N.'s Millennium Development Goals call
for reducing under-five mortality by two-thirds (MDG4) and
maternal mortality by three-fourths (MDG5) by 2015. While
acknowledging that most African nations are not on track to
meet the goals by then, the report highlights noteworthy
exceptions. For example, Eritrea has achieved an annual 4
percent rate of reduction in under-five mortality since
1990, Tanzania and Ghana have experienced up to 30 percent
declines since 2000, and Malawi was recently declared itself
on track for MDG4.
"Ghana has achieved a reduction in under-five mortality over
the past five years as well as an increase in skilled
attendance at birth, but to get on track for the Millennium
Development Goals by 2015, we [must] value the
evidence-based priorities presented in this report," said
Professor Reginald Fraser Amonoo, president of the Ghana
Academy Arts and Sciences, which is celebrating its 50th
anniversary this year and hosting the ASADI conference.
The new report, SCIENCE IN ACTION: SAVING THE LIVES OF
AFRICA'S MOTHERS, NEWBORNS, AND CHILDREN, encourages
policymakers and other stakeholders to use a scientific
approach when setting priorities to improve maternal,
newborn, and child health. In particular, local data should
be used to identify and prioritize strategic,
evidence-based, and essential health interventions that, if
scaled up, would have the greatest impact on saving lives.
The report includes a new analysis in which modeling
software called the LIVES SAVED TOOL (LIST) was used to
estimate the number of lives that would be saved by
increasing coverage of a range of essential maternal,
newborn, and child health interventions. The analysis
suggests that if, by 2015, 90 percent of children under five
years old and mothers were covered by already well-known and
essential health interventions, about 4 million lives would
be saved annually, avoiding an estimated 85 percent of
current maternal, newborn, and child deaths; this would
exceed the MDGs for maternal and child health. Some of the
most effective interventions include increased availability
of contraception, skilled attendance at childbirth, neonatal
resuscitation and improved newborn care, case management of
pneumonia, and promotion of breastfeeding, malaria
prevention, and immunization.
The authors of the report also used national data to assess
the effect of achievable increases within two years in
priority interventions in the seven countries with science
academies participating in ASADI -- Cameroon, Ghana, Kenya,
Nigeria, Senegal, South Africa, and Uganda -- as well as
Ethiopia and Tanzania. Achievable increases are defined as
improvements in the quality of care for all births that take
place in facilities and a 20 percent increase in selected
interventions provided outside of facilities. The analysis
showed that such increases in coverage in the nine example
countries would save the lives of 770,000 women, newborns,
and children each year.
Because the context of health systems varies among
countries, interventions have different effects. The report
authors therefore showed how many lives could be saved by
selected priority interventions in different health system
contexts. For example, in settings with few births in
facilities, increasing family planning is feasible, saves
many lives, and is relatively low cost. The estimated cost
of these priority interventions is "extremely affordable" on
a per capita basis, the report notes. In fact, the average
cost for increasing these selected high-impact interventions
to achievable levels in the nine example countries within
two years is less than $2 per capita.
Based on the evidence, priorities for maternal, newborn, and
child health in sub-Saharan Africa include making childbirth
safe, giving newborn babies a healthy start, and preventing
and managing infections in newborns and young children, the
report says. The evidence also shows that high-impact
interventions are most effective and efficient when
integrated into existing health delivery systems, yet more
research is needed on how to deliver care closer to home and
reach populations in remote areas. More study is needed on
the use of alternative cadres for certain tasks as well.
The report was authored by representatives of the seven
African science academies and a team they assembled of more
than 60 experts. One of the report's coordinating authors,
Joy Lawn, director of global evidence and policy at Saving
Newborn Lives/Save the Children in Cape Town, South Africa,
believes that the report will serve as a call to action.
"Accelerated action now based on data and science has the
potential to saves millions of lives every year and to put
many African countries on track to reach the Millennium
Development Goals for maternal and children survival," she
said. "All of us have a role to play."
The development of the report was supported by the U.S.
National Academies; Save the Children; the Academy of
Sciences of South Africa; Johns Hopkins Bloomberg School of
Public Health; Mars, Inc.; and UNICEF. The report,
additional details on the analysis and on assumptions used
in the LIST model, a list of contributors, and more
information about ASADI are available at
http://national-academies.org/asadi.
ASADI is a collaboration among the African science
academies, the U.S. National Academies, and others to
strengthen the ability of the African academies to inform
policymaking and public discourse through evidence-based
advice. The initiative is funded by a grant from the Bill &
Melinda Gates Foundation.
1112 Back pain
permanently sidelines soldiers at war [Baltimore MD]--Military
personnel evacuated out of Iraq and Afghanistan because of
back pain are unlikely to return to the line of duty
regardless of the treatment they receive, according to
research led by a Johns Hopkins pain management specialist.
In a study published in the Nov. 9 Archives of Internal
Medicine, researchers found that just 13 percent of service
members who left their units with back pain as their primary
diagnosis eventually returned to duty in the field. Women,
officers, those deployed in Afghanistan and those with
previous back pain had better outcomes, but only marginally.
Aside from combat injuries sustained during battle, the
return-to-duty rate for spinal pain and other
musculoskeletal disorders is lower than for any other
disease or non-combat injury category except for psychiatric
illness, the researchers said.
"The whole mission of the medical corps for the military is
to preserve unit strength, to keep people doing what they're
doing," says study leader Steven P. Cohen, M.D., associate
professor of anesthesiology at the Johns Hopkins University
School of Medicine and a colonel in the U.S. Army Reserves.
"If you have only a 13 percent success rate, this is a
failure. There's a systemic problem."
Cohen and his team looked at data from 1,410 soldiers who
were medically evacuated out of war zones complaining
chiefly of back pain from 2004 through 2007. More than 95
percent of the service members were taken to the U.S.
military's treatment facility in Landstuhl, Germany.
Researchers assessed how many were returned to their
stationed units within two weeks and how many were sent to
the United States unable to perform their duties.
A previous study done by Cohen showed that when soldiers
with back pain were taken to a pain clinic in Iraq, all
patients returned to their units. When they were sent to
pain clinics in Germany or in Washington, fewer than 2
percent did. Both this previous study and the new research
suggest that the further away the evacuee is treated, the
less likely they are to return to that unit. Cohen notes
that it can be difficult for certain soldiers to return to
their jobs, particularly those in physically demanding
combat-related roles. "It's the rule in war: People will
have back pain because you have to go on these long road
marches and carry heavy equipment, wear body armor," he
says. "The roads are not paved. Riding in these vehicles
while wearing body armor, it hurts your back."
Cohen explains that the reasons why few military personnel
return to their units after leaving with back pain may
simply be a reflection of the outcomes for back pain in
civilian life. "Back pain has notoriously low success rates
for treatment," he says. The biggest predictors of a poor
outcome, he said, are psychosocial factors. People who are
depressed or anxious, who cope poorly with stress, who are
unhappy in their jobs, and those with other psychological
issues are more likely to remain disabled by back pain.
Cohen, who is also director of chronic pain research at
Walter Reed Army Medical Center, said those with back pain
who remain in the country where they are deployed may be
more motivated to stay on the job or are more satisfied with
their role in the military.
The military needs to find a way to get soldiers with back
pain back to their units wherever possible, Cohen says. He
suggests that could be accomplished if there were more pain
management options in Iraq or Afghanistan, following the
model used for soldiers with symptoms of combat stress. When
those symptoms are treated at mental health clinics on base,
approximately 95 percent of service members returned to
their units. When treated in a transitional unit in nearby
Kuwait, the figure was around 50 percent. When sent to
Germany, fewer than 10 percent returned.
Other researchers on the study include Shruti G. Kapoor,
M.D., M.P.H., a resident in the Department of Anesthesiology
at Johns Hopkins University School of Medicine; Maj. Conner
Nguyen, M.D., chief of physical medicine and rehabilitation
at Landstuhl Regional Medical Center in Germany; and Col.
Leslie Foster, D.O., and Maj. Anthony Plunkett, M.D., both
of Walter Reed Medical Center.
The research was funded in part by a congressional grant
from the John P. Murtha Neuroscience and Pain Institute,
Johnstown, Pa., the U.S. Army and the Army Regional
Anesthesia & Pain Medicine Initiative, Washington, D.C.
1112 Fewer emergency
patients seen within recommended time frame [New Haven CT]--One
in four emergency department patients in 2006 waited longer
to be evaluated by a clinician than recommended at triage,
an increase from one in five in 1997, according to a report
in the November 9 issue of Archives of Internal Medicine,
one of the JAMA/Archives journals.
"Prolonged emergency department (ED) wait time decreases
patient satisfaction, limits access, increases the number of
patients who leave before being seen and is associated with
clinically significant delays in care for patients with
pneumonia, cardiac symptoms and abdominal pain," the authors
write as background information in the article. Previous
analyses have noted an increase in the amount of time ED
patients wait to see a clinician. Between 1997 and 2004,
median wait times increased 36 percent, from 22 minutes to
30 minutes. However, wait time alone is an imperfect measure
of the timeliness of emergency care because it does not take
into account the nature of patients' illnesses or injuries.
Leora I. Horwitz, M.D., M.H.S., of Yale–New Haven Hospital
and Yale University School of Medicine, New Haven, Conn.,
and Elizabeth H. Bradley, Ph.D., also of Yale University
School of Medicine, analyzed data from the National Hospital
Ambulatory and Medical Care Survey to examine trends in the
percentage of patients seen within the target time
recommended during triage (initial process of prioritizing
patients for treatment according to the seriousness of their
condition).
"Emergency departments are
increasingly overcrowded, thereby straining resources," the
authors write. "Triage assessment is intended to mitigate
this strain by ensuring that the most acutely ill patients
are prioritized for assessment, regardless of the competing
demands on ED physicians' time. Considering wait time within
the clinical context of triage assessment therefore allows
for a more nuanced understanding of the timeliness of ED
care than wait time in aggregate."
A total of 151,999 ED visits between 1997 and 2006 were
categorized in the database as emergent (recommended that
clinicians see in zero to 14 minutes), urgent (see in 15
minutes to 60 minutes), semi-urgent (see in 61 minutes to
two hours) or non-urgent (see in more than two to 24 hours).
For all categories, the percentage of patients seen within
the triage target time declined an average of 0.8 percent
per year, from 80 percent in 1997 to 75.9 percent in 2006.
The decline was greater—2.3 percent per year—for emergent
patients, who had 87 percent lower odds than semi-urgent
patients of being seen within the triage target time.
"Overall, 56.6 percent of emergent patients were seen within
the triage target time compared with 100 percent of
non-urgent patients," the authors write. Results did not
differ for patients with or without insurance, or for those
of different racial or ethnic groups.
Many causes likely exist for increased wait times, the
authors note. Per capita ED use has increased during the
same timeframe, with much of the increase among less acutely
ill patients. Moreover, high hospital occupancy rates
decrease the number of beds available for patients admitted
through the ED.
"The multifactorial nature of prolonged ED wait time lends
itself to numerous avenues for improvement," the authors
conclude. These include increasing patients' access to
alternate sites of care; interventions to improve ED
processes; and redesign of the physical environment.
"Comparative research into the most effective methods of
reducing ED crowding, decreasing ED length of stay and
limiting ED wait times is urgently needed to help EDs
prioritize their quality improvement activities and maximize
their impact."
Editor's Note: This study was supported by Clinical and
Translational Science Award grants from the National Center
for Research Resources, a component of the National
Institutes of Health, and NIH roadmap for Medical Research.
Dr. Horwitz is supported by Yale–New Haven Hospital and by
the NCRR.
Editorial: Variety of Solutions Needed to Solve ED
Problems
"Increasing attention, both in the media and in the academic
literature, has been placed on emergency department crowding
in the past few decades," write Renee Y. Hsia, M.D., M.Sc.,
and Jeffrey A. Tabas, M.D., of the University of California,
San Francisco, in an accompanying editorial.
"What are the consequences of ED crowding? Crowding in the
ED has been associated with poorer process measures,
including delays in treatment of pain, delays in antibiotic
treatment for community-acquired pneumonia and decreases in
the satisfaction of patients with their ED stay and
hospitalization. There is also increasing evidence to
suggest that ED crowding is associated with poorer clinical
outcomes, such as increased in-hospital morbidity and
mortality."
"The problem of ED crowding and wait times is certainly not
unique to the United States, and no single solution will
solve overcrowding," Drs. Hsia and Tabas conclude. "However,
the problem is serious and worsening, and we must implement
a variety of solutions in the areas of ED input, throughput
and output as well as broader health system reform.
Otherwise, our patients will remain waiting, waiting,
waiting."
1112 Exposure to
several common infections over time may be associated with
risk of stroke [New York NY]--Cumulative exposure
to five common infection-causing pathogens may be associated
with an increased risk of stroke, according to a report
posted online today that will appear in the January 2010
print issue of Archives of Neurology, one of the JAMA/Archives
journals.
Stroke is the third leading cause of death and leading cause
of serious disability in the United States, according to
background information in the article. Known risk factors
include high blood pressure, heart disease, abnormal
cholesterol levels and smoking, but many strokes occur in
patients with none of these factors. "There is therefore
interest in identifying additional modifiable risk factors,"
the authors write.
Some evidence exists that prior infection with pathogens
such as herpes viruses promotes inflammation, contributes to
arterial disease and thereby increases stroke risk. Mitchell
S. V. Elkind, M.D., M.S., of Columbia University Medical
Center, New York, and colleagues studied 1,625 adults
(average age 68.4) living in the multi-ethnic urban
community of northern Manhattan, New York. Blood was
obtained from all participants—none of whom had a stroke—and
was tested for antibodies indicating prior exposure to five
common pathogens: Chlamydia pneumoniae, Helicobacter pylori,
cytomegalovirus and herpes simplex virus 1 and 2. A weighted
composite index of exposure to all five pathogens was
developed.
Participants were followed up annually over a median
(midpoint) of 7.6 years. During this time period, 67 had
strokes. "Each individual infection was positively, though
not significantly, associated with stroke risk after
adjusting for other risk factors," the authors write. "The
infectious burden index was associated with an increased
risk of all strokes after adjusting for demographics and
risk factors."
There were several reasons to investigate these five
particular pathogens, the authors note. "First, each of
these common pathogens may persist after an acute infection
and thus contribute to perpetuating a state of chronic,
low-level infection," they write. "Second, prior studies
demonstrated an association between each of these pathogens
and cardiovascular diseases." Studies examining several of
these pathogens individually have suggested some may
contribute to stroke risk.
"Our study could have potential clinical implications," the
authors conclude. "For example, treatment and eradication of
these chronic pathogens might mitigate future risk of
stroke. Antibiotic therapy directed against C pneumoniae has
been tested in randomized controlled trials without evidence
of benefit against heart disease. Whether the same holds
true for stroke has not yet been established. More studies
will be required to further explore infectious burden as a
potential modifiable risk factor for stroke."
Editor's Note: This research was supported by National
Institutes of Health/National Institute of Neurological
Disorders and Stroke grants.
1112 Deep creep means
milder, more frequent earthquakes along Southern
California's San Jacinto fault [Miami FL]--With
an average of four mini-earthquakes per day, Southern
California's San Jacinto fault constantly adjusts to make it
a less likely candidate for a major earthquake than its
quiet neighbor to the east, the Southern San Andreas fault,
according to an article in the journal Nature Geoscience.
"Those minor to moderate events along the San Jacinto fault
relieve some of the stress built by the constantly moving
tectonic plates," said Shimon Wdowinski, research associate
professor at the University of Miami's Rosenstiel School of
Marine and Atmospheric Science.
Previous estimates may have overstated the likelihood of a
major event on the 140-mile long San Jacinto fault, which
begins between Palm Springs and Los Angeles and runs south
toward the Salton Sea east of San Diego. The US Geological
Survey (USGS) is forecasting a 31 percent chance that an
earthquake with a magnitude of 6.7 or higher on the Richter
Scale will occur on the San Jacinto fault in the next 30
years. Only the San Andreas fault, with a 59 percent chance,
is more likely to have a major event during the same period.
"Thirty-one percent is a high probability, when it comes to
earthquake forecasting—the second highest in Southern
California," said Wdowinski. "Our data show that the next
significant event for the San Jacinto fault would probably
be between 6.0 and 6.7. It doesn't sound like much, but in
earthquake terms it is the difference between a major
earthquake and a moderate event."
A magnitude 6.0 earthquake may be felt for dozens of miles
from the epicenter, but building damage especially in
California, due to strict building codes, would be minimal.
As the magnitude approaches and passes 7.0, which is ten
times stronger than an earthquake with a magnitude of 6.0,
more serious property damage and loss of life may occur.
Wdowinski feels that the San Jacinto fault is not as
dangerous as predicted, because "deep creep" releases
elastic strain of the moving plates approximately six to ten
miles beneath the surface. As a result, the accumulation of
strain along the fault occurs in the upper six miles of
crust, which may be released by more frequent, moderate
earthquakes. However a major event can still occur on the
San Jacinto fault, but with lower probability, if two
segments of the fault rupture simultaneously.
By contrast, the more famous Southern San Andreas fault to
the east is locked some 10 miles down, throughout the entire
seizmogenic crust. It has had very few earthquakes to
release that strain but promises to release much more
energy—a major earthquake—when a rupture occurs.
"It's like bending a stick," said Wdowinski. "You can bend
it until it breaks and releases the energy. The San Jacinto
fault [on the left in the figure below] is like a stick that
has a cut in it. When you begin bending it and it breaks,
less energy is released. Deep creep—evidenced by those
small, more frequent earthquakes—in effect forms that small
cut that reduces the release of energy when the rupture
finally occurs. We are less likely to have the big energy
release of a major earthquake because the energy is not
allowed to build up."
The Southern San Andreas fault to the east is like a thicker
stick without any stress-relieving cuts, which will snap
with much greater force. USGS predicts that the San Andreas
fault has a 59 percent chance of a major earthquake (greater
than a magnitude of 6.7) in the next 30 years.
Aside from earthquakes, Wdowinski's primary research
interest at the University of Miami is hydrology and water
flow in wetlands and the Florida Everglades, in particular.
The link between desert earthquakes and swamps is geodesy,
the study of the earth's size, shape, orientation,
gravitational field, and their variations over time. He uses
satellite imaging and the Global Positioning System (GPS) to
measure those slight changes.
"These are the new tools of geodesy," said Wdowinski, who
co-authored a May 2009 paper in the journal Eos,
Transactions, a publication of the American Geophysical
Union. The article highlighted "Geodesy in the 21st
Century", a look at how technological advances are
benefiting the field and are applicable to many important
societal issues, such as climate change, natural hazards,
and water resources.
After completing his doctoral degree at Harvard, Wdowinski
completed a post-doctoral fellowship at Scripps
Oceanographic Institute in Southern California, where he
studied the San Jacinto fault. A native of Israel, Wdowinski
joined the Rosenstiel School faculty in 2005.
1112 Psychiatric impact
of torture could be amplified by head injury [Boston MA]--Depression
and other emotional symptoms in survivors of torture and
other traumatic experiences may be exacerbated by the
effects of head injuries, according to a study from the
Harvard Program in Refugee Trauma (HPRT), based in the
Massachusetts General Hospital (MGH) Department of
Psychiatry. In the November 2009 Archives of General
Psychiatry, the researchers report finding structural
changes in the brains of former South Vietnamese political
detainees who had suffered head injuries and clearly link
those changes to psychiatric symptoms often seen in
survivors of torture.
"This is the first study since the 1950s to demonstrate
brain changes in survivors of extreme violence. That work
looked at Holocaust survivors, and now we are the first to
connect similar brain damage with mental health issues in
survivors of political torture," says Richard Mollica, MD,
director of the HPRT and leader of the study. "We believe,
although it has not yet been proven, that these physical
effects may help explain why survivors of both torture and
traumatic head injury often don't do well with standard
therapies for depression and anxiety."
Studies by Mollica's team and others have documented the
fact that head injures are a common form of torture among
prisoners of war and political detainees. But no previous
work has investigated whether the neurologic effects of head
injuries were related to the chronic psychiatric disorders
often reported in torture survivors. The current study
analyzed information from 42 Vietnamese immigrants, now
resettled in the U.S., who had been detained in so-called
"re-education camps" and 15 Vietnamese immigrants of similar
ages who had not been detained.
All study participants completed questionnaires regarding
any history of head injuries and on their exposure to
torture or other traumatic experiences before being
interviewed by study investigators to assess current
symptoms of depression and post-traumatic stress disorder.
Comprehensive magnetic resonance imaging studies measured
the size and thickness of brain structures that previous
reports have associated with depression, anxiety and
post-traumatic stress disorder (PTSD) and also have
suggested could be affected by traumatic head injuries.
Among the former detainees, 16 reported having experienced
head injuries at some time, and 26 did not. Not only were
detainees with a history of head injury more likely than
those without to report symptoms of depression, the imaging
studies showed they had significant reductions in the
thickness of the frontal and temporal lobes of the cerebral
cortex, reductions not seen in non-head-injured detainees.
Participants whose head injuries were more severe had even
greater structural changes and more debilitating depression
symptoms. These head-injury-associated effects were
independent of the effects of other forms of torture or
trauma participants had experienced. While head-injured
ex-detainees did not have a greater risk of being diagnosed
with PTSD, their PTSD symptoms were more severe.
"It's well known in neuropsychology that the frontal and
temporal lobes affect executive function – which includes
planning, learning, self-monitoring, and flexibility in
social interactions," Mollica explains. "It could be that
torture survivors who don't do well with standard therapies
have head-injury-based cognitive deficits that interfere
with standard approaches like behavioral or exposure
therapy. It's very rare for patients to relate subsequent
health problems to a head injury or to recognize that a head
injury is affecting their emotions.
"In some cultures," he adds, "patients and families are
relieved to learn that emotional problems are related to a
physical injury and may become more committed to working
with programs specially designed to treat head injury
patients. We hope that our documenting physical effects of
brain damage in a group of torture survivors will provide
evidence leading to improved diagnostic and treatment
approaches. The next steps should be clinical trials
comparing the results of head-injury-specific treatment
programs with more traditional therapies for emotional
disorders in patients with a history of both trauma and head
injury."
Mollica also notes the need to improve training for the
physicians most likely to treat such patients in the
community. "Most primary care physicians are not prepared to
identify mild traumatic head injury either in patients who
may have experienced trauma or torture – including veterans
or refugees – or in survivors of assaults or even auto
accidents." He is a professor of Psychiatry at Harvard
Medical School.
Co-authors of the study – supported by grants from the U.S.
National Institute of Health and the Ministry of Education,
Science and Technology of South Korea – are James Lavelle,
LICSW, HRTP and MGH Psychiatry; In Kyoon Lyoo, MD, PhD,
McLean Hospital; Miriam Chernoff, PhD, Harvard School of
Public Health; Hoan Bui, Vietnamese-American Civic
Association, Dorchester, Mass.; Sujung Yoon, MD, PhD,
Catholic University Medical College, Seoul; Jieun Kim, MD,
Seoul National University; and Perry Renshaw, MD, PhD,
University of Utah.
1112 Study finds news
reports match misperception of civilian deaths [New York NY]--Researchers
reporting in BioMed Central's open access journal Conflict
and Health found that the discrepancy in media reporting of
casualty numbers in the Iraq conflict can potentially
misinform the public and contribute to distorted perceptions
and gross underestimates of the number of civilians killed
in the armed conflict.
In February of 2007 Associated Press conducted a survey of
1,002 adults across the United States about their
perceptions of the war in Iraq. Whilst the respondents
accurately estimated the death toll of U.S. soldiers (the
median estimate was 2,974 while the actual toll at the time
was 3,100), they grossly underestimated the number of Iraqi
civilian casualties (the median answer was 9,890 at a time
when several estimates put the toll at least 10 times that
number and some as high as 50 times that number). To assess
the potential reasons for this discrepancy, Schuyler W.
Henderson and colleagues at Columbia University examined 11
U.S. newspapers and 5 non-U.S. newspapers to collate the
number of Coalition and Iraqi fatalities reported in the
media between March 2003 and March 2008. They specifically
looked at tallies (numbers of death over a period of time)
and the descriptions of specific casualty events.
The results of their study showed U.S. newspapers reported
more events and tallies related to Coalition deaths than
Iraqi civilian deaths, although there were substantially
different proportions amongst the different U.S. newspapers.
In four of the five non-US newspapers, the pattern was
reversed.
The authors of the study suggest that as newspapers reflect
the interests of their readers, it is not surprising that
U.S. newspapers describe more casualties related to
Coalition deaths than Iraqi civilians, however they go on to
question whether this is consistent with the goals and
tenets of ethical and accurate journalism.
"We feel that this study casts an important light on the
role of the media in covering armed conflict and
communicating the human costs of war to the public" said
Schuyler. "Our paper calls into question the role of the
media in providing a tool for civilians to accurately gauge
the true effects and outcomes of military action and ongoing
warfare."
1. Reporting Iraqi civilian fatalities in a time of war,
Schuyler W Henderson, William E Olander and Les Roberts,
Conflict and Health (in press)
1107 Poll: Many
parents, high-priority adults who tried to get H1N1 vaccine
unable to get it [Boston MA]--A new national poll
from Harvard School of Public Health (HSPH) researchers
found that a majority of adults who tried to get the H1N1
vaccine for themselves or their children have been unable to
do so. The poll, which examines the American public's
response to the H1N1 vaccine shortage, is the fifth in a
series of surveys of public views concerning the H1N1 flu
outbreak undertaken by the Harvard Opinion Research Program
at HSPH. The polling was done October 30 to November 1,
2009.
Challenges to Getting H1N1 Vaccine
Vaccination: Since the H1N1 flu vaccine
became available in October, 17% of American adults, 41% of parents, and 21%
of high-priority adults have tried to get it. Among adults who tried to get
it for themselves, 30% were able to get the vaccine and 70% were unable to
get it. Among parents who tried to get the H1N1 vaccine for their children,
34% were able to get it and 66% were unable to get it. Among high priority
adults who tried to get the H1N1 vaccine, 34% were able to get it and 66%
were unable to get it.
Parents in this poll include those with children 6 months to less than 18
years. High-priority adults include adults who live with or care for a child
less than 6 months of age, pregnant women, health care and emergency health
personnel, and adults 25-64 with health conditions associated with higher
risk of medical complications from influenza, such as asthma or heart
disease.
The poll also shows that some people were not able to find information
about the location of available H1N1 flu vaccine. Approximately half who
tried to find such information (49%) were unable to find it.
"These findings suggest that the nationwide H1N1 vaccine shortage is
presenting a real challenge for those who have tried to get the vaccine,"
said Robert J. Blendon, Professor of Health Policy and Political Analysis at
HSPH, who co-directed the poll.
Personal Reactions to the Experience of Trying to Get H1N1 Vaccination
The poll suggests that nearly a third (29%) of those who have tried and
could not get the vaccine (either for themselves or for their children) are
very frustrated. That said, most who have tried and not been able to get it
yet (91%) say they will try again this year to get the vaccine for
themselves, their children or both.
"Public health officials who are encouraging H1N1 vaccination may be
relieved to see that most people who have so far been unable to get the
vaccine say they will try again," said Blendon.
Response to H1N1 Vaccine Shortage Overall
Looking more broadly at the issue of vaccine shortages, most Americans
(82%) believe there is a shortage of H1N1 vaccine in the United States, and
approximately 4 in 10 (41%) believe this is a major problem for the country.
More than half of adults (60%) believe there is a shortage of H1N1 vaccine
in their community.
Forty percent believe there will still not be enough H1N1 flu vaccine by
the end of November for everyone in their community who wants it. Nearly a
quarter (24%) say it will be a very serious problem for them and their
immediate family if the H1N1 vaccine is not available by then.
This is the fifth in a series of surveys of public views concerning the
H1N1 flu outbreak undertaken by the Harvard Opinion Research Program (HORP)
at HSPH. See below:
"Survey Finds Nearly Half of Americans Concerned They Or Their Family May
Get Sick from Swine Flu," May 1, 2009.
"Survey Finds Many Americans Have Taken Steps to Protect Themselves
Against H1N1," May 8, 2009
"National Survey Finds Six in Ten Americans Believe Serious Outbreak of
Influenza A (H1N1) Likely in Fall/Winter," July 15, 2009
"Survey Finds Just 40% of Adults Absolutely Certain They Will Get H1N1
Vaccine," October 2, 2009
Another survey from HORP looked at business preparedness:
"Four-Fifths of Businesses Foresee Severe Problems Maintaining Operations
If Significant H1N1 Flu Outbreak," September 9, 2009
Methodology
This poll is part of an on-going series of surveys focused on the public
and biological security by the Harvard Opinion Research Program (HORP) at
Harvard School of Public Health. The study was designed and analyzed by
researchers at the Harvard School of Public Health (HSPH). The project
director is Robert J. Blendon of the Harvard School of Public Health. The
research team also includes Gillian K. SteelFisher, John M. Benson, and Mark
M. Bekheit of the Harvard School of Public Health, and Melissa J. Herrmann
of SSRS/ICR. Fieldwork was conducted via telephone (including both landline
and cell phone) for HORP by SSRS/ICR of Media (PA) October 30-November 1,
2009.
The survey was conducted with a representative national sample of 1,073
adults age 18 and over, including oversamples of non-Hispanic African
Americans and Hispanics. Altogether, 107 non-Hispanic African Americans and
141 Hispanics were interviewed. In the overall results, these groups were
weighted to their actual proportion of the total adult population.
The margin of error for the total sample is plus or minus 3.8 percentage
points. Possible sources of non-sampling error include non-response bias, as
well as question wording and ordering effects. Non-response in telephone
surveys produces some known biases in survey-derived estimates because
participation tends to vary for different subgroups of the population. To
compensate for these known biases, sample data are weighted to the most
recent Census data available from the Current Population Survey for gender,
age, race, education, region, and number of adults in the household. Other
techniques, including random-digit dialing, replicate subsamples, and
systematic respondent selection within households, are used to ensure that
the sample is representative.
Funding
This Harvard School of Public Health series is funded under a cooperative
agreement with the Centers for Disease Control and Prevention (CDC). The
award enables HORP to provide technical assistance to the CDC as well as to
other national and state government health officials in order to support two
critical goals: (1) to better understand the general public's response to
public health emergencies, including biological threats and natural
disasters; and (2) to improve related public health communications.
1107 NHLBI stops
enrollment in study on resuscitation methods for cardiac
arrest - Different CPR durations found equally successful;
CPR device does not add benefit [Bethesda MD]--Enrollment
has ended early in a large, multicenter clinical trial
comparing two distinct resuscitation strategies delivered by
emergency medical service (EMS) providers to increase blood
flow during cardiac arrest.
The study's independent
monitoring board and the National Heart, Lung, and Blood
Institute (NHLBI), the lead sponsor of the study, stopped
enrollment based on preliminary data suggesting that neither
strategy significantly improved survival.
One strategy compared
different durations of manual cardiopulmonary resuscitation
(CPR) by EMS providers before they assessed whether
defibrillation was needed, and the other strategy tested the
potential benefits and risks of an investigational device to
maintain pressure in the chest during CPR.
After reviewing data on approximately 11,500 study
participants, the study's Data and Safety Monitoring Board (DSMB)
recommended on Oct. 23 that the NHLBI stop enrollment
because sufficient data had been gathered, and continuing
recruitment was unlikely to change the overall outcomes of
the study. The board had no concerns about the safety of any
of the interventions tested, and NHLBI accepted the DSMB
recommendations on the same day. Researchers will continue
to monitor study participants who agree to follow-up visits
for up to six months. They will analyze and publish the
final data in the coming months. The NHLBI is part of the
National Institutes of Health.
"Survival rates for patients who suffer cardiac arrest
before reaching a medical facility are tragically low," said
Susan Shurin, M.D., deputy director of the NHLBI, who
oversees clinical trials supported by NHLBI and accepted the
DSMB recommendation.
"This study provides important
evidence to help inform first responders and other health
care providers on safe and effective life-saving treatment
options. We will continue to search for new ways to save
lives in the precious few moments after cardiac arrest – and
evaluate the benefits and risks of commonly used practices."
The Resuscitation Outcomes Consortium (ROC), the largest
clinical research network to study prehospital treatments
for cardiac arrest in the United States and Canada, tested
both resuscitation strategies as part of the Prehospital
Resuscitation using an IMpedance valve and Early versus
Delayed (ROC PRIMED) clinical trial. An impedance valve,
also called an impedance threshold device (ITD), is a small,
hard plastic device about the size of a fist that is
attached to the face mask or breathing tube during CPR
administered by EMS providers. The device is designed to
improve circulation by enhancing changes in pressures within
the chest during CPR. Researchers found that ITD use did not
significantly improve or worsen survival rates for cardiac
arrest patients.
The early versus delayed strategy compared two currently
used timing strategies of assessing the heart's rhythm in
relation to when CPR is started by EMS providers. The heart
rhythm assessment is done to determine whether
defibrillation to restore the heart to its normal rhythm is
needed. The study compared patient survival rates after EMS
providers performed at least 30 seconds of CPR before
assessing the need for defibrillation with delivering three
minutes of CPR before the assessment. Based on current study
data, both timing strategies were equally effective.
EMS providers assess approximately 350,000 people with
cardiac arrest in the United States each year. Only 5 to 10
percent of people who have sudden cardiac arrest survive.
When administered as soon as possible, CPR and, in some
cases, rapid treatment with a defibrillator – a device that
sends an electric shock to the heart to try to restore its
normal rhythm – can be lifesaving. When delivered by EMS
professionals, CPR is a combination of chest compressions,
to keep oxygen-rich blood circulating until an effective
heartbeat is restored, and rescue breathing. Lay bystanders
are encouraged to immediately begin CPR using only chest
compressions until professional help arrives, according to
the American Heart Association.
ROC PRIMED was designed to test the two promising strategies
to increase the chance of survival without functional
impairments of patients who suffer cardiac arrest outside of
a hospital setting. To test the ITD strategy, patients were
randomly assigned to receive standard CPR from participating
EMS providers either with an ITD or with a non-working
replica (sham) of an ITD.
In animal studies and in small studies in humans, the ITD
has been shown to markedly increase blood flow to the heart
and to raise blood pressure. Human studies have also showed
a tendency toward improved short-term outcomes without
adverse effects. A modified version of the ITD is approved
by the Food and Drug Administration (FDA) for use in
conditions other than cardiac arrest.
However, a large human clinical trial was needed to show
whether the device significantly improves survival with
preserved neurologic function. Patients with preserved
neurologic function are able to carry out activities of
daily living. In contrast, patients who suffer neurological
damage following cardiac arrest may no longer be able to
care for themselves due to injury to parts of the brain.
The study's preliminary results indicate similar survival
rates of patients with preserved neurologic function between
both groups of patients, suggesting that standard CPR
without an ITD is as effective as using an ITD.
"While the ITD is based on a sound physiologic principle, in
this study it did not appear to improve survival rates for
adults in cardiac arrest outside of the hospital," said Tom
Aufderheide, M.D., a professor of emergency medicine at the
Medical College of Wisconsin in Milwaukee and a ROC
principal investigator. "We will continue to seek out and
thoroughly test new devices as well as alternative
applications that hold promise for saving the lives of
cardiac arrest patients."
The other principal strategy studied in ROC PRIMED was the
timing of assessing the heart's rhythm to determine whether
defibrillation is needed in relation to when CPR is started.
For patients randomly assigned to the Analyze Early group,
EMS providers were instructed to perform CPR until they were
able to analyze the patient's heart rhythm (approximately 30
to 90 seconds). Patients in the Analyze Later group received
CPR for at least three minutes before their heart rhythm was
analyzed. When indicated, defibrillation was provided.
Some smaller studies have suggested that longer periods of
CPR before defibrillation might increase survival, while
other studies have suggested that more immediate
defibrillation -- when the patient is treated within two
minutes after the start of cardiac arrest -- might be
better.
"The ROC PRIMED study answers a long-standing question in
the EMS community over whether it is better to defibrillate
earlier or later when trying to resuscitate a patient," said
Ian Stiell, M.D., professor and chair of the Department of
Emergency Medicine at the University of Ottawa, senior
scientist at the Ottawa Hospital Research Institute, and a
principal investigator for the ROC PRIMED Analyze Early vs.
Later protocol. "Both techniques appear to be equally
beneficial."
Myron Weisfeldt, M.D., ROC Steering Committee chair and
director of the Department of Medicine at the Johns Hopkins
University School of Medicine in Baltimore, added,
"Questions like this one – which address the relative
benefits of current medical practices – are an important
example of comparative effectiveness research and, in this
case, can help advance emergency medical care."
ROC PRIMED and other ROC clinical trials are conducted under
strict U.S. FDA and Canadian guidelines that allow for
patients in life-threatening situations to participate in
research under an exception to explicit informed consent,
according to U.S. and Canadian laws. This is necessary
because, among other reasons, participants in cardiac arrest
are unconscious and therefore cannot give consent. Before
any patients were enrolled, communities were consulted about
participation and made aware that informed consent will not
be obtained for most study participants, as required by law.
To ensure patient safety during the study, the DSMB that
monitors ROC studies reviews the accrued data approximately
every six months or more frequently if needed. The ROC DSMB
includes experts in trauma, cardiac arrest, statistics,
ethics, and the conduct of clinical trials. During its
interim data review on Oct. 23, the DSMB recommended
stopping enrollment in both ROC PRIMED assessments based on
results that suggest that both types of strategies were
equally beneficial and that continued enrollment was
unlikely to yield different results. The NHLBI accepted the
recommendation, and ROC clinical sites stopped enrollment.
The ROC is a large clinical research network of 10 centers
in the United States and Canada. Approximately 150 EMS and
fire services organizations, involving more than 20,000 EMS
providers who serve a combined population of more than 15
million people from diverse urban, suburban, and rural
regions participated in ROC PRIMED. ROC research focuses on
treatments for patients with life-threatening traumatic
injury or cardiac arrest in real-world settings, typically
where patients collapse or are critically injured, before
they reach the hospital. Participating EMS providers receive
intensive training, and give standard emergency care to all
patients, with some patients randomly selected to receive
the intervention to be tested in addition to usual care.
"The ROC is the largest research network to study
real-world, pre-hospital interventions for cardiac arrest,"
noted George Sopko, M.D., ROC project officer in the NHLBI
Division of Cardiovascular Sciences. "Conducting these
studies through this robust and experienced network allows
us to implement and compare clinical interventions in
meaningful ways and to disseminate the results as quickly as
possible so they can be applied to improve public health."
Earlier this year, the NHLBI stopped enrollment early for
two ROC clinical trials that examined whether concentrated
(hypertonic) saline improved survival over standard saline
for trauma patients. Patients in the study were either
suffering from shock due to significant blood loss or had
experienced a traumatic brain injury. In both types of
patients, hypertonic saline solution did not improve
outcomes over the use of a standard saline solution.
The NHLBI is the lead federal sponsor of the ROC studies.
Additional funding is provided by the NIH's National
Institute of Neurological Disorders and Stroke, the
Institute of Circulatory and Respiratory Health of the
Canadian Institutes of Health Research, US Army Medical
Research & Materiel Command, American Heart Association,
Defence Research and Development Canada, and the Heart and
Stroke Foundation of Canada.
Resuscitation Outcomes Consortium:
https://roc.uwctc.org/tiki/tiki-index.php
Q&A on ROC PRIMED:
http://public.nhlbi.nih.gov/newsroom/home/qanda.htm
Sudden Cardiac Arrest:
http://www.nhlbi.nih.gov/health/dci/Diseases/scda/scda_whatis.html
1107 Less than 1 in 3
Toronto bystanders who witness a cardiac arrest try to help:
Study [Toronto ON]--Researchers at St. Michael's
Hospital working in conjunction with EMS services,
paramedics and fire services across Ontario found that a
bystander who attempts cardiopulmonary resuscitation (CPR)
can quadruple the survival rate to over 50 per cent. But Dr.
Laurie Morrison and the research team at Rescu (www.rescu.ca)
have found only 30 per cent of bystanders in Toronto are
willing to help, one of the lowest rates of bystanders
helping others in the developed world.
"Over the last four years, we have been working hard with
paramedics and firefighters in Southern Ontario to increase
the survival rate of people who experience cardiac arrest
outside of the hospital," says Dr. Morrison. "Since 2004,
our efforts have managed to triple the survival rate in the
Toronto area but it is still less than 10 per cent."
Compared to other cities during the same time frame, Toronto
has much lower rates of bystander CPR and survival. The
research team wants to encourage all Canadians to learn the
basics of CPR. Home is one of the most common places for
cardiac arrests so learning CPR could mean saving a family
member's life.
"Even if you perform hands-only CPR, and focus on
compressing the chest, you can give a victim of cardiac
arrest as much as a 1 in 2 chance of surviving," says Dr.
Marco Di Buono, Director of Research at the Heart and Stroke
Foundation of Ontario, "on the contrary, doing nothing
virtually guarantees the victim will not survive at all."
Dr. Morrison's research group, Rescu
www.rescu.ca, is based out of St. Michael's and
dedicated to out of hospital resuscitation. It is a
collaborative network of EMS and fire services, paramedics
and firefighters and over 40 hospitals in Southern Ontario.
Rescu is the largest research program of its kind in Canada
and the US, and is world renowned for their clinical trials
in out of hospital treatment of cardiac arrest and life
threatening emergencies.
The trial included Peel EMS, Peel Fire Brampton, Peel Fire
Mississauga, Muskoka EMS, Toronto EMS, Toronto Fire, Durham
(Ajax Fire, Brock Fire, Clarington Fire, Oshawa Fire,
Pickering Fire, Scugog Fire, Uxbridge Fire and Whitby Fire)
and Halton.
The study looked at the impact of bystanders using Automated
External Defibrillators (AEDs). An AED is a portable
electronic device that treats life threatening cardiac
rhythms through electrical therapy, allowing the heart to
reestablish an effective rhythm. The researchers found that
AEDs used in casinos and airports demonstrated an
unprecedented survival rate of 50 per cent or greater. The
study found that the use of AEDs in Toronto to be very low.
Only one per cent of cardiac arrest victims had an AED
applied to their chest.
Although more than an estimated 1,800 AEDs are in public
places in Toronto and adjacent cities, the study found only
750 of the devices were registered with Toronto EMS. This is
problematic when a 911 dispatcher cannot alert a bystander
or EMS person that an AED is close by. In times of an
emergency the dispatcher can be an effective coach for
bystanders to help others.
Even with a 911 dispatcher talking them through the process,
many bystanders do not feel comfortable doing CPR or using
an AED. Minimal training is required and people can learn
CPR or how to use an AED in an emergency by listening to the
dispatcher's coaching until paramedics and fire fighters
arrive.
"You can learn CPR in 20 minutes with a personal learning
kit available through the Heart and Stroke Foundation
website
www.heartandstroke.ca/restart
or by simply watching a video on Youtube," explains Dr.
Morrison. "I believe that we should be teaching CPR and AED
use in all schools so that helping someone in cardiac arrest
is a learned behaviour. You may never need to use your
training but if you are a witness, you will be more likely
to jump in and help. If you do nothing, very few will
survive."
Under Ontario's Good Samaritan Act of 2001, bystanders who
assist others with all good intentions are not liable.
1107 Use of N95 masks
challenged - Infectious diseases prevention experts say
current H1N1 guidance for healthcare workers not supported
by science [Arlington VA]--Three leading
scientific organizations specializing in infectious diseases
prevention issued a letter to President Obama today
expressing their significant concern with current federal
guidance concerning the use of personal protective equipment
(PPE) by healthcare workers in treating suspected or
confirmed cases of 2009 H1N1 influenza.
The Society for Healthcare
Epidemiology of America (SHEA), the Infectious Diseases
Society of America (IDSA) and the Association for
Professionals in Infection Control and Epidemiology (APIC)
urged the administration to modify the guidance and issue an
immediate moratorium on Occupational Safety and Health
Administration’s (OSHA) enforcement of the current
requirements.
Federal PPE guidance and requirements issued recently by the
Centers for Disease Control and Prevention (CDC) and OSHA
include the use of fit-tested N95 respirators by healthcare
workers rather than the use of standard surgical masks.
According to these
organizations--representing scientists, infectious disease
specialists and healthcare professionals dedicated to
healthcare quality, safety and infection control--this
guidance does not reflect the best available scientific
evidence.
Their letter to the White
House cited two recent studies demonstrating that the use of
N95 respirators does not offer additional protection over
that provided by the use of surgical masks.
Mark Rupp, MD, president of SHEA called the current
requirements “deeply flawed” and expressed his concern over
the “potential for considerable untoward consequences” that
could result from the guidance. Among the consequences, Rupp
cited significant confusion among healthcare professionals
and administrators and the potential for further limiting
the availability of the already scarce respirators in
situations where they are truly warranted.
“During a time of a national emergency, healthcare
professionals need clear, practical and evidence-based
guidance from the government,” said Richard Whitley MD,
president of IDSA. “The current guidance is not supported by
the best-available science and only serves to create
skepticism toward federal public and occupational health
decision-making.”
“The supply of N95 respirators is rapidly being depleted in
our healthcare facilities,” said APIC 2009 President
Christine Nutty, RN, MSN, CIC. “We are concerned that there
won’t be an adequate supply to protect healthcare workers
when TB patients enter the healthcare system.”
The organizations have provided input to federal agencies
including the CDC regarding the handling of 2009 H1N1
influenza in the past and say they stand ready to continue
to lend their knowledge and expertise as the pandemic
advances.
1107 When should flu
trigger a school shutdown? Analysis of data from Japan
suggests a protocol for schools to follow [Boston MA]--As
flu season approaches, parents around the country are
starting to face school closures. But how bad should an
influenza outbreak be for a school to shut down? A study led
by epidemiologists John Brownstein, PhD, and Anne Gatewood
Hoen, PhD of the Children's Hospital Boston Informatics
Program, in collaboration Asami Sasaki of the University of
Niigata Prefecture (Niigata, Japan), tapped a detailed set
of Japanese data to help guide decision making by schools
and government agencies. The analysis was published by the
Centers for Disease Control and Prevention in the November
issue of Emerging Infectious Diseases.
"Currently many U.S. schools don't have specific or
consistent algorithms for deciding whether to shut down,"
says Brownstein. "They don't always use quantitative data,
and it may be a political or fear-based decision rather than
a data-based one."
Sasaki, Hoen and Brownstein analyzed flu absenteeism data
from a Japanese school district with 54 elementary schools.
Tracking four consecutive flu seasons (2004-2008), they
asked what pattern of flu absenteeism was best for detecting
a true school outbreak -- balanced against the practical
need to keep schools open if possible.
"You'd want get a school closed before an epidemic peaks, to
prevent transmission of the virus, but you also don't want
to close a school unnecessarily," explains Brownstein. "We
also wanted an algorithm that's not too complex, that could
be easily implemented by schools."
A school outbreak was defined as a daily flu absentee rate
of more than 10 percent of students. After comparing more
than two dozen possible scenarios for closing a school, the
analysis suggested three optimal scenarios:
1. A single-day influenza-related absentee rate of 5 percent
2. Absenteeism of 4 percent or more on two consecutive days
3. Absenteeism of 3 percent or more on three consecutive
days
The scenarios #2 and #3 performed similarly, with the
greatest sensitivity and specificity for predicting a flu
outbreak (i.e., the fewest missed predictions and the fewest
"false positives.") Both gave better results than the
single-day scenario (#1). The researchers suggest that
scenario #2 (with a sensitivity of 0.84 and a specificity of
0.77) might be the preferred early warning trigger,
balancing the need to prevent transmission with the need to
minimize unnecessary closures.
"Our method would give school administrators or government
agencies a basis for timely closure decisions, by allowing
them to predict the escalation of an outbreak using past
absenteeism data," says Hoen. "It could be used with data
from schools in other communities to provide predictions. It
would leave decision-making in the hands of local officials,
but provide them with a data-driven basis for making those
decisions."
Japan makes a good model for studying influenza in schools
because it closely monitors school absenteeism due to flu,
requires testing for the flu virus in students who become
ill, and has a track record of instituting partial or
complete school closures during outbreaks. However,
Brownstein cautions that the scenarios might play out
differently in the U.S. than they would in Japan, mainly
because students here aren't required to be tested for
influenza as they are in Japan, so it's less certain whether
they actually have the flu. Also, the vaccination status of
students in this study was unknown.
Last spring, during the early days of the H1N1 influenza
pandemic, the CDC recommended first a 7-day school closure,
then a 14-day closure after appearance of the first
suspected case. Later, as more became known about the extent
of community spread and disease severity, the CDC changed
the recommendation to advise against school closure unless
absentee rates interfered with school function. CDC's
current guidelines
don't provide a specific algorithm, but state that "the
decision to selectively dismiss a school should be made
locally," in conjunction with local and state health
officials, "and should balance the risks of keeping the
students in school with the social disruption that school
dismissal can cause." When the decision is made to dismiss
students, CDC recommends doing so for 5 to 7 calendar days.
Researchers at the Harvard School of Public Health, the
Boston University School of Public Health, and Niigata
University were coauthors on the study. The study was funded
by the Takemi Program, the Japan Foundation for the
Promotion of International Medical Research Cooperation, the
National Institute of Allergy and Infectious Disease, the
National Institutes of Health Research and the Canadian
Institutes of Health Research.
Citation: Sasaki A, et al. Evidenced-based tool for
triggering school closures during influenza outbreaks,
Japan. Emerg Infect Dis 2009 Nov.
1107 Study finds big
air pollution impacts on local communities - Traffic
corridors in Long Beach and Riverside are a major
contributor to illness from childhood asthma [Los Angeles
CA]--Heavy traffic corridors in the cities of
Long Beach and Riverside are responsible for a significant
proportion of preventable childhood asthma, and the true
impact of air pollution and ship emissions on the disease
has likely been underestimated, according to researchers at
the University of Southern California (USC)
The study, which appears in an online edition of the
American Journal of Public Health, estimated that nine
percent of all childhood asthma cases in Long Beach and six
percent in Riverside were attributable to traffic proximity.
The study also found that ship emissions from the Los
Angeles-Long Beach port complex contributed to the
exacerbation of asthma. For example, approximately 1,400
yearly episodes of asthma-related bronchitis episodes in
Long Beach (21 percent of the total) were caused by the
contribution of ship emissions to nitrogen dioxide levels in
the city.
Although there has been extensive research on the effects of
traffic proximity on asthma risk, this study is one of the
few that has estimated the number of cases—or "burden of
disease"—associated with traffic in specific high risk
communities, says principal investigator Rob McConnell,
M.D., professor of preventive medicine at the Keck School of
Medicine of USC and deputy director of the Children's
Environmental Health Center at USC.
"The traditional approach to estimating the burden of air
pollution-related disease has markedly underestimated the
true effect," McConnell says. "Our results indicate that
there is a substantial proportion of childhood asthma that
may be caused by living within 75 meters (81 yards) of a
major road in Long Beach and Riverside. This results in a
much larger impact of air pollution on asthma symptoms and
health care use than previously appreciated. This is also
one of the first studies to quantify the contribution of
ship emissions to the childhood asthma burden."
Such specific data about the local health burden of air
pollution is useful for evaluating proposals to expand port
facilities or transportation infrastructure in the L.A.
area, McConnell noted. Both Long Beach and Riverside already
have heavy automobile traffic corridors as well as truck
traffic and regional pollution originating in the port
complex, which is the largest in the United States.
The study drew upon data from the Children's Health Study
(CHS), a longitudinal study of respiratory health among
children in 12 Southern California communities, including
Riverside and Long Beach. Researchers estimated the number
of asthma cases and related complications that occurred
because of air pollution, using information from
epidemiological studies that they then applied to current
exposure to air pollution and traffic in Southern
California. The results showed that approximately 1,600
cases of childhood asthma in Long Beach and 690 in Riverside
could be linked to living within 81 yards of a major road.
"The impact of roadway proximity on the overall burden of
asthma-related illness is remarkable," McConnell says. "Air
pollution is a more important contributor to the burden of
childhood asthma than is generally recognized, especially to
more severe episodes requiring visits to a clinic or
emergency room."
Unlike regional air pollutants, the local traffic-related
pollutants around homes and their effects are not currently
regulated, he notes.
"This is a challenge to communities, to regulatory agencies
and to public health," McConnell says. "Traffic-related
health effects should have a central role on the
transportation planning agenda."
The study, an international collaboration between USC, the
Center for Research in Environmental Epidemiology (CREAL) in
Spain and the University of Basel in Switzerland, was
supported by the National Institute of Environmental Health
Sciences, the U.S. Environmental Protection Agency, the
South Coast Air Quality Management District, the Hastings
Foundation, the Center for Research in Environmental
Epidemiology (Switzerland) and the Fundacion Insitut
Municipal d'Investigacio Medica (Barcelona). The authors
acknowledge the insights of the staff and members of the
Long Beach Alliance for Children with Asthma and the Center
for Community Action and Environmental Justice.
Laura Perez, Nino Kuenzli, Ed Avol, Andrea M. Hricko, Fred
Lurmann, Elise Nicholas, Frank Gilliland, John Peters, Rob
McConnell. "Global Goods Movement and the Local Burden of
Childhood Asthma in Southern California." American Journal
of Public Health. Doi: 10.2105/AJPH.2008.154955
1107 Community
education and evacuation planning saved lives in Sept. 29
Samoan tsunami [Atlanta GA]--Community-based
education and awareness programs minimized the death toll
from the recent Samoan tsunami, though there are still ways
to improve the warning and evacuation process, according to
a team of researchers that traveled to Samoa last month.
The team, funded by a National Science Foundation (NSF)
grant, collected data Oct. 4 through Oct. 11 to document the
impacts of the 8.1 earthquake and the ensuing tsunami that
occurred on Sept. 29. They examined flow depths, run-up
heights, inundation distances, sediment depositions and
damage patterns at various scales.
"In addition to timing – the fact that the tsunami struck in
the daylight morning hours when most people were on their
way to work or school – tsunami education, awareness and
evacuation exercises really contained the death toll," noted
Hermann Fritz, one of the principal investigators and an
associate professor of civil and environmental engineering
at the Georgia Institute of Technology. "The technical
solution doesn't always work for coastlines near the
epicenter with less than 30 minutes between earthquake and
onslaught of the tsunami. Earthquakes with durations of more
than 30 seconds serve as a natural warning, resulting in a
spontaneous self-evacuation."
Nearly 190 people were killed
in the tsunami, with the majority of deaths reported in
Samoa, a country governing the western part of the Samoan
Islands in the South Pacific Ocean. The two main islands of
Samoa are Upolu and Savai'i. American Samoa, a territory of
the United States southeast of Samoa, is comprised of main
island Tutuila, the Manu'a Islands, Rose Atoll and Swains
Island. The Samoan government estimates the total damage
from the tsunami at $147 million.
The team's survey circled all of the main Samoan islands and
spanned 350 kilometers from Ofu in the east to Savai'i in
the west. The researchers learned that the tsunami impact
peaked at Poloa near Tutuila's western tip and Lepa at
Upola's southeast coast. Maximum run-up heights reached 17
meters at Poloa, and inundation distances and damage were
recorded at Pago Pago, more than 500 meters inland. The
harbor at Pago Pago, well-protected from ordinary storm
waves, is vulnerable to long-period tsunami waves.
In addition, researchers noticed a marked difference between
the evacuation process in Samoa and American Samoa. While
most villagers in Samoa knew to rapidly evacuate after
experiencing an earthquake, only a month earlier they had
been told that cars help with evacuations, a deadly
directive since most roads run parallel to the beach.
"Many perished trapped inside cars waiting in congested
small roads or in long lines behind vehicles stopped by
landslides or debris on the road," said Costas Synolakis,
principal investigator and professor of civil engineering at
University of Southern California. "I have been on more than
20 tsunami field surveys, and in many ways this was one of
the most surprising in terms of how carnage varied over
fairly short distances. This was also the first time we
noted what we suspected: misinformation kills."
Emile Okal, a seismologist and professor of earth and
planetary sciences at Northwestern University, conducted
approximately 120 interviews with tsunami survivors in 70
different locations around Tutuila and Upolu. He found that
most people were educated about tsunamis and knew how to
react because of community-based educational programs, not
ancestral stories.
"The last significant tsunami
in Samoa occurred in 1917 and was very similar in seismology
to the Sept. 29 tsunami. Surprisingly, no one I interviewed
said they knew of family members being in a similar
situation," Okal observed. "Since the 2004 Indian Ocean
tsunami and the 2007 Solomon Islands tsunami, there has been
a concerted effort on the part of the local government in
American Samoa to post signs and conduct evacuation drills
in some Samoan communities. Many villages were completely
destroyed, so I am impressed that the death toll was not
larger. The bottom line is education worked."
While Synolakis agreed that the death toll was probably
minimized due to educational efforts, he said there is still
a lot of progress that can be made. While working in the
field on Oct. 7, the team experienced a real tsunami warning
and witnessed first-hand the tremendous confusion and
disorganization that followed.
"Although there are warning signs along the beaches in
American Samoa, there is no information about where the
evacuation routes are," he said. "It's also just as
important to let people know when it's safe to come back as
it is to warn them. We definitely have our work cut out for
us."
The collected field data serves as benchmarking and
validation of numerical tsunami models with wide-ranging
applications including forecasting, warning and sediment
transport. The researchers will present their findings at
special sessions at the American Geophysical Union Fall
Meeting in San Francisco this December. Brief publications
summarizing the immediate results will follow in research
journals.
This survey was partially supported by the Pacific
Earthquake Research Center (PEER).
1107 New insight into
predicting cholera epidemics in the Bengal Delta [Medford
MA]--Cholera, an acute diarrheal disease caused
by the bacterium Vibrio cholerae, has reemerged as a global
killer. Outbreaks typically occur once a year in Africa and
Latin America. But in Bangladesh the epidemics occur twice a
year – in the spring and again in the fall.
Scientists have tried, without much success, to determine the cause of
these unique dual outbreaks – and advance early detection and prevention
efforts – by analyzing such variables as precipitation, water temperature,
fecal contamination and coastal salinity. Now, researchers from Tufts
University, led by Professor of Civil and Environmental Engineering Shafiqul
Islam, have proposed a link between cholera and fluctuating water levels in
the region's three principal rivers – the Ganges, Brahmaputra and Meghna.
"What we are establishing is a way to predict cholera outbreaks two to
three months in advance," says Islam, who also holds an appointment as
professor of water and diplomacy at The Fletcher School at Tufts. "It's not
a microbiological explanation. The key is the river discharge and regional
climate."
The Tufts researchers' findings were reported in the latest issue of
Geophysical Research Letters, published October 10, 2009.
Understanding cholera's environmental catalysts
Vibrio cholerae lives and thrives among phytoplankton and zooplankton in
brackish estuaries where rivers come into contact with the sea. The Bengal
Delta, which scientists have considered the native land of cholera, is fed
by three rivers.
Almost all of the rainfall in the region occurs during the four-month
monsoon season between June and September. Water levels in the river system
rise, causing floods that cover 20 percent of the land in an average year.
Water levels then fall rapidly, though low-lying, depressed areas remain
submerged for weeks.
The Tufts team tracked the month-by-month incidence of cholera using data
from the International Center for Diarrhoeal Disease Research, a treatment
center that recorded incidences of cholera for the biggest population center
of Bangladesh from 1980 to 2000.
The Tufts team correlated these cholera incidence statistics with an
analysis of water discharges from the three rivers. Their findings suggested
two distinctive epidemic patterns that are associated with the seasonal
cycles of low river flows and floods.
A spring outbreak occurs in March, during the period of low river flow in
Bangladesh. The low river flow allows seawater from the Bay of Bengal to
move inland, transporting bacteria-carrying plankton.
A second epidemic occurs in September and October, after monsoon rains
have raised water levels. Here, a different dynamic takes place. Floodwaters
have mixed water from sewers, reservoirs and rivers. As the floods recede,
contamination is left behind..
Predicting cholera before it happens
Islam and his team linked the incidence of cholera cases to the level of
water flow in the rivers. In order to confirm their findings, the
researchers looked for a consistent pattern. They analyzed the incidence of
cholera in five years of severely low river flow from 1980 to 2000 and
compared it with five years of average and below average river flow. The
same analysis was done for extreme, average and below average floods to
study the fall epidemic.
The researchers found a relationship between the magnitude of cholera
outbreaks and the severity of the region's seasonal low river flow and
floods. "The more severe the low river flow, the larger the spring
epidemic," says Islam. "The same thing is true with flooding during the
fall." Islam says that the findings will contribute to the development of
systems to anticipate and predict cholera outbreaks based on the
hydroclimate of the region.
This research was funded in part by the
National Science Foundation and a National Institutes of Health Fellowship.
Researchers included engineering doctoral students Ali S. Akanda and
Antarpreet S. Jutla.
Akanda, A. S., A. S. Jutla, and S. Islam (2009), "Dual peak cholera
transmission in Bengal Delta: A hydroclimatological explanation," Geophys.
Res. Lett., 36, L19401, doi: 10.1029/2009GL039312.
1107 Earthquakes
actually aftershocks of 19th century quakes - Repercussions
of 1811 and 1812 New Madrid quakes continue to be felt
[Chicago IL]--When small earthquakes shake the
central U.S., citizens often fear the rumbles are signs a
big earthquake is coming. Fortunately, new research instead
shows that most of these earthquakes are aftershocks of big
earthquakes (magnitude 7) in the New Madrid seismic zone
that struck the Midwest almost 200 years ago.
The study, conducted by researchers from Northwestern
University and the University of Missouri-Columbia, will be
published in the Nov. 5 issue of the journal Nature.
"This sounds strange at first," said the study's lead
author, Seth Stein, the William Deering Professor of
Geological Sciences in the Weinberg College of Arts and
Sciences at Northwestern. "On the San Andreas fault in
California, aftershocks only continue for about 10 years.
But in the middle of a continent, they go on much longer."
There is a good reason, explains co-investigator Mian Liu,
professor of geological sciences at Missouri. "Aftershocks
happen after a big earthquake because the movement on the
fault changed the forces in the earth that act on the fault
itself and nearby. Aftershocks go on until the fault
recovers, which takes much longer in the middle of a
continent."
The difference, Stein explains, is that the two sides of the
San Andreas fault move past each other at a speed of about
one and a half inches in a year -- which is fast on a
geologic time scale. This motion "reloads" the fault by
swamping the small changes caused by the last big
earthquake, so aftershocks are suppressed after about 10
years. The New Madrid faults, however, move more than 100
times more slowly, so it takes hundreds of years to swamp
the effects of a big earthquake.
"A number of us had suspected this," Liu said, "because many
of the earthquakes we see today in the Midwest have patterns
that look like aftershocks. They happen on the faults we
think caused the big earthquakes in 1811 and 1812, and
they've been getting smaller with time."
To test this idea, Stein and Liu used results from lab
experiments on how faults in rocks work to predict that
aftershocks would extend much longer on slower moving
faults. They then looked at data from faults around the
world and found the expected pattern. For example,
aftershocks continue today from the magnitude 7.2 Hebgen
Lake earthquake that shook Montana, Idaho and Wyoming 50
years ago.
"This makes sense because the Hebgen Lake fault moves faster
than the New Madrid faults but slower than the San Andreas,"
Stein noted. "The observations and theory came together the
way we like but don't always get."
Aftershocks go on for long times in other places inside
continents, Stein said. It even looks like we see small
earthquakes today in the area along Canada's Saint Lawrence
valley where a large earthquake occurred in 1663.
The new results will help investigators in both
understanding earthquakes in continents and trying to assess
earthquake hazards there. "Until now," Liu observed, "we've
mostly tried to tell where large earthquakes will happen by
looking at where small ones do." That's why many scientists
were surprised by the disastrous May 2008 magnitude 7.9
earthquake in Sichuan, China -- a place where there hadn't
been many earthquakes in the past few hundred years.
"Predicting big quakes based on small quakes is like the
'Whack-a-mole' game -- you wait for the mole to come up
where it went down," Stein said. "But we now know the big
earthquakes can pop up somewhere else. Instead of just
focusing on where small earthquakes happen, we need to use
methods like GPS satellites and computer modeling to look
for places where the earth is storing up energy for a large
future earthquake. We don't see that in the Midwest today,
but we want to keep looking."
The Nature paper is titled "Long Aftershock Sequences within
Continents and Implications for Earthquake Hazard
Assessment."
1107 Study suggests
rainwater is safe to drink [Adelaide SA]--A world
first study by Monash University researchers into the health
of families who drink rainwater has found that it is safe to
drink.
The research was led by Associate Professor Karin Leder from
the Department of Epidemiology and Preventive Medicine in
conjunction with Water Quality Research Australia
(previously the Cooperative Research Centre for Water
Quality and Treatment)
"This is the first study of its kind. Until now, there has
been no prospective randomised study to investigate the
health effects of rainwater consumption, either in Australia
or internationally," Associate Professor Leder said.
The study involved three hundred volunteer households in
Adelaide that were given a filter to treat their rainwater.
Only half of the filters were real while the rest were
'sham' filters that looked real but did not contain filters.
The householders did not know whether they had a real
filter. Families recorded their health over a 12-month
period, after which time the health outcomes of the two
groups were compared.
"The results showed that rates of gastroenteritis between
both groups were very similar. People who drank untreated
rainwater displayed no measurable increase in illness
compared to those that consumed the filtered rainwater,"
Associate Professor Leder said.
Adelaide was the location chosen for the study as it the
city with the highest use of rainwater tanks in Australia.
Associate Professor Leder said some health authorities had
doubts about drinking rainwater due to safety concerns,
particularly in cities where good quality mains-water is
available.
"This study confirms there is a low risk of illness. The
results may not be applicable in all situations;
nevertheless these findings about the low risk of illness
from drinking rainwater certainly imply that it can be used
for activities such as showering/bathing where inadvertent
or accidental ingestion of small quantities may occur.
"Expanded use of rainwater for many household purposes can
be considered and in current times of drought, we want to
encourage people to use rainwater as a resource," she said.
The study was funded by the National Health and Medical
Research Council and Water Quality Research Australia.
1107 World Trade Center
responders plagued with asthma [New York NY]--Responders
to the 2001 World Trade Center (WTC) terrorist attacks, who
were exposed to caustic dust and toxic pollutants following
the 9/11 disaster, suffer from asthma at a rate more than
twice that of the general US population, according to new
research presented at CHEST 2009, the 75th annual
international scientific assembly of the American College of
Chest Physicians (ACCP).
As many as 8 percent of the workers and volunteers who engaged in rescue
and recovery, essential service restoration, and cleanup efforts in the wake
of 9/11 reported experiencing post-9/11 asthma attacks or episodes, compared
with 4 percent of the general population. Furthermore, the lifetime
prevalence of asthma in WTC responders was marked by a dramatic increase
from 3 percent pre-9/11 to a high of 16 percent in each of the years from
2005 through 2007.
"Although previous WTC studies have shown significant respiratory
problems, this is the first study to directly quantify the magnitude of
asthma among WTC responders compared with the general US population," said
Hyun Kim, ScD, Instructor of Preventive Medicine at Mount Sinai School of
Medicine (MSSM), New York, NY, and lead author of the analysis which uses
data obtained from the federally-funded World Trade Center Medical
Monitoring and Treatment Program. "Six years out from 9/11, the World Trade
Center Program was still observing responders affected by asthma episodes
and attacks at more than double the percentage of people not exposed to
World Trade Center dust."
WTC Study Details
In the multicenter clinical study, researchers from the MSSM-coordinated
WTC Program reported on health-related findings of 20,843 WTC responders who
received an initial medical screening examination during the program's first
5-1/2 years of existence, from July 2002 through December 2007. Asthma
outcomes assessed were the following: (1) prevalence of asthma
episodes/attacks reported by responders to have occurred during the previous
12 months, and (2) lifetime asthma prevalence, as measured by participants
reporting having ever been told by a physician that they had asthma. Results
were compared with the US National Health Survey Interviews (NHIS) adult
sample data for the year 2000 (pre-9/11) and years 2002 through 2007.
WTC Study Results
In the general population, the prevalence of asthma episodes and/or
attacks in the previous 12 months remained relatively constant at slightly
less than 4 percent throughout the period from 2000 to 2007. In contrast,
among WTC responders, while fewer than 1 percent recalled asthma episodes or
attacks during the year 2000, that percentage increased to 8 percent, and
then remained constant, through the period from 2005 to 2007. WTC responders
were 2.3 times more likely to report asthma episodes/attacks that had
occurred during the previous 12 months when compared with the general
population of the United States. Additionally, the increase in lifetime
prevalence of asthma among responders undergoing their initial program
screening any time during the study period grew from a reported 3 percent
for (pre-9/11) diagnoses to 13 percent in 2002. The lifetime prevalence of
asthma subsequently rose through the years to plateau at 16 percent from
2005 through 2007.
"It is important to note that this report focused on findings from
baseline or initial visit examinations," said Philip J. Landrigan, MD, MSc,
Ethel H. Wise Professor and Chair of MSSM's Department of Preventive
Medicine, and principal investigator of the WTC Program Data and
Coordination Center. "Where the data shows an increasing percentage of
responders reporting asthmatic episodes, rising to double that seen in the
general population, it is clearly vital that we continue to track
responders' health and look further into the medical outcomes of this
population."
Of the study's rescue and recovery workers, 86 percent were men; 59
percent were Caucasian; and the average duration of work at WTC sites was 80
days. The study followed uniformed and other law enforcement and protective
service workers (42 percent), as well as construction workers and other
responders who had engaged in paid and volunteer WTC-related rescue and
recovery, essential service restoration, and/or debris removal and cleanup
efforts.
"Asthma and other chronic lung conditions remain a significant burden for
rescue and recovery workers responding to the attacks on the World Trade
Center," said Kalpalatha Guntupalli, MD, FCCP, President of the American
College of Chest Physicians. "The significant chronic health problems
associated with the World Trade Center attacks only reinforces the need for
stronger disaster preparedness plans, as well as long-term medical follow-up
for 9/11 responders and individuals who respond to disaster-related events."
1107 Report on H1N1
cases in California shows hospitalization can occur at all
ages, with many severe [Richmond CA]--In contrast
with some common perceptions regarding 2009 influenza
A(H1N1) infections, an examination of cases in California
indicates that hospitalization and death can occur at all
ages, and about 30 percent of hospitalized cases have been
severe enough to require treatment in an intensive care
unit, according to a study in the November 4 issue of JAMA.
"Since April 17, 2009, when the first 2 cases of pandemic
influenza A(H1N1) virus infection were reported in
California, the virus has rapidly spread throughout the
world," the authors write. They add that preliminary
comparisons with seasonal influenza suggest that this
influenza infection disproportionately affects younger ages
and causes generally mild disease.
Janice K. Louie, M.D., M.P.H., of the California Department
of Public Health, Richmond, Calif., and colleagues examined
the clinical and epidemiologic features of the first 1,088
hospitalized and fatal cases due to pandemic 2009 influenza
A(H1N1) infection reported in California, between April 23
and August 11, 2009. On April 20 of this year the California
Department of Public Health and 61 local health departments
initiated enhanced surveillance for hospitalized and fatal
cases of this infection.
The researchers found that of the 1,088 A(H1N1) cases, 344
(32 percent) were children younger than 18 years, with
infants having the highest rate of hospitalization and
persons age 50 years or older having the highest rate of
death once hospitalized. The median (midpoint) age of all
cases was 27 years. Fever, cough, and shortness of breath
were the most common symptoms. Underlying conditions
previously associated with severe influenza were reported in
68 percent of cases. Other underlying medical illnesses
recorded included obesity, hypertension, hyperlipidemia and
gastrointestinal disease. The median length of
hospitalization among all cases was 4 days.
Three hundred forty cases (31 percent) were admitted to
intensive care units, and of the 297 intensive care cases
with available information, 65 percent required mechanical
ventilation. Of the 884 cases with available information, 79
percent received antiviral treatment, including 496 patients
(71 percent) with established risk factors for severe
influenza. Of the 833 patients who had chest radiographs, 66
percent had infiltrates (evidence of infection involving the
lungs), suggestive of pneumonia or acute respiratory
distress syndrome. Rapid antigen tests were falsely negative
in 34 percent of cases evaluated.
"Overall fatality was 11 percent (118/1,088) and was highest
(18 percent - 20 percent) in persons aged 50 years or
older," the researchers write. "Of the deaths, 8 (7 percent)
were children younger than 18 years. Among fatal cases, the
median time from onset of symptoms to death was 12 days."
The most common causes of death were viral pneumonia and
acute respiratory distress syndrome.
"In the first 16 weeks of the current pandemic, 2009
influenza A(H1N1) appears to be notably different from
seasonal influenza, with fewer hospitalizations and
fatalities occurring in elderly persons. In contrast with
the common perception that pandemic 2009 influenza A(H1N1)
infection causes only mild disease, hospitalization and
death occurred at all ages, and up to 30 percent of
hospitalized cases were severely ill. Most hospitalized
cases had identifiable established risk factors; obesity may
be a newly identified risk factor for fatal pandemic 2009
influenza A(H1N1) infection and merits further study."
"Clinicians should maintain a high level of suspicion for
pandemic 2009 influenza A(H1N1) infection in patients
presenting currently with influenza-like illness who are
older than 50 years or have known risk factors for influenza
complications, regardless of rapid test results.
Hospitalized infected cases should be carefully monitored
and treated promptly with antiviral agents," the authors
conclude.
1107 Sneezing in times
of a flu pandemic [Ann Arbor MI]--The swine flu
(H1N1) pandemic has received extensive media coverage this
year. The World Health Organization, in addition to
providing frequent updates about cases of infection and
death tolls, recommends hyper vigilance in daily hygiene
such as frequent hand washing or sneezing into the crook of
our arms. News reports at all levels, from local school
closures to airport screenings and global disease
surveillance, continue to remind us of the high risk.
In times of heightened health concerns, everyday behaviors
like sneezing can serve as a reminder to wash our hands or
take our vitamins. But, what if we overreact to everyday
sneezes and coughs and sniffles? Can these signals transform
healthy discretion into an unreasonable fearfulness about
germs and more?
New research, forthcoming in Psychological Science, a
journal of the Association for Psychological Science, from
University of Michigan psychologists, Spike Lee and Norbert
Schwarz, tested whether a heightened perception of risk for
a flu pandemic might unconsciously trigger fears of other,
totally unrelated hazards.
To test this, the researchers stationed an experimenter in a
busy campus building and instructed her to sneeze loudly as
students passed. The researchers then administered a survey
to some of the students asking them to indicate their
perceived risk of an "average American" contracting a
serious disease, having a heart attack before age 50, or
dying from a crime or accident.
The researchers found that those who had just witnessed
someone sneezing perceived a greater chance of falling ill.
They also indicated an increased fear of dying of a heart
attack before age 50, dying in an accident or as a result of
a crime. The researchers suggest that the public sneeze
triggered a broad fear of all health threats, even ones that
couldn't possibly be linked to germs.
The researchers then asked the same people their views on
the country's existing health care system. Those within
hearing distance of the sneezing actor had far more negative
views of health care in America.
This finding was so striking that the psychologists ran
another version of the sneezing scenario at a mall. This
time, the interviewer himself sneezed and coughed while
conducting a survey on federal budget priorities (i.e.,
should the government spend money on vaccine production or
on green jobs?).
Participants were more likely to favor federal spending of
$1.3 billion on the production of flu vaccines rather than
the creation of green jobs when the experimenter sneezed.
Thus, in times of a flu pandemic, "public sneezing has the
power to shift policy preferences from other current
priorities (i.e., green jobs) to the production of flu
vaccines," says Schwarz.
1107 Researchers
discover links between city walkability and air pollution
exposure [Vancouver BC]--A new study compares
neighborhoods' walkability (degree of ease for walking) with
local levels of air pollution and finds that some
neighborhoods might be good for walking, but have poor air
quality. Researchers involved in the study include
University of Minnesota faculty member Julian Marshall and
University of British Columbia faculty Michael Brauer and
Lawrence Frank.
The findings highlight the need for urban design to consider
both walkability and air pollution, recognizing that
neighborhoods with high levels of one pollutant may have low
levels of another pollutant.
The study, done for the city of Vancouver, British Columbia,
is the first of its kind to compare the two environmental
attributes, and suggests potential environmental health
effects of neighborhood location, layout and design for
cities around the globe.
The research study is published in the November 2009 issue
of Environmental Health Perspectives, the peer-reviewed
journal of the United States' National Institute of
Environmental Health Sciences, part of the U.S. Department
of Health and Human Services.
The research team found that, on average, neighborhoods
downtown are more walkable and have high levels of some
pollutants, while suburban locations are less walkable and
have high levels of different pollutants. Neighborhoods that
fare well for pollution and walkability tend to be a few
miles away from the downtown area. These "win-win" urban
residential neighborhoods--which avoid the downtown and the
suburban air pollution plus exhibit good walkability--are
rare, containing only about two percent of the population
studied. Census data indicate that these neighborhoods are
relatively high-income, suggesting that they are desirable
places to live. Neighborhoods that fare poorly for both
pollution and walkability tend to be in the suburbs and are
generally middle-income.
"Research has shown that exposure to air pollution adversely
affects human health by triggering or exacerbating a number
of health issues such as asthma and heart disease," said
Marshall, a civil engineering faculty member in the
University of Minnesota's Institute of Technology.
"Likewise, physical inactivity is linked to an array of
negative health effects including heart disease and
diabetes. Neighborhood design can influence air pollution
and walkability; more walkable neighborhoods may encourage
higher daily activity levels."
In the study, researchers evaluated concentrations of nitric
oxide, a marker of motor vehicle exhaust, and ozone, a
pollutant formed when vehicle exhaust and other pollutants
react, for 49,702 postal codes (89 percent of all postal
codes) in Vancouver. The researchers assigned a walkability
score by analyzing four common attributes of neighborhood
design: land-use mixing, intersection density, population
density and for retail areas, the relative amount of land
area for shopping versus for parking.
More walkable neighborhoods tend to have mixed land uses,
with destinations such as stores and shops within walking
distance of people's houses. A conventional street grid and
other more walkable road networks tend to have a higher
intersection density, while less walkable neighborhoods
often have circuitous road networks and low intersection
density, thereby increasing average travel distances and
reducing the likelihood that people will walk. More walkable
areas generally have higher population density. Finally, in
less walkable areas, stores devote a greater fraction of
their land to parking.
"The finding that nitric oxide concentrations are highest
downtown, while ozone concentrations are highest in the
suburbs, is not surprising," said Marshall. "Motor vehicle
exhaust is most concentrated downtown, leading to the high
nitric oxide concentrations downtown. In contrast, ozone
takes time to form. Air masses have moved away from
downtown--often, to suburban areas--by the time ozone
concentrations reach their highest levels. Thus, reductions
in vehicle emissions can benefit people who live near
high-traffic areas and also people living in less dense
areas."
Creating neighborhoods that are more walkable and that allow
for alternative travel modes such as walking, biking or
public transportation is one approach to reducing motor
vehicle emissions, the study suggests. Another approach is
reducing emissions per vehicle, for example through mandated
emission standards. The research did not study conditions
for individual people, but points out that high-rise
buildings may allow people to live in walkable neighborhoods
while being somewhat removed from street-level vehicle
emissions.
The study's new findings indicate that neighborhood design
is an important consideration for improving pollution levels
and providing opportunities for daily physical activity. The
study identified neighborhoods that are walkable yet have
low levels of pollution, but those neighborhoods encompass a
very small percentage of the population. Researchers hope
that future investigation of those "win-win" neighborhoods
will suggest urban design features that could usefully be
applied elsewhere.
In the future, the researchers hope to investigate changes
over time in pollution and walkability, and also study other
urban areas to see how spatial patterns may differ
elsewhere.
1107 The entwined
destinies of mankind and leprosy bacteria [Lausanne
Switzerland]--For thousands of years an
undesirable and persistent companion has been travelling
with man wherever he goes. Mycobacterium leprae, the
bacterium that causes leprosy, has only one known natural
host – mankind. And because of man's many travels, this
bacillus has colonized the entire earth. Its history is
therefore intimately tied to our own, and it is this
migratory relationship that Stewart Cole, EPFL professor of
Microbial Pathogenesis, and his team have analyzed in a
study to be published in Nature Genetics.
Geneticists, microbiologists, and even archeologists have
followed the bacteria's traces from their lab to the Silk
Road and the tombs of Egyptian mummies.
The scientists started with the past history of the disease by
investigating the remains of English, Croatian, and Bulgarian medieval
cemeteries along with an ancient Egyptian burial site to find traces of the
bacteria's DNA. "A person infected with the bacteria shows specific signs of
bone deformations, like hands gripped closed in the form of a claw,"
explains Steward Cole, "and these clues helped us determine if we were
dealing with the bodies of people who died from the disease."
In the wake of commercial ships
Even though Egypt is geographically close to East Africa, where one of
the four strains of leprosy comes from, DNA from a 4th century mommy shows
traces of the European strain. Not necessarily surprising, for the Pharaonic
Empire was economically and culturally tied to the old continent. With
humans being the only possible vessel for the bacteria, it naturally
navigated along with man throughout the trade routes of the seas.
The four strains of the leprosy bacilli that the scientific team found
are: European, East African, West African and Indian. Their current
distribution around the world echoes the history of population movements.
Other examples in the study include Madagascar where, in spite of its
geographic proximity to the African coast, the Indian strain is found on the
island, where the majority of the inhabitants are of Indian origin. In
Brazil, the West African strain is dominant, a probable consequence of the
slave trade, but we also find the European strain – brought most likely from
colonization.
"One of the most interesting surprises is the discovery that the bacteria
found in China are of European origin," explains Stewart Cole, "and one
would have naturally expected the Indian strain. The most probable
explanation is that the strain was carried by traders along the Silk Road."
A stable DNA, more efficient treatments
There is little doubt that the bacillus originated in East Africa –
Stewart Cole will examine this hypothesis in a future study – and then
mutated into the four different strains. "The results of our analysis are
surprising," says Cole, "the difference between the different strains is
very small. It is one of the most stable organisms ever observed, even if
half of its genome is dead." There are only around a hundred different
variations between the DNA of two different strains, whereas with HIV or the
flu there may be thousands of difference mutations.
In the case of HIV, mutations are so frequent that it is almost possible
to say whether a person was infected in Geneva or in Lausanne," explains
Stewart Cole, "but in the case of leprosy, the most we can do is place the
infection on a continental scale." But this is not bad news. Frequent
mutation by a bacterium often leads to disturbing resistances to antibiotic
treatments, such as with tuberculoses. But a more stable bacillus responds
more efficiently to treatment regardless of the strain. "Resistant cases are
extremely rare for leprosy."
Yet the disease remains a persistent public health issue in certain
regions in India and Brazil. Currently, more than 700,000 people are
infected world-wide and the length of treatment of at least one year can
complicate its application. We have not yet head the last from Mycobacterium
leprae, but public health politics, spurred on by work done by the likes of
Stewart Cole and his scientific team, could put an end to the common history
between leprosy and its unwilling human host.
1107 Cause of common
chronic diarrhea revealed in new research [London England]--A
common type of chronic diarrhoea may be caused by a hormone
deficiency, according to new research published in the
November issue of Clinical Gastroenterology and Hepatology.
The authors of the paper, from Imperial College London, with
collaborators from King's College London and the University
of Edinburgh, say their results could help more doctors
recognise this type of diarrhoeal illness, and may lead to
the development of more effective tests and treatments to
help improve the lives of many people suffering with chronic
diarrhoea.
Chronic idiopathic bile acid diarrhoea affects an estimated
one in 100 people in the UK and it can cause people to have
up to ten watery bowel movements a day, often for months at
a time. This type of diarrhoea occurs when an overload of
bile acid reaches the colon and causes excess water to be
secreted into the bowel.
Today's study suggests that bile acid diarrhoea is caused by
the body producing too much bile acid, because of a
deficiency in a hormone called FGF19, which normally
switches off bile acid production. The authors of the study
say that new hormone-based treatments could be developed in
the future to treat the condition and doctors could
potentially test people's hormone levels to diagnose it.
Dr Julian Walters, lead author of the study from the
Division of Medicine at Imperial College London, said: "Bile
acid diarrhoea is a common condition, likely to affect more
people than Crohn's disease or ulcerative colitis, yet until
now we did not understand exactly what causes it. People
with bile acid diarrhoea need to use the toilet urgently
many times during the day and night. This can have a big
impact on their lives, at home, at work and while they are
travelling, as they always need to be near a toilet.
"If they are diagnosed, we have treatments that can remove
bile acid from the colon, alleviate the symptoms and improve
their quality of life. However, the current test used to
diagnose the condition is not available in many countries
and requires patients to attend the hospital twice. This
means many people are not diagnosed. Our new findings mean
that in the future doctors may be able to diagnose the
condition by doing a quick and simple blood test," added Dr
Walters.
Bile acid is produced by enzymes in the liver, to help the
body digest fats. Its production is controlled by a hormone
called Fibroblast Growth Factor 19 (FGF19). Over 90% of the
bile acid is absorbed from the intestine back into the blood
and is then reused. In healthy people, when bile acid is
absorbed by the intestine, the body makes more FGF19 to stop
new bile acid from being produced.
However, results of today's study suggest that people with
bile acid diarrhoea make less FGF19, so the hormone 'switch'
fails to stop the liver from producing more bile acid than
the body needs. Because of this, more is produced than the
intestine can absorb. This then irritates the colon and the
resulting watery secretion causes diarrhoea.
The researchers say that testing the amount of FGF19 in
people's blood could lead to a fast, easy and cheap way of
diagnosing bile acid diarrhoea. They also hope today's
findings will help scientists develop new treatments to
increase the production of FGF19 and reduce the amount of
bile acid being made in patients.
The researchers tested the amount of bile acid being
produced in the livers of 17 patients diagnosed with bile
acid diarrhoea and 19 healthy controls. They did this by
measuring the amount of a molecule called C4 in the blood,
which indicates how much bile acid is being made. The
results showed that the people with bile acid diarrhoea were
producing an average of nearly three times more bile acid
than the controls, with 51 nanograms of C4 per millilitre of
blood in the patient group, compared to 18 nanograms per
millilitre in the control group.
The researchers then measured the amount of FGF19 in the
patients and controls. The results showed that the people
with bile acid diarrhoea were producing around half the
level of the hormone than the controls, with 120 picograms
of FGF19 per millilitre of blood levels in the patient
group, compared to 231 picograms per millilitre in the
control group.
These results suggest that there is a significant link
between bile acid production and decreased levels of FGF19
in people with bile acid diarrhoea. The researchers say
that, following this small study, further research is needed
to see if these findings can be replicated.
1107 Modified Bluetooth
speeds up telemedicine [Coimbatore India]--A
telemedicine system based on a modified version of the
Bluetooth wireless protocol can transfer patient data, such
as medical images from patient to the healthcare provider's
mobile device for patient assessment almost four times as
fast as conventional Bluetooth and without the intermittent
connectivity problems, according to a paper in the
forthcoming issue of the International Journal of Medical
Engineering and Informatics.
Telemedicine is a rapidly developing technology of clinical
medicine where medical information is transferred via
telephone, the internet or other networks for the purpose of
consulting as a remote medical procedure. However, there are
drawbacks to using direct connections between monitoring
devices and the healthcare provider, not least the
intermittency of standard connections.
Now, T. Kesavamurthy and Subha Rani of the PSG College of
Technology Peelamedu, in Coimbatore, India, have devised a
dedicated embedded system that uses the short-range
Bluetooth wireless networking protocol to connect patient
data to the network and then on to the healthcare provider.
This avoids the problem of trying to ensure that a viable
connection between monitoring devices and the internet or
cellular phone network is maintained constantly.
The team has demonstrated a specific application of their
technology which involves the transfer of patient medical
images (CT scans) to the healthcare provider's personal
digital assistant (PDA) device as an example of how
Bluetooth might work for telemedicine.
"In medical imaging, picture archiving and communication
systems (PACS) are computers in networks dedicated to the
storage, retrieval, distribution and presentation of
images," the team explains. However, PACS, which replaces
hard-copy based means of managing medical images, such as
film archives, cannot circumvent the connectivity issues
associated with standard internet connections.
The team has developed a system that can handle the digital
imaging and communications in medicine (DICOM) standard for
medical images and use it to produce compressible images
that can be transferred readily using Bluetooth.
The embedded system used in this project is an ARM based
processor (AT91SAM9263), which is a 32 bit advanced embedded
processor of the type commonly used in mobile data devices.
"The design and implementation of an embedded wireless
communication platform using Bluetooth serial communication
protocol is proposed and problems and limitations are
investigated," the team explains.
The team adds that tests with DICOM images of approximately
1.5 megabytes can be transferred using their modified
Bluetooth system in just 120 seconds, compared with 400
seconds for standard Bluetooth.
"DICOM medical image transmission using Bluetooth through
ARM based processor for telemedicine applications" in Int.
J. Medical Engineering and Informatics, 2010, 2, 52-71
1107 PATH Malaria
Vaccine Initiative shares strategy for developing
'next-generation' malaria vaccines [Nairobi Kenya]--Marking
its tenth anniversary year, the PATH Malaria Vaccine
Initiative (MVI) today unveiled a new strategy that sets the
stage for an aggressive push targeting the long-term goal of
eliminating and eradicating malaria. Malaria is one of the
world's deadliest infectious diseases, killing nearly
900,000 people a year, most of them children in sub-Saharan
Africa.
Released at the Fifth Multilateral Initiative on Malaria Pan-African
Malaria Conference, the MVI strategy represents a multi-pronged approach to
developing the next generation of malaria vaccines. The international
community in 2006 set a long-term goal of having a malaria vaccine by 2025
that is at least 80 percent effective against clinical disease and lasts
longer than four years.
"The malaria community has made impressive strides in reducing deaths in
the last ten years, but malaria still incurs a crushing global burden," said
Dr. Christian Loucq, Director of MVI. "History has shown us that a vaccine
would add a powerful, cost-effective way to save lives and help eliminate
this disease."
A key component of MVI's approach will build on the success-to-date of
GlaxoSmithKline Biologicals' (GSK Bio) RTS,S malaria vaccine candidate,
which has advanced to a further stage of development than ever seen before.
In a Phase 2 study reported in 2008 in the New England Journal of Medicine,
this vaccine was found to be 53 percent effective against clinical disease
in young children. RTS,S is being developed through a partnership among MVI,
GSK Bio, and study centers located across Africa.
If successful in Phase 3 testing and licensure, RTS,S could satisfy the
intermediate goal set forth in the international community's Malaria Vaccine
Technology Roadmap of a "first-generation" malaria vaccine that is at least
50 percent effective against severe disease and death and lasts more than
one year. While this would be a landmark achievement, the road to
elimination and eradication requires filling the vaccine pipeline with
promising new candidates that both build on the success of RTS,S and take
different paths toward immunization.
"Our new strategy will build, efficiently and aggressively, on the
incredible knowledge generated in MVI's first decade of operation," Loucq
added.
Cultivating new approaches
While most malaria vaccine candidates use one or more components of the
malaria parasite to elicit an immune response, another approach uses a
weakened form of the whole parasite. MVI is working with Sanaria Inc. to
develop a novel vaccine candidate that uses this approach with Plasmodium
falciparum. Sanaria's vaccine approach is currently being tested in adult
volunteers in the United States.
In addition to these vaccine approaches being tested in humans, MVI has
numerous feasibility studies underway to develop the vaccine candidates of
the future, most focused on developing specific vaccine components. Only the
most promising of these will advance to clinical development.
Like RTS,S, many of these studies are focused on the pre-erythrocytic
approach. They aim to trigger the immune system to defend against the
parasite as soon as it enters a person's bloodstream or infects liver cells.
This prevents the parasite from maturing and multiplying in the liver,
reentering the bloodstream, and infecting red blood cells.
Another approach targets the malaria parasite when it is most
destructive: at the blood stage, when the parasite replicates rapidly in red
blood cells. Blood-stage vaccines are not expected to block all infection.
Instead, they aim to decrease the number of parasites in the blood, reducing
the severity of malaria. MVI will continue to make limited investments in
this area, but sees the fruit of this effort as yielding additional
components that could be combined with a pre-erythrocytic vaccine, for
example, to further boost its effectiveness.
Targeting the mosquito and the most widespread form of malaria
MVI is also looking for vaccine candidates that block the transmission of
malaria from mosquitoes to humans. Transmission-blocking vaccines attempt to
interrupt the life cycle of the parasite by inducing antibodies that prevent
the parasite from maturing in the mosquito after it bites a vaccinated
person. Transmission-blocking vaccines would not prevent people from getting
malaria, but they could significantly limit the spread of infection.
Another element of MVI's strategy addresses the need to develop vaccines
against P. vivax, the less severe but more widespread malaria parasite
affecting humans. MVI plans to intensify its support for vivax approaches in
hopes of eventually combining them with vaccines targeting P. falciparum,
the parasite most deadly to humans and the one targeted by most vaccine
research, including MVI's.
Developing tools to measure success
As the number of potential malaria vaccine candidates increases,
scientists will need new and better technologies to assess their potential
efficacy and decide which should go forward. MVI is supporting the
refinement and development of both laboratory tools and methodologies for
evaluating vaccine candidates in humans. For example, MVI is supporting
development of the Human Challenge Center at the Seattle Biomedical Research
Institute that, beginning in 2010, will offer early-stage testing in humans
of the safety and efficacy of malaria vaccine candidates.
Continuing need for collaboration
Over the past ten years, MVI has worked with a wide range of partners and
the numbers continue to grow.
"We are looking both inside and outside the malaria research community,
towards investing aggressively in approaches and technologies that are at an
earlier stage of development," Loucq said. "This approach involves many
smaller investments in projects that are evaluated as quickly as possible
for their feasibility, another way we seek to maximize efficiency and use of
scarce resources."
This partnership-based approach has yielded positive results, according
to MVI, as seen in the advancement of RTS,S to a Phase 3 trial, the
upgrading of clinical trial and research capacity in locations across
Africa, and in the decisions by several African countries to put in place
mechanisms to facilitate informed decision-making on malaria vaccine use,
once one becomes available.
"We see the scientific aspects of our work resulting in a toolbox
containing the components for highly effective vaccines against malaria,"
said Ashley Birkett, MVI's Director of Preclinical Research and Development.
"But we are always conscious that our first priority is simply to save the
lives of those who need it most—the children of Africa."
MVI stresses, however, that its new strategy is a work in progress and
one that will require sustained support.
"Our plan is to maintain sufficient flexibility so that if one or more of
our approaches is highly successful, we will be able to realign budget and
strategy to accelerate its development," said Loucq. "But what is still as
true today as ten years ago is that we cannot achieve our goals without the
sustained commitment of partners, including national governments, industry,
other researchers, and donors."
1107 Study examines
associations between antibiotic use during pregnancy and
birth defects [Atlanta GA]--Penicillin and
several other antibacterial medications commonly taken by
pregnant women do not appear to be associated with many
birth defects, according to a report in the November issue
of Archives of Pediatrics & Adolescent Medicine, one of the
JAMA/Archives journals. However, other antibiotics, such as
sulfonamides and nitrofurantoins, may be associated with
several severe birth defects and require additional
scrutiny.
Treating infections is critical to the health of a mother
and her baby, according to background information in the
article. Therefore, bacteria-fighting medications are among
the most commonly used drugs during pregnancy. Although some
classes of antibiotics appear to have been used safely
during pregnancy, no large-scale studies have examined
safety or risks involved with many classes of antibacterial
medications.
Krista S. Crider, Ph.D., of the Centers for Disease Control
and Prevention, Atlanta, and colleagues analyzed data from
13,155 women whose pregnancies were affected by one of more
than 30 birth defects (cases). The information was collected
by surveillance programs in 10 states as part of the
National Birth Defects Prevention Study. The researchers
compared antibacterial use before and during pregnancy
between these women and 4,941 randomly selected control
women who lived in the same geographical regions but whose
babies did not have birth defects.
Antibacterial use among all women increased during
pregnancy, peaking during the third month. A total of 3,863
mothers of children with birth defects (29.4 percent) and
1,467 control mothers (29.7 percent) used antibacterials
sometime between three months before pregnancy and the end
of pregnancy.
"Reassuringly, penicillins, erythromycins and cephalosporins,
although used commonly by pregnant women, were not
associated with many birth defects," the authors write. Two
defects were associated with erythromycins (used by 1.5
percent of the mothers whose children had birth defects and
1.6 percent of controls), one with penicillins (used by 5.5
percent of case mothers and 5.9 percent of controls), one
with cephalosporins (used by 1 percent of both cases and
controls) and one with quinolones (used by 0.3 percent of
both cases and controls).
Two medications—sulfonamides and nitrofurantoins (each used
by 1.1 percent of cases and 0.9 percent of controls)—were
associated with several birth defects, suggesting that
additional study is needed before they can be safely
prescribed to pregnant women.
"Determining the causes of birth defects is problematic,"
the authors write. "A single defect can have multiple
causes, or multiple seemingly unrelated defects may have a
common cause. This study could not determine the safety of
drugs during pregnancy, but the lack of widespread increased
risk associated with many classes of antibacterials used
during pregnancy should be reassuring."
Editor's Note: The National Birth Defects Prevention Study
is funded by a cooperative agreement from the Centers for
Disease Control and Prevention.
1107 Ineffective
monotherapies common in high-burden malarious countries
[Nairobi Kenya]--ACTwatch, a research project led
by PSI, in collaboration with the London School of Hygiene
and Tropical Medicine, released evidence today that
indicates that artemisinin combination therapy, the most
effective medicines for treating malaria, continue to have a
significantly low presence on the market among populations
considered to be most at risk.
Announcing the results at the 5th Multilateral Initiative on
Malaria (MIM) Pan-African Malaria Conference in Nairobi, Dr.
Kathryn O'Connell presented on the current state of the
antimalarial market across 6 sub-Saharan African countries
and Cambodia. Data on availability, pricing and volumes for
23,000 antimalarials, sourced from 20,000 outlets, revealed
a diverse market structure across countries. The majority of
malaria endemic countries changed malaria treatment policies
more than three years ago in the face of widespread drug
resistance to monotherapies, adopting extremely effective
artemisinin combination therapy; however, years later, the
availability of these more effective medicines has been
shown to be as low as 20% in public sector health
facilities. Even in the private sector, where the majority
of patients seek treatment, availability is still relatively
low compared to cheaper, but less effective, drugs.
"These data confirm that access to ACTs is restricted by
their high price. A full course of an adult treatment of ACT
can be up to 65 times the minimum daily wage. This provides
an overpowering incentive for a consumer to make the wrong
antimalarial choice," says Dr. Desmond Chavasse, Vice
President of Malaria Control and Child Survival at PSI.
Worryingly, in most countries, ACTs currently make up only
5% of the total volume of antimalarials on the market,
with ineffective monotherapies dominating the market share.
More disturbing still, despite a call by the World Health
Organisation to ban artemisinin monotherapies, these
continue to permeate private sector markets in key countries
such as Nigeria and the Democratic Republic of Congo, which
together account for 30% of the total malaria-related
disease burden in sub-Saharan Africa. In the Nigerian
context this is particularly important as approximately 95%
of all antimalarials are delivered through the private
sector.
With most people accessing antimalarial medication through
the private sector, price becomes a critically important
barrier affecting demand and utilisation of the more
expensive but also most effective treatments. Artemisinin
combination therapies can be over twenty times more
expensive than ineffective therapies such as chloroquine;
for example, some artemisinin combination therapies cost as
much as $11 in the private sector, while ineffective
antimalarials typically cost a mere $0.30 cents.
ACTwatch data from Cambodia, a country that has implemented
a subsidy with the support of PSI, reveals that the most
effective antimalarials are sold at around $1.20, which
although still expensive compared to ineffective monotherapy
sold for $0.20 cents, is a marked improvement compared to
other countries. In fact, 60% of all antimalarials provided
to patients in Cambodia are now the more effective
artemisinin combination therapies.
"The operation of the distribution chain has a major
influence on which antimalarials are available to retailers,
and their price and quality," says Dr. Kara Hanson of the
London School of Hygiene & Tropical Medicine. "Influencing
practices of providers near the top of the chain may be the
most cost-effective way to change outcomes in this market."
Funded by a $10 million grant to PSI from the Bill & Melinda
Gates Foundation, ACTwatch is providing the critical
information necessary to make evidence-based policy
decisions around the issue of increasing access to ACTs. The
project will serve as a thermometer for the success of
global interventions aimed at reducing the price and
increasing the availability of the most effective
antimalarials, including global financing mechanisms such as
the Affordable Medicines Facility for malaria (AMFm).
1107 First national
zinc campaign for childhood diarrhea increases awareness,
but use lags behind [International Center for Diarrhoeal
Research]--In a study assessing the impact of the
first national campaign to scale up zinc treatment of
diarrhea in Bangladesh, researchers found that awareness was
high but usage lagged behind.
In this week's open access
journal PLoS Medicine, Charles Larson and colleagues from
International Centre for Diarrhoeal Disease Research,
Bangladesh (ICDDR,B) report the results of seven repeated
ecologic surveys in four areas in Bangladesh, representing
1.5 million children under the age of 5.
The researchers found that awareness was less than 10% in
all communities pre-launch and peaked 10 months later at 90,
74, 66 and 50% in urban non-slum, municipal, urban slum, and
rural sites, respectively. After 23 months 25% of urban
non-slum, 20% of municipal and urban slum, and 10% of rural
children under 5 years were actually receiving zinc for
childhood diarrhea.
Use of zinc was found to be
safe, with few side-effects, and did not affect the use of
traditional treatments for diarrhea. The researchers also
found that many children were not given the correct 10-day
course of treatment: 50% of parents were sold seven or fewer
zinc tablets.
The ''Scaling Up of Zinc for Young Children'' (SUZY)
project, funded by the Bill & Melinda Gates Foundation, was
established in 2003 to develop a scale-up campaign, produce
and distribute zinc tablets, train health professionals to
provide zinc treatment, and create media campaigns (such as
adverts in TV, radio, and newspapers) to raise awareness and
promote the use of zinc for diarrhea.
Diarrheal disease is a significant global health problem
causing about 4 billion cases and 2.5 million deaths
annually, and disproportionately affecting those in the
developing world. Clinical trials show that zinc can help
reduce the severity and duration of diarrhea as well as
lower the likelihood of a repeat episode in the future. Zinc
is now included in the guidelines by the World Health
Organization (WHO)/UNICEF for treatment of childhood
diarrhea.
Funding: This study was funded by the Bill & Melinda Gates
Foundation, grant number 00231. The funders had no role in
study design, data collection and analysis, decision to
publish, or preparation of the manuscript.
Citation: Larson CP, Saha UR, Nazrul H (2009) Impact
Monitoring of the National Scale Up of Zinc Treatment for
Childhood Diarrhea in Bangladesh: Repeat Ecologic Surveys.
PLoS Med 6(11): e1000175. doi:10.1371/journal.pmed.1000175
1107 Genes and
environment may interact to influence risk for
post-traumatic stress disorder [New Haven CT]--Individuals
who experience both childhood adversity and traumatic events
in adulthood appear more likely to develop post-traumatic
stress disorder than those exposed to only one of these
types of incidents, according to a report in the November
issue of Archives of General Psychiatry, one of the JAMA/Archives
journals. In addition, the risk was further increased in
individuals with a certain genetic mutation.
Although 40 percent to 70 percent of Americans have
experienced traumatic events, only about 8 percent develop
PTSD during their lifetimes, according to background
information in the article. PTSD is a complex anxiety
disorder that involves re-experiencing, avoidance and
increased arousal following exposure to a life-threatening
event. "In addition to the obvious effect of environmental
factors, PTSD has a heritable component," the authors write.
Recent studies estimate that genetic factors account for
approximately 30 percent of the difference in PTSD symptoms.
Pingxing Xie, B.S., of Yale University School of Medicine,
New Haven, Conn., and VA Connecticut Healthcare Center, West
Haven, and colleagues studied 1,252 individuals who had
experienced childhood adversity (including abuse or
neglect), adult trauma (such as combat, sexual assault or a
natural disaster) or both. Participants age 17 to 79
(average age 38.9) were interviewed and assessed for a
variety of psychiatric and substance use disorders. DNA was
extracted and used to differentiate between versions of a
particular polymorphism or gene mutation—known as the
5-HTTLPR genotype—previously found to be associated with
emotional response after stressful life events.
About one-fifth of the participants (229, or 18.3 percent)
met criteria for PTSD. A total of 552 of the 1,252
participants (44.1 percent) experienced both childhood
adversity and traumatic events in adulthood. These
individuals were more likely to have a lifetime diagnosis of
PTSD than were those who experienced trauma in only one life
stage (29 percent vs. 9.9 percent).
"Although the 5-HTTLPR genotype alone did not predict the
onset of PTSD, it interacted with adult traumatic events and
childhood adversity to increase the risk for PTSD,
especially for those with high rates of both types of trauma
exposure," the authors write. The genotype may influence the
way the brain processes the neurotransmitter serotonin,
affecting an individual's anxiety levels and changing the
way neurons react to fearful stimuli, they note.
"It was only in the group of subjects who could be
characterized as having had the highest rates of trauma
exposure (i.e., in both childhood and adulthood) that an
impact of 5-HTTLPR could be detected," the authors conclude.
"This suggests that there may be many neurobiological
(including genetically determined) 'buffers' to PTSD; only
in instances of extreme and/or repeated trauma exposure
(which, it should be pointed out, characterizes those trauma
'types' with the highest conditional risk for PTSD, e.g.,
domestic violence and military combat), in which these
buffers are overwhelmed, can the impact of specific genes
such as 5-HTTLPR be detected."
This work was supported by National Institutes of Health
grants.
1107 Many US children
may live in families receiving food stamps [St Louis MO]--Nearly
half of all American children will reside in a household
receiving food stamps at some point between the ages of 1
and 20, according to a report in the November issue of
Archives of Pediatrics & Adolescent Medicine, one of the
JAMA/Archives journals.
"Research has repeatedly demonstrated that two of the most
detrimental economic conditions affecting a child's health
are poverty and food insecurity," the authors write as
background information in the article. The receipt of food
stamps serves as a marker of both, since families receiving
them must have low incomes and few assets.
"Understanding the degree to
which American children are exposed to the risks of poverty
and food insecurity across the length of childhood would
appear to be an essential component of pediatric knowledge,
particularly in light of the growing emphasis on the
importance of community pediatrics."
Mark R. Rank, Ph.D., of the George Warren Brown School of
Social Work, Washington University, St. Louis, and Thomas A.
Hirschl, Ph.D., of Cornell University, Ithaca, New York,
analyzed 30 years of longitudinal data from a nationally
representative sample of the U.S. population, the Panel
Study of Income Dynamics. During household interviews
conducted between 1968 and 1997, demographic and other
information was collected regarding children ages 1 through
20, and families reported whether they had received food
stamps over the prior year.
By age 1, 12.1 percent of children had lived in households
receiving food stamps; 26.1 percent had by age 5, 35.9
percent by age 10, 43.6 percent by age 15, and 49.2 percent
by age 20. By age 20, in addition to nearly half receiving
food stamps during at least one year of the study period,
about one-third of children received them for two or more
years, 28.1 percent for three or more years, 26.4 percent
for four or more years and almost one-fourth (22.8 percent)
for five or more years.
Race, education and marital status all were associated with
the receipt of food stamps among children. Black children
and those who lived in households headed by adults who were
unmarried or had less than 12 years of education were more
likely to receive food stamps.
Poverty has been estimated to raise the direct expenditures
on children's health care by approximately $22 billion per
year. "American children are at a high risk of encountering
a spell during which their families are in poverty and food
insecure as indicated through their use of food stamps," the
authors conclude. "Such events have the potential to
seriously jeopardize a child's overall health."
Funding for the analysis in this study was provided by a
Joint Center for Poverty Research Development Grant,
Northwestern University/University of Chicago.
Editorial: Pediatricians Must Advocate for Children's
Interests
"This experience with the Food Stamp Program/Supplementary
Nutritional Assistance Program reflects the broader fact
that a large portion of American families rely on safety net
programs for the necessities of life," writes Paul H. Wise,
M.D., M.P.H., of Lucile Packard Children's Hospital and
Stanford University, Stanford, Calif., in an accompanying
editorial.
"The paradox at the heart of our current safety net system
is that the economic conditions generating the growing need
for services are, at the same time, also undermining our
collective ability to provide them," Dr. Wise writes. "The
bottom line is that the current recession is likely to
generate for children in the United States the greatest
level of material deprivation that we will see in our
professional lifetimes. The recession is harming children by
both reducing the earning power of their parents and the
capacity of the safety net to respond."
"However, it is also essential to recognize that children
have been made extremely vulnerable to this recession by a
decades-long deterioration in their social position," Dr.
Wise continues. "In response, the pediatric community will
have to address the enhanced needs of patients, strengthen
its capability to take collective action and invigorate its
voice in public discourse."
1107 Notorious
'man-eating' lions of Tsavo likely ate about 35 people --
not 135 [Santa Cruz CA]--The legendary
"man-eating lions of Tsavo" that terrorized a railroad camp
in Kenya more than a century ago likely consumed about 35
people--far fewer than popular estimates of 135 victims,
according to a new analysis led by researchers at the
University of California, Santa Cruz. The study also yields
surprises about the predatory behavior of lions.
Despite the notoriety of the attacks--the harrowing
nine-month saga has been the subject of three Hollywood
films, and the lions remain a popular exhibit at the Field
Museum of Natural History in Chicago--the number of victims
has been a matter of dispute. The new study, "Cooperation
and Individuality Among Man-Eating Lions," appears in the
Nov. 2 issue of the Proceedings of the National Academy of
Sciences. The research utilized a sophisticated
stable-isotope analysis to investigate this vexing question.
By analyzing samples of the hair and bone of the lions,
researchers were able to estimate that one lion likely ate
11 humans and the other consumed 24 people during the
animals' final nine months. Both lions were shot and killed
in December 1898 by Lt. Col. John H. Patterson, a British
officer and engineer hired to restore safety in the region.
For years after, Patterson, who gained great notoriety for
the feat, claimed the lions had killed 135 people--far more
than the Ugandan Railway Company's estimate of 28 victims.
"This has been a historical puzzle for years, and the
discrepancy is now finally being addressed," said Nathaniel
J. Dominy, an associate professor of anthropology at UCSC.
"We can imagine that the railroad company might have had
reasons to want to minimize the number of victims, and
Patterson might have had reasons to inflate the number. So
who do you trust? We're removing all those factors and
getting down to data."
Dominy and lead author Justin D. Yeakel, a doctoral
candidate in ecology and evolutionary biology at UCSC,
collaborated on the project with Bruce D. Patterson, the
MacArthur Curator of Mammals at the Field Museum (no
relation to John H. Patterson).
To investigate each lion's lifetime dietary patterns, Yeakel
analyzed samples of their bone collagen and hair keratin
that were provided by the Field Museum. He then compared
those data to the isotopic signatures of the lions'
presumptive prey, including modern grazing and browsing
animals, and humans. Human samples were obtained from the
remains of Kenya's Taita population that were gathered by
anthropologist Louis Leakey during his famous East African
Archaeological Expedition of 1929.
The results suggest that during the final months of what
John Patterson described as the lions' "reign of terror,"
fully half of one lion's diet consisted of humans, with the
balance made up of mid-sized grazing animals such as
gazelles and impala. Strikingly, the other lion ate very few
humans, subsisting instead on herbivores. That dietary
disparity leads Dominy and Yeakel to infer that the Tsavo
lions worked together to scatter everyone, both humans and
wild game, setting the stage for one to gorge on humans and
the other to feed on herbivores.
"The idea that the two lions were going in as a team yet
exhibiting these dietary preferences has never been seen
before or since," said Dominy.
Cooperative hunting is beneficial when lions are stalking
large prey like Cape buffalo and zebra, but humans are small
enough that lions don't typically need to work together to
make a kill. In this case, an array of conditions may have
temporarily altered the lions' behavior, including drought
and disease that depleted the availability of the lions'
conventional prey. In addition, large numbers of people and
animals had gathered for the railroad project, and severe
dental problems and a jaw injury suffered by one of the
lions probably greatly inhibited its ability to hunt.
"These findings underscore the complexity of what lions are
capable of doing, and the complex interplay of costs and
benefits that determine the size of their coalitions," he
said.
The stark dietary differences highlight the importance of
considering individuals within populations, said Yeakel. "In
ecology, we often think of a population as being the sum of
its parts, but there can be really rich things happening
among individuals in a population," he said. "It's a new way
of thinking about how populations work to consider how
individuals affect the whole."
More than a century after the attacks, the Tsavo lions
remain notorious; last year, the National Museum of Kenya
began an effort to recover the remains of the lions, saying
they represent an important part of the country's history
and heritage. The grisly chapter finally ended in December
1898, when John Patterson--after nine months spent in
pursuit of the animals--shot and killed one lion, then
killed the second lion 20 days later. During the final three
months of the nine-month siege, lion attacks were a "nightly
occurrence," and work on the railroad expansion had ground
to a halt as terrified laborers refused to work, said Dominy,
noting that the delay prompted the first and only mention of
lions in Britain's House of Parliament as members demanded
an explanation for the work stoppage.
Ending the terror earned John Patterson widespread and
enduring fame, but Dominy wonders if the boastful hunter
might have exaggerated his estimate of victims to enhance
his own reputation. "The railroad company attributed the
deaths of 28 Indian nationals to the lions, and Patterson
may have reasonably assumed scores of Africans were also
killed," said Dominy. "But based on our statistical
analysis, there's an outside chance they ate as many as 75
people. Our evidence attests only to the number of people
eaten, not the number of people killed."
In 1924, John Patterson sold the hides of the lions--which
he had used as rugs--to the Field Museum, where taxidermists
restored and stuffed the pelts and mounted a diorama that
continues to fascinate museum visitors today. Patterson's
1907 book, The Man-Eaters of Tsavo, was an international
bestseller when it was published, and it remains in print
today.
"The fact that we can determine both the diet and the
behavior of two animals killed more than a century ago is a
testament to the enduring value of museum collections and
the science that interprets them," said Field Museum curator
Bruce Patterson. "The rather extravagant claims (Colonel)
Patterson made in his book can now be pretty much
dismissed."
For Dominy, downgrading the number of human victims of the
Tsavo lions is the latest chapter in a legend that takes a
new turn with the insights about lion predation offered by
these animals. The path of human evolution has been shaped
by predation, said Dominy, noting that the efficiency
benefits of bipedalism are gained at the cost of speed,
making humans vulnerable to quick, four-legged predators,
including lions.
"In a discussion of bipedalism, Louis Leakey once said,
'People are not cat food,' " said Dominy. "But they are.
This study proves that."
In addition to Dominy, Yeakel, and Bruce Patterson,
coauthors on the paper are Kena Fox-Dobbs, assistant
professor of geology at the University of Puget Sound;
Mercedes M. Okumura, research curator in human evolutionary
anatomy at the Leverhulme Centre for Human Evolutionary
Studies at the University of Cambridge; Thure E. Cerling,
distinguished professor of biology and of geology and
geophysics at the University of Utah; Jonathan W. Moore,
assistant professor of ecology and evolutionary biology at
UCSC; and Paul L. Koch, professor of earth and planetary
sciences at UCSC.
1103 Mount Sinai
assessing health impacts of 1 of the nation's largest
environmental disasters [New York NY]--Over
nearly a century, thousands of residents and workers in
Libby, MT, have been exposed to asbestos-contaminated
vermiculite ore, leading to markedly higher rates of lung
disease and autoimmune disorders, and causing to Libby in
2002 to be added to the federal Environmental Protection
Agency's "National Priorities List."
Researchers at Mount Sinai School of Medicine, leading a
team of investigators from four institutions, are now
launching three investigations into disease pathology in the
town and to determine recommended cleanup efforts.
The Principal Investigator of the project is Stephen Levin,
MD, Associate Professor of Preventive Medicine at Mount
Sinai School of Medicine and a nationally known expert in
occupational medicine and asbestos-related diseases who has
also served as PI of the nationwide World Trade Center
Medical Monitoring & Treatment Program, coordinated by Mount
Sinai since 2002.
"The asbestos-related disease in Libby is far more
aggressive and rapidly progressive than what's seen in most
asbestos-exposed workers, with high rates of cancers and
severe effects on respiratory function," said Dr. Levin.
"For that reason alone, the health problems in Libby are
important to study and understand."
The first of the three programs will focus on particular
risks of exposure to Libby asbestos during childhood, when
lungs are still developing and maturing. This research may
determine the level of environmental cleanup necessary in
Libby to protect children, who are a particularly sensitive
target population.
A second study will compare lung scarring among Libby
residents who were exposed to asbestos only in their
environment (and not at their place of employment) with lung
scarring seen in workers with historically long-term, heavy
exposure to common commercial forms of asbestos. Researchers
hope to discover why Libby residents have advanced rates of
lung scarring. They will also investigate the mechanism for
asbestos-related scar formation and approaches to preventing
scar formation after exposure has already occurred.
The third investigation will examine the relationships
between autoimmune disorders, autoimmune antibody
abnormalities, and CT-scan evidence of scarring lung disease
in the context of exposure to Libby asbestos. Auto-immune
disorders such as rheumatoid arthritis and lupus have been
found to occur more frequently in Libby, and antibody levels
to the body's own tissues are found in Libby residents more
frequently and at higher concentrations.
Mount Sinai researchers will collaborate on the research
effort, to be known as the Libby Epidemiology Research
Program, with Libby's Center for Asbestos Related Disease
(CARD), investigators from the University of Montana and
Idaho State University, and a national scientific advisory
group. The research will be supported by a grant of over
$4.8 million from the Agency for Toxic Substances and
Disease Registry (ATSDR) of the federal Center for Disease
Control and Prevention.
The crisis in Libby, a mining town whose history has been
shaped by vermiculite-producing corporations since the
1920s, is the result of community-wide occupational and
environmental exposure to Libby's naturally occurring
vermiculite, contaminated with asbestos and asbestos-like
silicate fibers up to 26% by weight.
Health effects have been detected not just in mine and
processing plant workers, area lumber mill workers and
loggers (from asbestos dusting of forests) and their
families, but also among other Libby residents and their
children. Many were exposed through ambient air or to mine
tailings and other contaminated materials provided to the
town by mining companies for the construction of ball
fields, school running tracks, playgrounds, public buildings
and facilities, as well as for private gardens and house and
business insulation.
There is evidence that even relatively low-level exposures
to Libby asbestos can cause serious scarring lung diseases,
which markedly impair respiratory function, as well as
asbestos-related cancers like lung cancer and mesothelioma,
which occur at higher rates among the Libby population than
elsewhere in the United States.
The health crisis potentially extends far beyond the borders
of Libby, since millions of homes and businesses in North
America have used vermiculite from Libby as attic
insulation, fireproofing and soil conditioner. The ore from
Libby was shipped by rail to 49 plant locations throughout
North America and the Caribbean for processing, exposing
many more workers and communities to the hazardous dust.
CARD Director Brad Black, MD, said, "The pattern of asbestos
disease caused by exposure to Libby amphibole asbestos has
led to excessive morbidity and mortality for the Libby
population, and has been exceedingly challenging for the
medical community. The severity of nonmalignant pulmonary
disease in non-occupational exposure has been very unusual,
raising question as to the potency of the unique amphibole
mixture. We look forward to working with Dr. Levin and Mount
Sinai to find some of these answers."
1103 Flu vaccine given
to women during pregnancy keeps infants out of the hospital
[New Haven CT]--Infants born to women who
received influenza vaccine during pregnancy were
hospitalized at a lower rate than infants born to
unvaccinated mothers, according to preliminary results of an
ongoing study by researchers at Yale School of Medicine. The
team presented the study October 29 at the 47th annual
meeting of the Infectious Diseases Society of America in
Philadelphia.
Influenza is a major cause of serious respiratory disease in
pregnant women and of hospitalization in infants. Although
the flu vaccine is recommended for all pregnant women and
children, no vaccine is approved for infants less than six
months of age. Preventive strategies for this age group
include general infection control and vaccination of those
coming in close contact with them. Few studies have examined
the effectiveness of the flu vaccine during pregnancy.
Led by Marietta Vázquez, M.D., assistant professor of
pediatrics at Yale School of Medicine, this new study is a
case-control trial of the effectiveness of vaccinating
pregnant women to prevent hospitalization of their infants.
During nine flu seasons from 2000 to 2009, Vázquez and
colleagues identified and tracked over 350 mothers and
infants from 0 to 12 months of age who were hospitalized at
Yale-New Haven Hospital. They compared 157 infants
hospitalized due to influenza to 230 influenza-negative
infants matched by age and date of hospitalization. The team
interviewed parents to determine risk factors for influenza
and reviewed medical records of both infants and their
mothers to determine rates of vaccination with the influenza
vaccine.
"We found that vaccinating mothers during pregnancy was 80
percent effective in preventing hospitalization due to
influenza in their infants during the first year of life and
89 percent effective in preventing hospitalization in
infants under six months of age," said Vázquez.
"These results not only have a positive impact on the health
of susceptible infants, but also may be very cost effective,
as it involves one vaccine providing protection to two
individuals," Vázquez added. "The findings may also help
establish public health policy, increase awareness of the
importance of influenza vaccination during pregnancy, and
even help to overcome barriers to vaccination."
Other authors on the abstract include Isaac Benowitz, Daina
Esposito, Kristina DePeau, Richard A. Martinello, M.D. and
Eugene D. Shapiro, M.D.
1103 Poorly cleaned
public cruise ship restrooms may predict norovirus outbreaks
[Boston MA]--A team of researchers from Boston
University School (BUSM), Carney Hospital, Cambridge Health
Alliance and Tufts University School of Medicine, have found
that widespread poor compliance with regular cleaning of
public restrooms on cruise ships may predict subsequent
norovirus infection outbreaks (NoVOs). This study, which
appears in the November 1st issue of Clinical Infectious
Diseases, is the first study of environmental hygiene on
cruise ships.
Outbreaks of acute gastroenteritis (AGE) often occur in
close populations, such as among cruise ship passengers.
Recent epidemiologic investigations of outbreaks of AGE
confirmed that 95 percent of cruise ship AGE outbreaks are
caused by norovirus. Despite biannual sanitation monitoring
and hand hygiene interventions among passengers and crew
members, 66 ships monitored by the United States Centers for
Disease Control and Prevention experienced NoV infection
outbreaks (NoVOs) between 2003 and 2008.
Trained health care professionals evaluated the thoroughness
of disinfection cleaning of six standardized objects (toilet
seat, flush handle or button, toilet stall inner handhold,
stall inner door handle, restroom inner door handle, and
baby changing table surfaces) with high potential for fecal
contamination in cruise ship public restrooms.
The researchers found only 37 percent of the 273 randomly
selected public restrooms that were evaluated on 1,546
occasions were cleaned daily. The overall cleanliness of the
six standardized surfaces on each ship ranged from four to
100 percent. Although some objects in most restrooms were
cleaned at least daily, on 275 occasions no objects in a
restroom were cleaned for at least 24 hours.
Overall, the toilet seat was the best-cleaned object and the
least thoroughly cleaned object was the baby changing table.
Furthermore, 19 objects in 13 ships were not cleaned at all
during the entire five-to-seven-day monitoring period.
Toilet area handholds were largely neglected, accounting for
more than half of the uncleaned objects on 11 ships.
Although almost all standardized objects were assessed at
the time of each evaluation, baby changing tables were not
found in public restrooms on 79 percent of vessels. On three
ships, none of the changing tables were cleaned during the
study period. The thoroughness of cleaning did not differ by
cruise line and did not correlate with Center for Disease
Control and Prevention Vessel Sanitation Program inspection
scores which averaged 97 out of a possible 100 points for
the study vessels.
According to the researchers these findings are of
particular note because five of the six evaluated objects
could readily be directly contaminated by pathogens during
regular use. "Although hand hygiene with soap after
toileting may diminish the transmission of enteric pathogens
via bathroom door knobs or pulls, hand washing is unlikely
to mitigate the potential for any of the other toilet area
contact surfaces to serve as a source of transmission of
enteric pathogens," said lead author Philip Carling, MD, a
professor of clinical medicine at BUSM. "Furthermore, there
was a substantial potential for washed hands to become
contaminated while the passenger was exiting the restroom,
given that only 35 percent of restroom exit knobs or pulls
were cleaned daily. Only disinfection cleaning by cruise
ship staff can reasonably be expected to mitigate these
risks," he added.
Although the thoroughness of disinfection cleaning was 30
percent on more than half of the ships, near-perfect
cleaning was documented on several vessels, providing
evidence that a high level of environmental hygiene is
achievable. "We believe that additional studies on the role
of contaminated surfaces in cruise ship NoV transmission are
warranted to determine whether improved environmental
hygiene will decrease the incidence, duration, or severity
of outbreaks," added Carling.
Co-authors include Lou Ann Bruno-Murtha, DO, clinical
instructor in medicine of Cambridge Health Alliance, and
senior author, Jeffrey K. Griffiths, MD, MPH&TM, an
associate professor in the department of public health and
community medicine at Tufts University School of Medicine.
1103 Health literacy
rates are lower for the disabled and those with lower
English proficiency [Columbia MO]--According to
the Institute of Medicine, more than 90 million Americans
suffer from low health literacy -- a mismatch between
patients' abilities to understand healthcare information and
providers' abilities to communicate complex medical
information in an understandable manner. In two recent
studies, researchers at the University of Missouri found
that two groups — those with limited English proficiency and
those with disabilities — experience significantly lower
health literacy than the general population.
"There is already a problem with low health literacy within
the general population," said Diane Smith, assistant
professor of occupational therapy and occupational science
in the University of Missouri School of Health Professions.
"When looking at populations with disabilities or limited
English proficiency, people need to be more conscious that
these particular populations may have more difficulty
understanding information, such as treatment options or
medication instructions, from their physicians."
In the two studies, researchers found that patients with
disabilities or limited English proficiency (LEP) often
perceived that their physicians did not listen to them,
explain treatment options, treat them with respect, spend
enough time with them, or involve them in the treatment
decisions. In comparison to the general population, these
concerns were much higher among these two groups. Among both
groups, a lack of cultural understanding may contribute to
poor patient-physician communication, Smith said.
In the LEP population, researchers found, in addition to
health literacy issues, those with limited English
proficiency had a significantly reduced access to
healthcare. Few doctors have multi-lingual backgrounds —
especially in rural areas — and it can be difficult to find
a provider who can accommodate LEP patients. As a result,
these patients make fewer doctor visits and receive less
screenings and preventative care. LEP patients also may
delay going to the doctor to avoid dealing with the
frustrations of the language problems, Smith said.
The researchers found that communication complications also
can be a problem among those with disabilities. Individuals
who rely on sign language may need an interpreter to
communicate with their doctors; interpreters are not always
accessible. Assumptions about the disabled community also
may contribute to low health literacy.
"Even within the health environment, there is a tendency to
assume that if there is a physical disability there is a
cognitive one as well," Smith said.
To try and manage the disparities, researchers suggest
improving awareness of the problem among doctors.
Organizations like Health Literacy Missouri and the
University of Missouri Center for Health Policy host
training sessions for physicians and other healthcare
providers to help them understand health literacy and
strategies to better communicate with their patients.
Communicating with medical students is an important strategy
identified in the study. Training students about health
literacy issues may improve health literacy in the future.
To help those with LEP, Smith encourages the use of
telehealth communications — a network that uses
telecommunications technology to communicate health
information and services. Currently, the Missouri Telehealth
Interpretation Project provides LEP patients access to
interpreters that would otherwise not be available.
University of Missouri Health Care provides patients and
families spoken and sign-language interpreter services and
written translation services for 55 languages.
"Health literacy is being addressed in the healthcare reform
debates because it's a safety issue and it's a cost issue,"
Smith said. "It costs a lot of money when people have to go
back to the hospital because they aren't using their
medications appropriately."
The researchers used data from the 2006 Medical Expenditure
Panel Survey to conduct both studies. Further studies may
look at other factors contributing to access to health care
to help identify appropriate intervention strategies.
"If people don't understand instructions, they're not going
to follow them," Smith said. "All the best treatment plans
in the world aren't going to help if patients don't
understand what they are supposed to do."
The study "Health Care Disparities for Persons with Limited
English Proficiency: Relationships from the 2006 Medical
Expenditure Panel Survey" was accepted into the Journal of
Healthcare Disparities Research and Practice and will be
published later this year. The study, "Disparities in
patient-physician communication for persons with a
disability from the 2006 Medical Expenditure Panel Survey,"
was published in Disability and Health Journal in 2009.
1103 Scientists report
major advance in human antibody therapy against deadly Nipah
virus [Rockville MD]--A collaborative research
team from the Uniformed Services University of the Health
Sciences (USU), Australian Animal Health Laboratory and
National Cancer Institute, a component of the National
Institutes of Health, reports a major step forward in the
development of an effective therapy against two deadly
viruses, Nipah virus and the related Hendra virus.
Nipah and Hendra viruses are
found in Pteropid fruit bats (flying foxes) and are
characterized by their recent emergence as agents capable of
causing illness and death in domestic animals and humans.
In experiments carried out in ferrets at the Australian
Animal Health Laboratory in Geelong, Victoria, Australia,
where there is a high-level safety and security facility for
working with live Nipah and Hendra viruses, the team of
researchers demonstrated that giving an anti-virus human
monoclonal antibody therapy after exposure to Nipah virus
protected the animals from disease.
"These findings are extremely encouraging and clearly
suggest the potential that a treatment for Hendra virus
infection in a similar manner should be possible, given the
very strong cross-reactive activity this antibody has
against Hendra virus," said Deborah Middleton, D.V.M.,
Ph.D., who directed the animal experiments at the Australian
Animal Health Laboratory.
Recent earlier work at the National Cancer Institute and USU
resulted in the discovery and development of a human
monoclonal antibody, m102.4, which could attack a critical
component of both the Nipah and Hendra viruses.
Antibodies—proteins found in blood or other bodily fluids of
vertebrates—are used by the immune system to identify and
neutralize viruses and bacteria.
The study's corresponding authors are Christopher C. Broder,
Ph.D., professor of microbiology at USU, and Katharine
Bossart, Ph.D., a USU alumna, now an assistant professor in
the Department of Microbiology, Boston University School of
Medicine and an investigator at the National Emerging
Infectious Diseases Laboratories Institute in Boston. The
pair led a team of researchers to test the effectiveness of
the new antibody therapy in animals. The experiments were
supported in part by the National Institute of Allergy and
Infectious Diseases, NIH. The Henry M. Jackson Foundation
for the Advancement of Military Medicine, Inc. provides
research support and management capabilities to the research
team.
"We now have good evidence that this antibody could save
human lives and the insights offered about how it works also
could potentially provide a starting point to developing
tools for targeting other diseases," said study co-author
Dimiter S. Dimitrov, Ph.D., senior biomedical research
scientist at the National Cancer Institute.
Nipah and Hendra viruses, members of the henipavirus family,
are highly infectious agents that emerged from flying foxes
in the 1990s to cause serious disease outbreaks in humans
and livestock in Australia, Bangladesh, India, Malaysia and
Singapore. Recent outbreaks have resulted in acute
respiratory distress syndrome and encephalitis,
person-to-person transmission, and up to 75 percent case
fatality rates among humans. Additionally, these properties
could allow the viruses to be used as bioterror weapons.
Initial experiments by the researchers using ferrets found
that m102.4 was well tolerated, exhibited no adverse effects
and retained high neutralizing activity. The findings
suggested that m102.4 could potentially be used as a
preventive or post-exposure agent, a diagnostic probe or a
research reagent.
Hendra virus re-emerged again in August 2009, resulting in
the death of several horses and one human. During the
outbreak, in a compassionate attempt to save a human life,
an available low dose of m102.4 was administered to an
individual with advanced encephalitic disease. Although
there were no adverse side effects, the patient did not
improve as the irreversible damage by the virus had already
been done. Like other antimicrobials, the clinical success
of this antibody will depend on dose and time of
administration. As Hendra and Nipah viruses cause severe
disease in humans, a successful application of this antibody
as a post-exposure therapy will likely require early
intervention.
"In order to make clinical use of this therapeutic antibody
against Hendra or Nipah virus, larger amounts will need to
be prepared under proper manufacturing guidelines, carefully
evaluated again in animal models and safety tested for human
use" said Dr. Broder.
Dr. Bossart noted, "We hope this demonstration of anti-viral
activity will foster some immediate activities to facilitate
further development for future use in humans."
"There are currently no licensed and approved vaccines or
therapeutics for prevention and treatment of disease caused
by these viruses for humans or livestock," said Dr. Broder.
"This fully-human monoclonal antibody is the first antiviral
agent against the Nipah and Hendra viruses that has a
genuine potential for human therapeutic use."
"The generation of these antibodies as therapeutics could
help control outbreaks in geographical regions susceptible
to henipaviruses, and could turn information from a deadly
pathogen into a benefit for mankind," said Dr. Dimitrov.
The results of this finding
appear Oct. 30, 2009, in the open access journal PLoS
Pathogens at
http://dx.plos.org/10.1371/journal.ppat.1000642.
1103 A look at public
policies and motorcycle safety in the US [Coral Gables FL]--One
of the joys of riding a motorcycle is the freedom that comes
with that form of travel. However the absence of physical
barriers to protect riders puts motorcyclists at a higher
risk of injury than other motorists.
Motorcycle fatalities have
been on the rise for many years, according to the National
Highway Transportation Safety Administration. Hence a group
of researchers from the University of Miami (UM) and Florida
International University (FIU) conducted one of the first
longitudinal analyses of the effect of public policies to
reduce motorcycle injuries and fatalities.
The researchers believe this study to be the first to use
rigorous econometric techniques, to analyze whether traffic
and alcohol policies affect non-fatal as well as fatal
motorcycle injuries. The findings offer evidence that
certain state policies can effectively reduce the morbidity
and mortality associated with motorcycle riding. The
findings were published in a recent issue of the Journal of
Health Economics.
According to the study, the most significant policy in
reducing both fatal and non-fatal motorcycle injuries is the
universal helmet laws. The findings indicate that about 489
lives could have been saved if universal helmet laws were in
effect in all 48 states in 2005. The researchers also found
that mandatory rider education programs can reduce non-fatal
motorcycle injuries.
"We were not surprised by the consistently significant
effect of universal helmet laws on motorcycle fatalities and
injuries, but the large magnitude was a bit unexpected,"
says Michael T. French, director of Health Economic Research
Group (HERG), in the UM Department of Sociology and
co-author of the study. "In addition, the fact that
universal helmet laws dominated all other traffic safety
policies further highlights the importance of wearing a
helmet to minimize the physical consequences associated with
a crash."
On the other hand, two of the policies (speed limits on
rural interstates and administrative license revocation)
worked in the opposite direction from what was expected in
the models for the non-fatal injury rate. Having an
administrative license revocation policy was associated with
higher rates of non-fatal injuries, while having a higher
speed limit was associated with lower rates of non-fatal
injuries.
"One possible explanation for these results is that states
with these policies have more dangerous road conditions, so
that a fatal rather than non-fatal injury is more likely to
occur in the event of a crash," says Jenny Homer, senior
research associate at HERG, in the UM Department of
Sociology. In addition, rural states, which have less
traffic congestion, may be more likely to have higher speed
limits.
To obtain their results, the researchers first compiled an
extensive dataset with fatal and non-fatal motorcycle
injuries, state alcohol and traffic policies, and state
demographic and environmental characteristics for the period
from 1990 to 2005.
The data on fatal injuries were obtained from the National
Highway Traffic Safety Administration's Fatality Analysis
Reporting System, while non-fatal injury data were collected
through personal correspondence with state traffic agencies.
The information was analyzed to estimate the effects of the
alcohol and traffic policies on fatal and non-fatal
injuries. All of the models included state and year fixed
effects to account for unobserved characteristics associated
with a specific state or year.
"As a result of data limitations, we are not able to account
for certain characteristics that vary from state to state,
such as policy enforcement and grass-roots efforts by
advocacy groups. Nevertheless, the study contains valid
information that can significantly impact public policy
regarding motorcycle safety," says Gulcin Gumus, assistant
professor in the Department of Health Policy and Management,
and the Department of Economics at FIU and co-author of the
study.
The next stage of the investigation will involve
understanding how the universal helmet policies reduce
fatalities, and whether their effects change over time.
1103 Cell phones become
handheld tools for global development [Seattle WA]--Mobile
phones are on the verge of becoming powerful tools to
collect data on many issues, ranging from global health to
the environment.
Computer scientists at the University of Washington have
used Android, the open-source mobile operating system
championed by Google, to turn a cell phone into a versatile
data-collection device. Organizations that want a fully
customizable way to, say, snap pictures of a deforested
area, add the location coordinates and instantly submit that
information to a global environmental database now have a
flexible and free way to do it.
UW computer scientists were already working on mobile tools
for the developing world when Android, the first
comprehensive open-source platform for mobile devices, was
announced two years ago by the Open Handset Alliance, a
group of companies of which Google is a member. For the past
year UW computer science and engineering doctoral students
Carl Hartung, Yaw Anokwa and Waylon Brunette have worked at
Google's Seattle office using Android to create a
data-collection platform for use in developing regions.
Their free suite of tools, named Open Data Kit, is already
used by organizations around the world that need inexpensive
ways to gather information in areas with little
infrastructure. Seattle's Grameen Foundation Technology
Center is using it to evaluate its Ugandan text-messaging
information hotline; D-Tree International, a Boston-based
nonprofit, is using it in Tanzania to guide health workers
treating children under 5 years old; the University of
California, Berkeley's Human Rights Center is using it to
record human rights violations in the Central African
Republic. This fall the Jane Goodall Foundation in Tanzania
and the Brazilian Forest Service signed up to use it to
monitor deforestation.
"Many organizations need to be
able to make evidence-based decisions, and to do that they
need data," Anokwa said. "We hope our toolkit enables
organizations to gather the data quickly so they can analyze
it quickly and make the best decisions for the communities
they serve."
They tool is described in an article published this month in
the Institute of Electrical and Electronics Engineers'
Computer magazine. Gaetano Borriello, UW professor of
computer science and engineering, and Adam Lerer, a graduate
student at the Massachusetts Institute of Technology, are
co-authors.
In the past some researchers have harnessed individual cell
phone models to collect data in the field. But when the
phone gets outdated, so does the software. Instead of
creating a tool for a single phone, or even a single
purpose, the UW team built something that would provide a
reusable platform to collect all types of mobile data.
"We found a lot of organizations were building a lot of
one-off tools that were very similar," Hartung said. "We're
trying to make ours as compatible and flexible as possible."
Open Data Kit's versatile suite of tools can collect data;
store, view and export data on remote servers; and manage
devices in the field from a central office. The output is
compatible with emerging data standards such as the Open
Medical Records System, which aims to coordinate health
records in the developing world.
Many organizations are using Open Data Kit, but the biggest
project so far is a major effort to track and treat HIV
patients in Kenya. Led by the Academic Model Providing
Access to Healthcare, a U.S. Agency for International
Development-funded partnership between Indiana University
and Kenya's Moi University, it is one of the most
comprehensive HIV treatment programs in sub-Saharan Africa.
AMPATH trains Kenyan community health workers who conduct
door-to-door testing in rural areas for HIV, tuberculosis
and malaria, and offer ongoing personalized health
counseling.
Hartung and Anokwa traveled to Kenya this summer to meet
with AMPATH's community health workers and do a trial run
with 10 phones. They spent two weeks working with Kenyan
collaborators, then accompanied community health workers on
home visits to see the phone being used in the field.
"It's a pretty amazing experience to be sitting in a mud hut
seeing someone get counseled, maybe for the first time, on
HIV, and the counselor is using your tool to record
information," Hartung said. "It gives a whole new
perspective on the need for reliable software."
For the past two years AMPATH workers have conducted field
visits using a Palm Pilot and separate GPS unit. This
required workers to key in a 10-digit identifier for each
patient, stand outside and wait up to two minutes to get
location coordinates, and at the end of each day return to
the main office to upload their information to a central
database, which adds travel time and expense.
Phones running Open Data Kit can record location in seconds,
scan a barcode rather than requiring the numbers to be
entered by hand, and upload the data automatically using a
cellular network. AMPATH plans to deploy 100 Google-powered
phones by the end of this year. Ultimately, it aims to use
300 phones powered with Open Data Kit to reach 2 million
people.
"Adopting this technology was
kind of a win-win-win in terms of direction for our
organization," said Dr. Burke Mamlin, an assistant professor
of medicine at the Indiana University School of Medicine and
research scientist with the nonprofit Regenstrief Institute,
which supports AMPATH. "This opens doors by allowing us to
bring data collected in the field directly into our medical
records system. And now we have a phone, all the personal
digital assistant capability, the ability to read barcodes,
and the ability to capture images or video, all in one
unit."
The device also opens up new possibilities for the future.
If one family member is absent during a site visit health
workers can schedule a follow-up visit and have it
automatically appear in their calendars. Health workers
could cue up public-health videos if they thought the family
could benefit. Program managers in a central office could
track data in real time and send updates to field workers
without them having to come back to the base.
Building technology for use in the developing world offers
new challenges for computer scientists. Power and
connectivity may be intermittent, and users may have poor
eyesight or literacy.
There are also other issues specific to mobile devices. Web
developers in the Western world generally create white text
on a dark background, but it turns out dark text on a white
background works better in bright sunlight, where most of
these devices will be used. And touch-screen phones rely on
an electrical signal from users' fingers, but that signal
gets blocked by calluses. UW students found some rural users
needed to use a softer part of the finger pad, and this
meant designing bigger buttons.
The team is now back at the UW, where they are part of a
group called Change that studies technology in the
developing world. Funding for the project comes from
Google.org, the philanthropic arm of the company. The code
is freely available and ongoing research will be based at
the university. Hartung and Anokwa are co-teaching a new
course this fall, Mobile and Cloud Applications for Emerging
Regions
http://www.cs.washington.edu/education/courses/cse599y/09au/
in which undergraduate computer science and engineering
students learn skills and then apply them by creating new
features requested by Open Data Kit users.
"We've only seen the tip of the iceberg in terms of the
types of applications we can run that are really customized
to the person who's holding the device," said Gaetano
Borriello. "For places where resources are constrained,
where data is unavailable and where large problems exist,
this technology is very powerful."
More information on Open Data
Kit is at
http://change.washington.edu/projects/odk.
Watch a demonstration of the tool on YouTube at
http://tinyurl.com/lttrqj
1103 New model may help
scientists better predict and prevent influenza outbreaks
[Athens GA]--Each year, the influenza virus
evolves. And each year, public health officials try to
predict what the new strain will be and how it will affect
the population in order to best combat it.
A new study by an international team of researchers, led by
assistant professor Andrew W. Park, who holds a joint
appointment in the University of Georgia Odum School of
Ecology and in the College of Veterinary Medicine, may make
their task a little easier. The study breaks ground by
working across scales and linking sub-molecular changes in
the influenza virus to the likelihood of influenza
outbreaks. The paper, published in the Oct. 30 edition of
the journal Science, shows the relationship between the
evolution of the virus and immunization rates needed to
prevent an outbreak in the population.
Park explained that these findings can help inform efforts
to prevent future outbreaks. "Public health officials will
be able to assess the usefulness of a vaccine based upon its
relationship to the current influenza strain and the
population's immunity level," he said.
Through previous vaccinations or infections with earlier
strains of the influenza virus, many individuals already
have some level of immunity, Park noted. The influenza virus
is continually evolving, however. By substituting different
amino acids at key molecular points, the virus increases its
chances of evading the immune system's defenses, allowing it
to reproduce and spread.
As the number of amino acid differences between a new strain
and the strain an individual was vaccinated against
increases, the likelihood of becoming infected increases,
Park said, as does the likelihood of becoming infectious and
the length of time the individual will remain infectious.
These factors combine to increase the chance of an outbreak
in a population.
Working with equine influenza, the research team members
looked at the likelihood of an influenza outbreak in a
population that had all been vaccinated with the same strain
of the virus. They found that outbreaks began occurring when
there were two or more amino acid differences and that the
size of the outbreak increased with the number of amino acid
differences. They also found that large outbreaks were more
likely to occur if the virus and the vaccine were from
different antigenic clusters—meaning that a host's immune
system perceives the two strains as different. Comparing
these results with an earlier human influenza study revealed
similar trends.
Another key factor in determining the risk of an outbreak in
real populations, however, is the individual variation of
immunity in the population. Because the virus keeps
changing, so do the vaccines used against it. This causes
the immunity of the population to be heterogeneous—some
individuals have been infected with or vaccinated against
last year's influenza strain, some against strains from
previous years, and some have no immunity at all. Park and
his colleagues found that the degree of variability of
immunity in the population plays a crucial role in
determining the risk of an outbreak.
Park added that in measuring for the first time how the
difference between the population's immunity status and a
new virus strain influences the risk of an epidemic, the
team has taken a critical step toward linking these
relationships with the dynamics of epidemics, not just for
influenza but for a wide range of infectious diseases.
1103 Whooping cough
immunity lasts longer than previously thought [Ann Arbor MI]--Immunity
to whooping cough lasts at least 30 years on average, much
longer than previously thought, according to a new study by
researchers based at the University of Michigan and the
University of New Mexico. Details are published October 30
in the open-access journal PLoS Pathogens.
Once thought to be under control following widespread
childhood vaccination, whooping cough (pertussis) has been
on the rise since the 1980s in the United States and several
other countries. Several explanations have been proposed for
the surprising increase in cases, and one leading idea is
that the immunity enjoyed by vaccinated or previously
exposed people is waning. It has been documented that, in
some individuals, immunity has waned over time, but details
of how long protection typically lasts and how its waning
affects disease transmission have not been clear.
To try to answer these questions, Pejman Rohani (based at
the University of Georgia during completion of this study)
and Helen Wearing used mathematical models to explore
various scenarios and compared the predictions generated by
those models to data on whooping cough incidence.
The researchers constructed two different models based on
assumptions of the effects of pertussis exposure on a person
whose immunity has lapsed and that person's relative
contribution to transmission. Then they compared the models'
predictions to whooping cough incidence data from England
and Wales from both the pre-vaccine era (1945-1957) and the
vaccine era (1958-1972).
In particular, Rohani and Wearing looked for matches in two
key measures: the number of years between big outbreaks and
the frequency of "extinctions"---periods of time when no
whooping cough cases were reported in the population. The
analysis revealed that, on average, whooping cough immunity
lasts at least 30 years and perhaps as long as 70 years
after natural infection.
"This is surprising because clinical epidemiologists
currently believe the duration of pertussis immunity is
somewhere between four and 20 years," said Rohani.
In addition, repeat infections appear to contribute
relatively little to the transmission cycle, the researchers
found. And when people whose immunity has waned are
re-exposed to whooping cough, they rarely become infected.
In fact, their immunity to the disease may be boosted by
re-exposure, the study suggests. Still, the researchers are
cautious about drawing conclusions about current day
vaccination practices from their study of historical data.
"It's worth pointing out that in the past 20 years or so,
the nature of the vaccines that have been used has changed
quite fundamentally," Rohani said. The data we're using are
from a time when a whole-cell vaccine was in use; now an
acellular vaccine, which stimulates a different part of the
immune system, is typically used, especially in North
America."
In response, Rohani is doing new work using more recent data
from the U.S., such as birth rates, population size, and
vaccination coverage, to uncover relevant factors associated
with trends in whooping cough incidence.
This work was supported by the National Institutes of Health
(R01 GM69111), the National Science Foundation (DEB 0343176)
and a New Scholar Award in Global Infectious Disease from
the Ellison Medical Foundation to PR. HJW was supported, in
part, by start-up funds from the University of New Mexico.
1103 Lack of insurance
may have figured in nearly 17,000 childhood deaths
[Baltimore MD]--Lack of health insurance might
have led or contributed to nearly 17,000 deaths among
hospitalized children in the United States in the span of
less than two decades, according to research led by the
Johns Hopkins Children's Center.
According to the Hopkins researchers, the study, to be
published Oct. 30 in the Journal of Public Health, is one of
the largest ever to look at the impact of insurance on the
number of preventable deaths and the potential for saved
lives among sick children in the United States.
Using more than 23 million hospital records from 37 states
between 1988 and 2005, the Hopkins investigators compared
the risk of death in children with insurance and in those
without. Other factors being equal, researchers found that
uninsured children in the study were 60 percent more likely
to die in the hospital than those with insurance. When
comparing death rates by underlying disease, the uninsured
appeared to have increased risk of dying independent
regardless of their medical condition, the study found. The
findings only capture deaths during hospitalization and do
not reflect deaths after discharge from the hospital, nor do
they count children who died without ever being
hospitalized, the researchers say, which means the real
death toll of non-insurance could be even higher.
"If you are a child without insurance, if you're seriously
ill and end up in the hospital, you are 60 percent more
likely to die than the sick child in the next room who has
insurance," says lead investigator Fizan Abdullah, M.D.,
Ph.D., pediatric surgeon at Hopkins Children's.
The researchers caution that the study looked at hospital
records after the fact of death so they cannot directly
establish cause and effect between health insurance and risk
of dying. However because of the volume of records analyzed
and because of the researchers' ability to identify and
eliminate most factors that typically cloud such research,
the analysis shows a powerful link between health insurance
and risk of dying, they say.
"Can we say with absolute certainty that 17,000 children
would have been saved if they had health insurance? Of
course not," says co-investigator David Chang, Ph.D. M.P.H.
M.B.A. "The point here is that a substantial number of
children may be saved by health coverage."
"From a scientific perspective, we are confident in our
finding that thousands of children likely did die because
they lacked insurance or because of factors directly related
to lack of insurance," he adds.
Given that more than 7 million American children in the
United States remain uninsured amidst this nation's struggle
with health-care reform, researchers say policymakers and,
indeed, society as a whole should pay heed to their
findings.
"Thousands of children die needlessly each year because we
lack a health system that provides them health insurance.
This should not be," says co-investigator Peter Pronovost,
M.D., Ph.D., director of Critical Care Medicine at Johns
Hopkins and medical director of the Center for Innovations
in Quality Patient Care. "In a country as wealthy as ours,
the need to provide health insurance to the millions of
children who lack it is a moral, not an economic issue," he
adds.
In the study, 104,520 patients died (0.47 percent) out of
22.2 million insured hospitalized children, compared to 9,
468 (0.75 percent) who died among the 1.2 million uninsured
ones. To find out what portion of these deaths would have
been prevented by health insurance, researchers performed a
statistical simulation by projecting the expected number of
deaths for insured patients based on the severity of their
medical conditions among other factors, and then applied
this expected number of deaths to the uninsured group. In
the uninsured group, there were 3,535 more deaths than
expected, not explained by disease severity or other
factors. Going a step further and applying the excess number
of deaths to the total number of pediatric hospitalizations
in the United States (117 million) for the study period, the
researchers found an excess of 16,787 deaths among the
nearly six million uninsured children who ended up in the
hospital during that time.
Other findings from the study:
* More uninsured children were seen in hospitals in the
Northeast and Midwest than in the South and West. However,
hospitals from the Northeast had lower mortality rates than
hospitals from the South, Midwest and West.
* Insured children on average incurred higher hospital
charges than uninsured children, most likely explained by
the fact that uninsured children tend to present to the
hospital at more advanced stages of their disease, which in
turn gives doctors less chance for intervention and
treatment, especially in terminal cases, investigators say.
* Uninsured patients were more likely to seek treatment
though the Emergency Room, rather than through a referral by
a doctor, likely markers of more advanced disease stage
and/or delays in seeking medical attention.
* Insurance status did not affect how long a child spent
overall in the hospital.
The research was funded by the Robert Garrett Fund for the
Treatment of Children.
Co-investigators in the study include Yiyi Zhang, M.H.S.;
Thomas Lardaro, B.S.; Marissa Black; Paul Colombani, M.D.;
Kristin Chrouser, M.D. M.P.H.
1103 PTSD less common
than depression and alcohol misuse amongst UK troops [London
England]--Common mental disorders, such as
depression and alcohol misuse, are the top psychological
problems amongst UK troops post-deployment and not post
traumatic stress disorder (PTSD) as is widely believed. A
study published today in the open access journal, BMC
Psychiatry, also finds that reservists remain at special
risk of operational stress injury.
Since the beginning of the Iraq conflict, over 100,000 UK
Service personnel have been deployed to Iraq and
Afghanistan. These personnel are at increased risk of
operational stress injury, such as mental health problems.
However a detailed clinical picture of their specific health
needs has previously been lacking in the UK.
A study conducted by Dr Amy Iversen and colleagues from the
King's Centre for Military Health Research and the Academic
Centre for Defence Mental Health, Institute of Psychiatry,
UK, reports that alcohol abuse is the most common mental
health disorder amongst UK Service personnel returning from
Iraq and Afghanistan, with disorders such as depression and
anxiety being second most common. Dr Iversen said, "Although
our perception is that PTSD symptoms are the main source of
psychiatric illness in Service personnel, alcohol misuse and
depressive disorders are actually much more common.
Prevention and intervention in these areas should be high
priority."
The London-based team set out to assess the prevalence and
risk factors for common mental health disorders and PTSD
amongst the UK military, as well as to compare the data with
that from US forces. A total of 821 participants undertook a
structured telephone interview, which included the Patient
Health Questionnaire.
They found that the prevalence of all common mental
disorders was 27.2%, and PTSD symptoms, 4.8%. There were no
substantial differences in the prevalence of PTSD symptoms
between US and UK troops deployed to Iraq, which had been
previously found. In UK troops, the most common diagnoses
were alcohol abuse (18.0%) and depression/anxiety (13.5%).
The data also indicated that reservists who deployed to Iraq
are at greater risk of psychiatric injury than regular
personnel, thus initiatives in the UK to provide enhanced
assistance to reservists are still pertinent.
Dr Iversen concludes: "This research has helped build a
detailed picture of the specific heath needs of the UK
military. These data should be particularly valuable for
health service planners, providers and policy makers."
The prevalence of common mental disorders and PTSD in the UK
military: using data from a clinical interview-based study,
Amy C Iversen, Lauren van Staden, Jamie Hacker Hughes, Tess
Browne, Lisa Hull, John Hall, Neil Greenberg, Roberto J
Rona, Matthew Hotopf, Simon Wessely and Nicola T Fear, BMC
Psychiatry (in press)
1103 Undocumented
foreign-born Latinos face serious financial and language
barriers to quality health care [Los Angeles CA]--Where
Latinos are born and their immigration status affect the
quality of health care they receive in the US, according to
Professor Michael Rodríguez and colleagues from the UCLA
Department of Family Medicine and the Network for
Multicultural Research on Health and Healthcare based in Los
Angeles, California.
New information from this
just-released study highlights the need for improved health
systems for immigrants – documented or undocumented, US-born
or foreign-born. Findings are published online this week in
the Journal of General Internal Medicine.
Latinos are one of the fastest growing populations in the
US. To date, most of the research on quality of health care
has focused on the general Latino population. For the first
time, Rodríguez and the team's work looks at differences by
place of birth and immigration status in this group.
Perceived quality of health care is important because how
patients rate the quality of care they receive influences
their health outcomes. When patients rate their health care
as excellent or good, they are more likely to stick to
treatment programs and to be motivated to manage their
health problems.
The authors analyzed data from the 2007 Pew Hispanic
Center/Robert Wood Johnson Foundation Latino Health Survey –
a nationally representative telephone survey of more than
4,000 Latino adults in the US. They looked at the
differences in perceived quality of care, receipt of
preventive care, and usual source of health care among
US-born Latinos, foreign-born Latino citizens, Latino
permanent residents and undocumented Latinos.
The study found that perceived quality of care is different
by place of birth and immigration status. Compared to
US-born Latinos, undocumented Latinos were less likely to
have health insurance, had the lowest levels of usual source
of care, blood pressure and cholesterol checks and were less
likely to report excellent or good health care in the past
year. Undocumented Latinos were also the most likely group
to report receiving no health information from their doctor
in the past year. Forty-five percent of undocumented Latinos
believed they received poor quality of care because they
were unable to pay, 39 percent linked poor care to their
ethnic background, and 48 percent thought they received poor
care because of their accent.
The authors conclude: "These findings help increase our
understanding of the diversity among Latinos and why
reporting results by immigration status is important.
Policies supporting increased access to affordable,
culturally and linguistically competent services could be
beneficial to improve quality of health care among Latinos."
These findings have direct implications for the health care
debate as policies that leave the undocumented out and
possibly increase barriers to health care will likely have
negative consequences for the health care and health of
Latinos.
This research, entitled "Perceived Quality of Care, Receipt
of Preventive Care, and Usual Source of Health Care among
Undocumented and other Latinos," is one of nine articles
published in the special supplement, "Confronting Health
Inequities in Latino Health Care."
The research in the supplement
resulted from efforts of The Network on Multicultural
Research on Health and Healthcare, a consortium of leading
researchers from institutions around the country. This team
of multidisciplinary senior and junior faculty members
conducts health disparities research on the care provided to
minority subpopulations.
Guest editors for the
supplement, Michael Rodríguez, MD, MPH and his colleague
William Vega, PhD also serve as the co-directors of The
Network, which is funded by the Robert Wood Johnson
Foundation and is located within the UCLA David Geffen
School of Medicine, Department of Family Medicine.
Additional information on the
articles and relevant background information can be obtained
by visiting
http://media.multiculturalhealthcare.net/.
Reference
1. Rodriguez M et al (2009). Perceived Quality of Care,
Receipt of Preventive Care, and Usual Source of Health Care
among Undocumented and other Latinos. J Gen Intern Med. DOI
10.1007/s11606-009-1098-2
1103 Member of NFL Hall
of Fame diagnosed with degenerative brain disease [Boston
MA]--The Center for the Study of Traumatic
Encephalopathy (CSTE) at Boston University School of
Medicine (BUSM) announced today that a recently deceased
member of the NFL Hall of Fame suffered from the
degenerative brain disease Chronic Traumatic Encephalopathy
(CTE) when he died, becoming the 10th former NFL player
diagnosed with the disease.
Last week, CSTE researchers announced CTE had been diagnosed
post-mortem in a former college football player who died at
42, the first advanced case in a non-NFL football player.
Most concerning, all 11 of the former NFL and college
football players studied post-mortem at the CSTE have shown
signs of CTE.
Lou Creekmur, former offensive lineman for the Detroit Lions
and eight-time Pro Bowl player, was diagnosed with CTE by
neuropathologist and CSTE co-director Ann McKee, MD.
Creekmur played 10 seasons for the Detroit Lions, and was
famous for breaking his nose 13 times while playing without
a facemask. He died July 5, 2009 from complications of
dementia following a 30-year decline that included cognitive
and behavioral issues such as memory loss, lack of attention
and organization skills, increasingly intensive angry and
aggressive outbursts.
CTE can only be diagnosed by examining brain tissue
post-mortem. Creekmur's brain was studied by McKee who
determined that he was suffering from CTE and not another
cause of dementia such as Alzheimer's disease. McKee said,
"This is an important case because we are confident many CTE
cases are misdiagnosed as Alzheimer's disease. By examining
his brain, I was able to confirm that there was absolutely
no sign of Alzheimer's disease or any other type of
neurodegenerative disease except for severe CTE. This is the
most advanced case of CTE I've seen in a football player;
his brain changes were similar to those of profoundly
affected professional boxers."
President and CEO of the Alzheimer's Association Mass./N.H.
Chapter James Wessler stated, "This is a very important
finding that could explain the underlying cause of dementia
in countless individuals who have had histories of
repetitive head trauma."
The Creekmur case is also important in advancing discussion
of what risk factors may play a role in causing CTE other
than trauma. One hypothesis that has been put forward is
that anabolic steroids could play a role in CTE. However,
Creekmur played in the 1950s, a time that predates
documented steroid use in the NFL, so the case proves CTE
does occur in the absence of steroids.
Robert Stern, PhD, CSTE co-director, added, "The U.S. House
Judiciary Committee is holding a hearing on the football
head injury crisis on Oct. 28, and we feel that this
evidence should be part of the discussion. The long-term
consequences of brain trauma in sports are a tremendous
public health problem. CTE is the only fully preventable
cause of dementia. We need to make changes to the game of
football, at all levels of play, which will decrease the
risk of CTE to both pro and amateur athletes."
Creekmur was a member the NFL's Plan 88. The Plan was named
for former NFL star John Mackey's jersey number. Mackey, a
Hall-of-Fame tight end for the Colts in the 1960s and 70s,
suffers from severe dementia. The Plan was created by the
NFL to provide financial support to families of former
players who suffer from some form of dementia. Members of
the Plan have been diagnosed with "dementia," which refers
to progressive memory and cognitive deficits significant
enough to impair daily living. During life, it is not
possible to determine the underlying disease that causes
dementia. However, now that a Plan 88 member has been
examined pathologically, CSTE scientists have proven it is
possible to determine the cause of dementia, which in this
case was repetitive trauma from football.
Creekmur's wife of 33 years, Caroline Creekmur, had
extensive discussions with her husband prior to death about
his brain trauma history, and is confident he remembered "16
or 17" concussions, none that caused loss of consciousness
or necessitated a hospital visit. He did not have any
significant head trauma since retiring from the NFL.
There are approximately 100 former NFL players whose
families are receiving support through Plan 88, including
Ralph Wenzel, age 66, former lineman for the Pittsburgh
Steelers and San Diego Chargers, who now resides in an
assisted living facility with advanced dementia. Upon
learning of Creekmur's CTE diagnosis, Wenzel's wife, Dr.
Eleanor Perfetto, stated, "Sadly, these findings do not come
as a surprise. For those of us who have watched our husbands
deteriorate and lose their independence from progressive
dementia, our hope is that this research will one day lead
to changes in the game of football such that other players
and their families will not have to experience the pain that
we have experienced."
CTE is characterized by the build-up of a toxic protein
called tau in the form of neurofibrillary tangles (NFTs) and
neuropil threads (NTs) throughout the brain. The abnormal
protein initially impairs the normal functioning of the
brain and eventually kills brain cells. Early on, CTE
sufferers may display clinical symptoms such as memory
impairment, emotional instability, erratic behavior,
depression and problems with impulse control. However, CTE
eventually progresses to full-blown dementia. Although
similar to Alzheimer's disease, CTE is an entirely distinct
disease.
The CSTE was created in 2008 as a collaborative venture
between Boston University School of Medicine (BUSM) and
Sports Legacy Institute (SLI). The mission of the CSTE is to
conduct state-of-the-art research of Chronic Traumatic
Encephalopathy, including its neuropathology and
pathogenesis, the clinical presentation and course, the
genetics and other risk factors for CTE, and ways of
preventing and treating this cause of dementia.
Sports Legacy Institute is a 501(c)(3) nonprofit corporation
founded in 2007 to solve the sports concussion crisis. SLI
is dedicated to education, prevention, treatment, and
research on the effects of concussions and other brain
injuries in athletes and the military. SLI partnered with
Boston University School of Medicine to form the Center for
the Study of Traumatic Encephalopathy in 2008.
1103 Smoking gun: just
1 cigarette has harmful effect on the arteries of young
healthy adults [Edmonton AB]--Even one cigarette
has serious adverse effects on young adults, according to
research presented by Dr. Stella Daskalopoulou at the
Canadian Cardiovascular Congress 2009, co-hosted by the
Heart and Stroke Foundation and the Canadian Cardiovascular
Society.
Her study found that smoking one cigarette increases the
stiffness of the arteries in 18 to 30 year olds by a
whopping 25 per cent.
Arteries that are stiff or rigid increase resistance in the
blood vessels, making the heart work harder. The stiffer the
artery, the greater the risk for heart disease or stroke.
"Young adults aged 20-24 years have the highest smoking rate
of all age groups in Canada," says Dr. Daskalopoulou, an
internal medicine and vascular medicine specialist at McGill
University Health Centre. "Our results are significant
because they suggest that smoking just a few cigarettes a
day impacts the health of the arteries. This was revealed
very clearly when these young people were placed under
physical stress, such as exercise."
The study compared the arterial stiffness of young smokers
(five to six cigarettes a day) to non-smokers. The median
age was 21 years. Arterial measurements were taken in the
radial artery (in the wrist), the carotid artery (in the
neck), and in the femoral artery (in the groin), at rest and
after exercise.
Arterial stiffness in both smokers and non-smokers was
measured using a new but well established method called
applanation tonometry. Dr. Daskalopoulou introduced the
'arterial stress test' which measures the arteries' response
to the stress of exercise. The test is comparable to a
cardiac stress test, which measures the heart's response to
the stress of exercise.
"In effect we were measuring the elasticity of arteries
under challenge from tobacco," explains Dr. Daskalopoulou.
An initial arterial stress test was carried out to establish
a baseline measurement for both the non-smokers and the
smokers, who were asked not to smoke for 12 hours prior to
the test. After the first meeting, smokers returned and
smoked one cigarette each and then repeated the stress test.
During the final meeting, smokers were asked to chew a piece
of nicotine gum prior to the stress test.
Dr. Daskalopoulou found that after exercise the arterial
stiffness levels in non-smokers dropped by 3.6 per cent.
Smokers, however, showed the reverse: after exercise their
arterial stiffness increased by 2.2 per cent. After nicotine
gum, it increased by 12.6 per cent. After one cigarette, it
increased by 24.5 per cent.
Interestingly, there was no difference in the arterial
stiffness measurements between smokers and non-smokers at
rest.
"In effect, this means that even light smoking in otherwise
young healthy people can damage the arteries, compromising
the ability of their bodies to cope with physical stress,
such as climbing a set of stairs or running to catch a bus,"
says Dr. Daskalopoulou. "It seems that this compromise to
respond to physical stress occurs first, before the damage
of the arteries becomes evident at rest."
"More than 47,000 Canadians will die prematurely each year
due to tobacco use, which often starts in the teen years,"
warns Heart and Stroke Foundation spokesperson Dr. Beth
Abramson. "We know that over 90 per cent of teenagers who
smoke as few as three to four cigarettes a day may be
trapped into a lifelong habit of regular smoking, which
typically lasts 35 to 40 years."
Smoking contributes to the build up of plaque in the
arteries, increases the risk of blood clots, reduces the
oxygen in the blood, increases blood pressure, and makes the
heart work harder. Smoking also nearly doubles the risk of
ischemic stroke.
Dr. Abramson says this study reinforces the importance of
education, prevention programs, and legislation such as the
recently passed Bill C-32, Cracking Down on Tobacco
Marketing Aimed at Youth Act.
If you or someone you know wants to quit smoking, you can
order the Heart and Stroke Foundation's free Just Breathe:
Becoming and Remaining Smoke-Free brochure by phoning
1-888-HSF-INFO.
Health Canada's Go Smoke Free!
website
www.gosmokefree.ca also has
support resources, tips, and tools to help people become
smoke-free.
1103 Significant
regional variations exist regarding proximity to burn
centers [Seattle WA]--Although nearly 80 percent
of the U.S. population lives within 2 hours by ground or
helicopter transport to a verified burn center, there is
substantial state and regional variation in geographic
access to these centers, according to a study in the October
28 issue of JAMA.
More than 500,000 burn injuries occur in the United States
each year, causing approximately 4,000 burn-related deaths,
according to the American Burn Association. In addition,
more than 40,000 patients are admitted to hospitals each
year for treatment of burn injury. The authors write that
the delivery of optimal burn care to these patients is a
resource-intensive endeavor requiring specialized equipment
and experienced personnel, and that these resources are
typically available only at dedicated burn centers. They add
that timely access to a burn center may benefit patients.
The current distribution of burn centers relative to
geographic area and population is unknown, according to
background information in the article.
Matthew B. Klein, M.D., M.S., of the University of
Washington, Seattle, and colleagues conducted a study to
estimate the proportion of the U.S. population living within
1 and 2 hours by ground or helicopter transport of a burn
care facility, evaluating state, regional, and national
access. The researchers compiled and analyzed information
from the 2000 U.S. census, road and speed limit data, the
Atlas and Database of Air Medical Services database, and the
2008 American Burn Association Directory.
The researchers found that in the U.S. in 2008, there were
128 self-reported burn centers, including 51 verified burn
centers (verified by the American Burn Association, in which
the quality of burn care provided at a center is assessed
and confirmed). A total of 782 helipads and 804 helicopters
served these centers. Nationally, about 25 percent of the
U.S. population lived within 1 hour by ground transport of a
verified center; 46.3 percent lived within 2 hours; and 67.7
percent lived within 4 hours by ground transport of a
verified burn center.
"By air transport [helicopter], 53.9 percent and 79.0
percent of the population lived within 1 and 2 hours,
respectively, of a verified center, and 75.3 percent lived
within 1 hour and more than 96.4 percent lived within 2
hours of any self-reported center," the authors write. They
add that one-third of the U.S. population must be
transported by air to reach a verified burn care center
within 2 hours.
The researchers also found that there was significant
regional variation in access to verified burn centers by
both ground and rotary air transport. "The greatest
proportion of the population with access was highest in the
northeast region and lowest in the southern United States,"
they write.
"The variation in baseline geographic access rates found in
this study may be an influential predictor of optimal
regionalization strategy. For states and regions with a
relatively high baseline rate of access, the best strategy
for improving access and reducing time to definitive care
may involve optimization of air and ground emergency medical
service systems. For states and regions with a relatively
low baseline rate of access, the best strategy may involve
construction or verification of new regional burn care
facilities."
"While the optimal distribution of burn centers relative to
population and area remains to be determined, these data
provide important information about population access that
may be used to guide resource allocation in burn care," the
authors conclude.
1103 Patients starting
dialysis have increased risk of death [Leiden, the
Netherlands]--Compared to the general population,
patients starting dialysis have an increased risk of death
that is not attributable to a higher rate of death from
cardiovascular causes, as previously thought, according to a
study in the October 28 issue of JAMA.
Several studies have shown that cardiovascular disease
accounts for 40 percent to 50 percent of deaths in patients
with end-stage kidney disease, according to background
information in the article. "It is believed that the life
span of patients receiving dialysis is reduced mainly as a
consequence of premature cardiovascular death," the authors
write.
Dinanda J. de Jager, M.Sc., of the Leiden University Medical
Center, Leiden, the Netherlands, and colleagues estimated
cardiovascular and noncardiovascular rates of death in a
large group of European patients receiving dialysis (n =
123,407) and compared these estimates with mortality data
from the general European population, using data from
between January 1994 and January 2007.
The researchers found that among the patients receiving
dialysis, noncardiovascular death was the most prevalent
cause of death (50.8 percent), and 39.1 percent died because
of cardiovascular disease. The most common causes of
noncardiovascular death were infections and malignancies. In
the general population, 10,183,322 persons (58.4 percent)
died from noncardiovascular causes, 7,041,747 (40.4 percent)
from cardiovascular causes, and 201,050 (1.2 percent) from
unknown causes.
Analysis indicated that the overall all-cause mortality rate
was higher in patients starting dialysis than in the general
population. "In particular, noncardiovascular mortality
rates were higher than cardiovascular mortality rates in
patients starting dialysis," the authors write. "These
results suggest that excess mortality in patients receiving
dialysis is not specifically the result of increased
cardiovascular deaths."
"In summary, the present study shows that cardiovascular and
noncardiovascular mortality are equally increased during the
first 3 years of dialysis, compared with the general
population. This implies that the importance of
noncardiovascular mortality in patients receiving dialysis
has generally been underestimated. Therefore, research
should focus more on methods to prevent noncardiovascular
mortality," the researchers conclude.
1030 Risk of serious
flu-related sickness far outpaces risk of injectable vaccine
in pregnant women [Baltimore MD]--Pregnant women
who catch the flu are at serious risk for flu-related
complications, including death, and that risk far outweighs
the risk of possible side effects from injectable vaccines
containing killed virus, according to an extensive review of
published research and data from previous flu seasons.
The review, a collaboration among scientists from the Johns
Hopkins Children's Center, Emory University and Cincinnati
Children's Hospital, and published online Oct. 22 in the
American Journal of Obstetrics & Gynecology, found
substantial and persistent evidence of high complication
risk among pregnant women -- both healthy ones and those
with underlying medical conditions -- infected with the flu
virus, while confirming vaccine safety. The findings,
researchers say, solidify existing CDC recommendations that
make pregnant women the highest-priority group to receive
both the H1N1 and seasonal flu vaccines.
"The lessons learned from flu outbreaks in the distant and
not-too-distant past are clear and so are the messages,"
says lead investigator Pranita Tamma, M.D., an infectious
disease specialist at the Johns Hopkins Children's Center.
"If you are an expectant mother, get vaccinated. If you are
a physician caring for pregnant women, urge your patients to
get vaccinated."
Because even healthy pregnant women end up in the hospital
with preventable flu complications -- some devastating and
some fatal -- at a rate far higher than that of other
adults, and because of the proven effectiveness and overall
safety record of flu vaccines, all pregnant women should
consider getting vaccinated to prevent complications in both
the expectant mother and her offspring, researchers say.
"Healthcare providers will play a key role in women's
decisions about whether or not to be vaccinated against
H1N1," says study senior investigator Saad Omer, M.B.B.S.,
M.P.H. Ph.D., of Emory University. "There is substantial
evidence that vaccination is not only safe for pregnant
women but that it is critical for protecting women and their
infants against serious complications from the flu.
Physicians and other providers should talk about risks and
benefits with their patients and help alleviate any
unfounded fears."
Even though there are still no published data on the safety
of the new H1N1 vaccine, experts believe it to be just as
safe as the seasonal flu vaccine, Johns Hopkins' Tamma says,
because "the H1N1 vaccine is manufactured in the same
rigorous way as the seasonal flu vaccines and we expect it
to have a very similar safety profile as the other flu
vaccines."
In their extensive review of data from three past flu
pandemics and 11 published research studies on vaccine
safety outcomes over 44 years, the researchers found no
increased risk of either maternal complications or bad fetal
results from the inactivated (injection) flu vaccine.
Researchers point out that even though study after study has
found no link between the vaccine stabilizer thimerosal and
autism, thimerosal-free injectable versions of the flu
vaccine are available for those who have lingering concerns.
In their review, researchers say four studies have found
evidence that antibodies protective against the flu,
developed by the mother after vaccination, cross the
placenta and transfer some protection to the fetus that
lasts up to six months after birth.
Because pregnancy causes a variety of changes in the body,
most notably decreased lung capacity, along with increased
cardiac output and oxygen consumption, it puts pregnant
women at high risk for complications. In addition, parts of
the mother's immune system are selectively suppressed, a
process that offers essential protection to the fetus, but
decreases the mother's ability to fight off infection.
Other findings in the review:
* In the first four months of the H1N1 flu outbreak this
spring, pregnant women were hospitalized at four times the
rate of other healthy adults infected with the virus,
according to the CDC.
* Pregnant women made up 13 percent of all H1N1 deaths
during that period, and most of the women who died were
previously healthy.
* Pregnant women do not get infected with the flu more often
than other adults, but they develop more serious
complications and more often. Pregnant women with underlying
conditions such as asthma or diabetes are at even higher
risk for complications.
* During the 1918 Spanish flu pandemic, of the 1,350
flu-infected pregnant women who were studied, half developed
pneumonia, and more than half of those who did so died, with
most deaths occurring during the third trimester.
* During the 1957 pandemic, nearly half of all women of
childbearing age who died of the flu were pregnant.
* Eleven clinical studies closely followed pregnant women
and/or their fetuses after vaccination and found no evidence
of harmful side effects in either the mother or the fetus.
* The Vaccine Adverse Event Reporting System database, a
national repository of self-reports of adverse vaccine
effects, showed 26 reports of adverse effects between 2000
and 2003, a period during which 2 million pregnant women
were vaccinated against the flu. Of the 26 reports, six had
to do with wrongly administered vaccine without any negative
consequences; nine reports described brief injection site
tenderness; eight involved systemic symptoms, such as
malaise and fever; and three were miscarriages.
Investigators point out that these are self-reported events
and do not establish any evidence of cause and effect either
with respect to either miscarriage or side effects.
The research was funded partially by an NIH fellowship
training grant to Pranita Tamma. Co-investigator Neal
Halsey, M.D., of Johns Hopkins, receives grant support from
NIH, CDC, Berna, Intercel, Merck and Novartis, none of which
went toward this particular research.
Other investigators in the study include Kevin Ault, M.D.,
and Carlos Del Rio, M.D., of Emory University; and Mark
Steinhoff, M.D., of Cincinnati Children's Hospital.
1030 Pandemic flu
vaccine campaigns may be undermined by coincidental medical
events [Cincinnati OH]--The effectiveness of
pandemic flu vaccination campaigns – like that now underway
for H1N1 – could be undermined by the public incorrectly
associating coincidental and unrelated health events with
the vaccines.
This is the conclusion of a paper published online Oct. 31
by the Lancet and authored by an international team of
investigators led by Cincinnati Children's Hospital Medical
Center.
"Regardless of whether someone gets the vaccine, bad things
happen to people every day and generally occur at fairly
predictable rates," said Steven Black, M.D., lead author and
a physician in the Center for Global Health and Division of
Infectious Diseases at Cincinnati Children's. "Identifying
real safety concerns with new vaccines means we have to
untangle actual safety signals from background medical
events, which are those that would happen without
vaccination."
The team of investigators from 13 global medical
institutions and health agencies reviewed medical data from
prior studies and from hospital databases to identify
background rates of health events that occurred without any
vaccine. Their review showed the rates of adverse events
varied by year, country, age and sex of the population.
The problem the authors identified is that public concern
regarding medical events can interfere with important
vaccine programs, even if the vaccine is not the cause. One
example they cited is the interruption of a 2006 seasonal
influenza campaign in Israel, where four deaths occurred
within 24 hours of immunization. The clustering of
fatalities and close timing of vaccination resulted in
global news coverage, public trepidation and compromised the
inoculation campaign.
In actuality, the four patients who died all were in a group
already at high risk for sudden death from age and
underlying medical conditions. Their deaths were consistent
with a cardiac cause of death, and the number of deaths was
lower than would be expected normally for such a high risk
population. Further analysis of the fatalities in Israel
showed death normally occurs in this high risk group at a
rate greater than one per 1,000 individuals in the same time
period. Based on this, the researchers said 20 coincidental
deaths among that group could be expected to occur by chance
within 24 hours of an immunization.
The authors also revisited one of the concerns raised during
the 1976-77 swine flu vaccination program. The vaccine in
that campaign was associated with an increased number of
Guillian-Barre Syndrome cases, in which the body's immune
system mistakenly attacks part of the nervous system.
Guillian-Barre normally affects about one out of every
100,000 people a year. Based on this Guillian-Barre
background rate, if 100 million people in the United States
are inoculated in a pandemic flu vaccination campaign, the
researchers said one would expect 215 new cases of the
disease within six weeks of vaccine. These cases would be
expected to occur whether or not the vaccine had been given.
"The reporting of even a fraction of such a large number of
case as adverse events following immunization, with
attendant media coverage, would likely give rise to high
levels public concern, even though the occurrence of such
cases was completely predictable and would have happened in
the absence of a mass campaign," according to the paper.
To help address these concerns, the U.S. Centers for Disease
Control and Prevention (CDC) and other health agencies have
been creating systems to gather and accurately assess data
on background health events when evaluating vaccine safety.
The current paper presents some new data but also puts
existing data into context for the public, said Dr. Black,
who also serves as a pandemic flu vaccine safety consultant
to the National Vaccine Program Office at the Department of
Health and Human Services.
"In the heat of the moment of a pandemic vaccination
campaign, the public isn't good at evaluating comparative
risk or realizing that obviously some people die or develop
serious illnesses every day," Dr. Black said. "By putting
background rate data into proper context, we want to help
people make an informed decision about pandemic flu
vaccinations."
Also contributing to the research article were: the National
Institute of Health and Welfare, Helsinki, Finland; the
Center for Vaccinology and Neonatal Immunology, Department
of Pediatrics, University of Geneva, Geneva, Switzerland;
Institute for Vaccine Safety, Department of International
Health, Johns Hopkins Bloomberg School of Public Health,
Baltimore; Division of Infectious Diseases, Department of
Pediatrics, Dalhousie University, Halifax, Nova Scotia,
Canada; Vaccine Safety Section, Centre for Immunization and
Respiratory Infectious Diseases, Public Health Agency of
Canada; Health Protection Agency, Centre for Infections,
United Kingdom; National Vaccine Program Office, U.S.
Department of Health and Human Services; Center for
Biologics Evaluation and Research, U.S. Food and Drug
Administration; Discipline of Paediatrics, School of
Paediatrics and Reproductive Health, University of Adelaide,
Australia; Department of Pediatrics, Faculty of Medicine
University of Sao Paulo, Brazil; Quality, Safety and
Standards Team, World Health Organization; Immunization
Safety Office (CDC).
1030 Patients in US
five times more likely to spend last days in ICU than
patients in England [Columbia University]--Patients
who die in the hospital in the United States are almost five
times as likely to have spent part of their last hospital
stay in the ICU than patients in England. What's more, over
the age of 85, ICU usage among terminal patients is eight
times higher in the U.S. than in England, according to new
research from Columbia University that compared the two
countries' use of intensive care services during final
hospitalizations.
"Evaluating the use of intensive care services is
particularly important because it is costly, resource
intensive, and often traumatic for patients and families,
especially for those at the end of life" said Hannah Wunsch,
M.D., M.Sc., assistant professor of anesthesiology and
critical care medicine, of Columbia University, lead author
of the study. "We found far greater use of intensive care
services in the United States during terminal
hospitalizations, especially among medical patients and the
elderly."
Their findings were published in the November 1 issue of the
American Journal of Respiratory and Critical Care Medicine,
published by the American Thoracic Society.
Dr. Wunsch and colleagues wanted to examine the differences
in ICU usage in England and the U.S., because the countries'
similar life expectancies and population demographics
enabled a comparison of fundamentally different healthcare
systems.
England has one-sixth the number of intensive care beds
available per capita that are available in the U.S.
Furthermore, medical decisions in England are generally
considered to be the direct responsibility of the physician,
rather than that of the patient or the patient's surrogate
decision-maker(s) as it is in the U.S.
"In England, there is universal health care through the
National Health Service, and there is also much lower
per-capita expenditure on intensive care services when
compared to the U.S.," said Dr. Wunsch. "The use of
intensive care in England is limited by supply to a greater
degree than it is in the U.S., and there are consequently
implicit and explicit decisions regarding who gets those
limited services. We wished to examine what different
decisions are made."
Dr. Wunsch and colleagues examined data from the Hospital
Episodes Statistics database (in England) and all hospital
discharge databases of seven states (FL, MA, NJ, NY, TX, VA,
WA) in the U.S. They found that of all hospital discharges,
only 2.2 percent in England received intensive care,
compared to 19.3 percent in the U.S.
They also found that hospital mortality among those who
received intensive care was almost three times higher in
England than in the U.S. (19.6 percent vs. 7.4 percent). But
when examining deaths overall, only 10.6 of hospital deaths
in England involved the ICU, whereas 47.1 in the U.S. did.
Of those over 85, only 1.3 percent received ICU care in
England vs. 11 percent in the U.S. But young adults and
children received ICU services at similar rates in both
countries. "These numbers need to be interpreted with
caution," explains Dr. Wunsch, "as the differences in
mortality for ICU patients likely reflect the higher
severity of illness of patients admitted in the first place
in England. The data do bring up the interesting question of
how much intensive care is beneficial. Doing more may not
always be better."
While these findings highlight important differences within
the two countries' use of intensive care services, the
research was not designed to determine the direct impact of
these differences. Past surveys have suggested that the
majority of people would prefer not to die in the hospital,
but given that so many do, questions about use of intensive
interventions remain.
"Whether less intensive care for very elderly patients who
are dying is a form of rationing, or is actually better
recognition of what constitutes appropriate care at the end
of life warrants further research," said Dr. Wunsch. "These
findings highlight the urgent need to understand whether
there is over-use of intensive care in the U.S., or
under-use in England."
Furthermore, future research must further investigate not
just the origins, but the implications of these differences.
"Faced with a provocative finding of cross-national
difference, the scientific community faces a choice between
at least two paths," wrote Theodore Iwashyna, M.D., Ph.D.,
and Julia Lynch, Ph.D., in an editorial in the same issue of
the journal. "One path leads to carefully unpacking the
origins of this difference and teaching us something
generally true about how critical care systems develop. The
other path leads into the hospitals, using observational
data to imagine new ways to organize care and generate the
equipoise necessary for careful interventional studies of
such interventions. The first path helps us shape national
policy levers. The latter path helps us redesign care
organizations to bring change to patients. Both are
necessary."
1030 Important new
novel 2009 H1N1 flu advisory for cardiopulmonary
transplantation [New York NY]--Each year 3-5
million people have severe cases and 250-500,000 die from
complications of seasonal influenza world-wide. This year,
the novel 2009 H1N1 (nH1N1) influenza, previously called
swine flu, has reached pandemic status. Since novel 2009
H1N1 is a viral infection of the respiratory tract, there
are additional challenges for cardiopulmonary transplant
recipients and donors, as well as for the healthcare workers
involved in the transplant process. In an article published
online today in the Journal of Heart and Lung
Transplantation, physicians representing the International
Society for Heart & Lung Transplantation (ISHLT) Infectious
Disease Council issue an advisory for all programs in
cardiothoracic transplantation.
Mandeep R. Mehra, MBBS, FACC, FACP, Editor-in-Chief, the
Journal of Heart and Lung Transplantation observes, "Nowhere
is the threat of H1N1 more real than in cardiopulmonary
transplantation. The ISHLT's Infectious Disease Council has
developed what is assuredly the most comprehensive and
clinically relevant direction for prevention and management
of H1N1 flu in donors, recipients, care providers and family
members."
Recognition of the novel 2009 H1N1 influenza virus,
aggressive diagnosis and early treatment need be paired with
active preventative measures to stem the impact of infection
in the transplant population. This special advisory
addresses issues relevant to cardiothoracic transplant
candidates, selection of donors, recipient management and
patients with mechanical circulatory support devices. Since
transplant recipients are treated with anti-rejection drugs,
the advisory provides clear directions for specific dosing
of antiviral drugs and management of the background
immunosuppression. Specific guidelines for evaluation and
management of post-surgical transplant patients are also
given, as well as recommendations for how and when to
administer vaccines. On the donor side, the advisory
provides guidelines for how to evaluate and treat donors so
that organs can be safely used and not wasted. Finally, it
provides specific guidelines for the healthcare teams
managing such patients.
Writing in the article, Lara A. Danziger-Isakov MD MPH,
Cleveland Clinic Children's Hospital, states, "Interaction
with organ procurement organizations for organ selection
must take into account emerging data on the use of organs
from patients infected and treated for the novel 2009 H1N1
Influenza virus. Improved diagnostic testing with shorter
turnaround times is needed in donor evaluation. Individual
patient education, prevention measures and treatment
strategies will also require attention to the local patterns
of infection, availability of the novel 2009 H1N1 Influenza
virus vaccination, and emerging patterns of antiviral
resistance. Finally, efforts to contain and prevent the
novel 2009 H1N1 Influenza virus from spreading within the
cardiothoracic transplant setting can be accomplished
through infection control measures."
"This article is an initiative of the Infectious Disease
(ID) council of ISHLT to provide timely practical guidance
for cardiothoracic transplant programs facing a winter
pandemic of novel 2009 H1N1 influenza," comments Dr Margaret
M Hannan, Mater Misericordiae University Hospital, Dublin,
Chairman of ID council for ISHLT. "Evolving diagnostic
testing with limitations due to prolonged turnaround time
and availability are considered in donor and recipient
management. Ensuring that the most accurate diagnostic tests
are being carried out in a timely and systematic manner will
allow cardiothoracic transplant surgeons to make informed
decisions in 'real time' and avoid waste of usable organs."
Education of staff and patients in infection control and
prevention is fundamental to successful management of this
virus in the transplant recipient population.
The article is "The Novel 2009 H1N1 Influenza Virus
Pandemic: Unique Considerations for Programs in
Cardiothoracic Transplantation" by Lara A. Danziger-Isakov
MD MPH, Shahid Husain MD MS , Martha L. Mooney MD FACP,
Margaret M. Hannan MD for the ISHLT Infectious Diseases
Council. DOI 10.1016/j.healun.2009.10.001. Following advance
online publication on October 23, 2009, the article will
appear in the Journal of Heart and Lung Transplantation,
Volume 28, Issue 12 (December 2009) published by Elsevier.
1030 Boys with
urogenital birth defects are 33 percent more common in
villages sprayed with DDT [University of Pretoria]--Women
who lived in villages sprayed with DDT to reduce malaria
gave birth to 33 per cent more baby boys with urogenital
birth defects (UGBD) between 2004 and 2006 than women in
unsprayed villages, according to research published online
by the UK-based urology journal BJUI.
And women who stayed at home in sprayed villages, rather
than being a student or working, had 41 per cent more baby
boys with UGBDs, such as missing testicles or problems with
their urethra or penis.
The authors suggest that this is because they spent more
time in homes where domestic DDT-based sprays are still
commonly used to kill the mosquitos that cause malaria, even
in areas where organised mass spraying no longer takes
place.
Researchers led by the University of Pretoria in South
Africa studied 3,310 boys born to women from the Limpopo
Province, where DDT spraying was carried out in high-risk
areas between 1995 and 2003 to control malaria. The study
compared boys born to women in the 109 villages that were
sprayed, with those born to women from the 97 villages that
were not.
This showed that 357 of the boys included in the study –
just under 11 per cent – had UGBDs. The incidence of UGBDs
was significantly higher if the mother came from a sprayed
village.
"If women are exposed to DDT, either through their diet or
through the environment they live in, this can cause the
chemical to build up in their body" explains lead author
Professor Riana Bornman from the University's Department of
Urology.
"DDT can cross the placenta and be present in breast milk
and studies have shown that the residual concentration in
the baby's umbilical cord are very similar to those in
maternal blood.
"It has been estimated that if DDT exposure were to cease
completely, it would still take ten to 20 years for an
individual who had been exposed to the chemical to be clear
of it. Our study was carried out on boys born between 2004
and 2006, five to nine years after official records showed
that their mothers had been exposed to spraying.
"Records were not kept before 1995 in the Limpopo Province,
but it is reasonable to assume that DDT was being used
before that date to combat malaria.
"Although most countries have now banned the use of DDT,
certain endemic malarial areas still use indoor residual
spraying with DDT to decrease the incidence and spread of
the disease, which is caused by mosquitoes."
The two-year study included 2,396 boys whose mothers had
been exposed to DDT and 914 whose mothers had not.
A number of other factors were taken into account to rule
out possible causes of the birth defects. These included
smoking and drinking, the mother's age, how long she had
lived in her village and her race. These all proved
statistically insignificant.
The authors believe that their study highlights the
importance of educating people in high-risk malaria areas
about the dangers of DDT.
"The use of DDT has contributed to the success in reducing
malarial transmission and malarial deaths in South and
Southern Africa" says Professor Bornman.
"However, the present findings also strongly suggest that
indoor residual spraying with DDT is associated with UGBDs
in newborn boys.
"With global concerns about the effect of chemicals on
health, and the possibility of malaria resurgence and spread
as a result of climate change, all authorities should ensure
that the general public, including those living under indoor
residual spraying conditions, are aware of the possible
health risks.
"Educating people living in the DDT-sprayed communities
about ways of protecting themselves from undue DDT exposure
needs to be carried out as a matter of extreme urgency.
"There must be long-term monitoring of possible
environmental and human health impacts, particularly in
those areas where DDT will be introduced as part of the
fight against malaria.
"We are now carrying out further research to find out how
indoor spraying using DDT-based products affects humans and
how this risk can be reduced."
DDT and urogenital malformations in newborn boys in a
malarial area. Bornman et al. BJUI. Online publication 23
October 2009. doi: 10.1111/j.1464-410X.2009.09003.x
1030 Despite risk,
older African Americans more likely than others to avoid flu
vax [Buffalo NY]--A study about why African
American seniors do or do not get influenza vaccinations
finds that many of them do not have accurate and complete
information about the flu itself, the safety and efficacy of
the inoculations, and the ease and necessity of getting the
shots.
Co-author and health communications specialist Lance
Rintamaki, PhD, assistant professor of communication at the
University at Buffalo, says that in addition, misinformation
about the notorious 1932-72 Tuskegee syphilis studies of
African-American men may result in a lingering distrust of
some public health inoculation programs.
The study was published in Health Communications.
It notes that, despite the risk of influenza-related medical
complications among those 65 years and over, African
American seniors are less likely to be vaccinated against
flu than are non-Hispanic white seniors.
Rintamaki points out that, although the U.S. Department of
Health and Human Services wants to have 90 percent of
seniors vaccinated, the vaccination rates for American
adults 65 years and over averages 65 percent -- but is only
48 percent among older African Americans.
This is of great concern in the medical community, he says,
because 44,000 Americans 65 and older die from influenza and
its complications every year, compared to a total of 7,000
flu-related deaths in all other age groups.
According to Rintamaki, the researchers found several
reasons for the reluctance of African American seniors to
get flu shots.
"One," he says, is that study subjects did not understand
how often they need to be vaccinated. Some seniors thought
that, like vaccines against common childhood illnesses, the
flu vaccine provided lifelong protection against the flu.
Many did not know they needed to be re-vaccinated every
year.
"The participants knew there are different strains of
influenza," he says, "but they didn't realize they needed to
be vaccinated against each strain as it turned up.
"Some also thought -- as do many members of the public --
that the vaccines cause the flu. If they became sick with a
virus of one kind or other around the time they had a flu
shot," he says, "they drew the erroneous conclusion that the
shot made them sick.
"This is a common misperception and one that needs to be
corrected," Rintamaki adds. "We often tell people the
vaccine doesn't 'cause' flu but in failing to address why
they might assume that it does, we leave the door open for
them to think they are avoiding illness by avoiding the
vaccine."
The researchers say better and more targeted messages and
interventions are necessary to address concerns specific to
older African Americans and to emphasize how important it is
for those in this age group to be vaccinated.
The study involved six focus groups of African American
seniors in the Chicago area. Their average age was 75 and 85
percent of them were women. They were asked to identify
their current perceptions about influenza and influenza
vaccination.
Seventy-seven percent of participants said they had received
the flu vaccine at some time in their life, but only 50
percent had been vaccinated the previous year.
Despite the group size and the fact that their responses
cannot be projected to the community as a whole, the authors
say the results of the study confirm those conducted by the
Centers for Disease Control and Prevention and others.
Some disturbing news to emerge from the study, says
Rintamaki, is that the infamous Tuskegee syphilis
experiments continue to affect levels of trust among African
Americans toward public health programs.
The Tuskegee experiments, whose original goal was to justify
treatment programs for blacks, involved 399 African American
sharecroppers infected with syphilis. In 1932, when the
study began, the available treatments were highly toxic and
of limited effectiveness. The study aimed to determine if
patients were better off if they were not treated with those
remedies. The researchers also wanted to study the efficacy
of specific remedies for individual stages of the disease.
By 1947, penicillin was commonly used as an effective cure
for the disease. The researchers, however, failed to treat
study participants with the medication. As a result, many
men died of syphilis, wives contracted it from husbands and
children were born with congenital syphilis. The study was
not discontinued until news of this fact emerged, causing a
public uproar.
Rintamaki points out that although the some of the seniors
interviewed were not familiar with these experiments, those
who were thought that the Tuskegee researchers did more than
withhold treatment. They thought they actually injected the
men with syphilis.
"The Tuskegee experiments have stirred fear and suspicion in
the African American community over many health
initiatives," he says, "and the suspicion they spawned has a
continuing negative effect on the health of that community.
"In fighting the flu by encouraging inoculation, it is
imperative that as health communicators we recognize that
such fears exist and address such them," he says.
In addition to Rintamaki, the research team included Kenzie
A. Cameron, PhD, research assistant professor, Division of
General Internal Medicine, Feinberg School of Medicine
Northwestern University; Mafo Kamanda-Kosseh, clinical
coordinator, Center for Interventional Vascular Therapy,
Columbia University Medical Center; Gary A. Noskin, MD,
associate professor of medicine, Feinberg School of
Medicine, Northwestern University; David W. Baker, MD,
professor of medicine and chief of the division of general
internal medicine, Feinberg School of Medicine, Northwestern
University, and Gregory Makoul, PhD, vice president for
academic affairs, St. Francis Hospital and Medical Center.
1029 NIAID scientists
propose new explanation for flu virus antigenic drift
[Bethesda MD]--Influenza viruses evade
infection-fighting antibodies by constantly changing the
shape of their major surface protein. This shape-shifting,
called antigenic drift, is why influenza vaccines — which
are designed to elicit antibodies matched to each year's
circulating virus strains — must be reformulated annually.
Now, researchers from the National Institute of Allergy and
Infectious Diseases (NIAID), part of the National Institutes
of Health, have proposed a new explanation for the
evolutionary forces that drive antigenic drift. The findings
in mice, using a strain of seasonal influenza virus first
isolated in 1934, also suggest that antigenic drift might be
slowed by increasing the number of children vaccinated
against influenza.
Scott Hensley, Ph.D., Jonathan W. Yewdell, M.D., Ph.D., and
Jack R. Bennink, Ph.D., led the research team, whose
findings appear in the current issue of Science.
"This research elegantly combines modern genetic techniques
with decades-old approaches to give us new insights into the
mechanisms of antigenic drift and how influenza viruses
elude the immune system," says NIAID Director Anthony S.
Fauci, M.D."
"No one is sure exactly how the antigenic drift of flu
viruses happens in people," says Dr. Yewdell. According to
the prevailing theory, drift occurs as the virus is passed
from person to person and is exposed to differing antibody
attacks at each stop. With varying success, antibodies
recognize one or more of the four antigenic regions in
hemagglutinin, the major outer coat protein of the flu
virus. Antibodies in person A, for example, may mount an
attack in which antibodies focus on a single antigenic
region. Mutant viruses that arise in person A can escape
antibodies by replacing one critical amino acid in this
antigen region. These mutant viruses survive, multiply and
are passed to person B, where the process is repeated.
It is not possible to dissect the mechanism of antigenic
drift in people directly, notes Dr. Yewdell. So he and his
colleagues turned to a classic mouse model system developed
in the mid-1950s at the University of Chicago, but used
rarely since. The team infected mice with a strain of
seasonal influenza virus that had circulated in Puerto Rico
in 1934. Some mice were first vaccinated against this virus
strain and developed antibodies against it, while others
were unvaccinated.
After infecting the vaccinated and unvaccinated mice with
the 1934 influenza strain, the scientists isolated virus
from the lungs of both sets of mice and passed on these
viruses to a new set of mice. They did this nine times.
After the final passage, the researchers sequenced the gene
encoding the virus hemagglutinin protein. Of course, says
Dr. Yewdell, gene sequencing was not possible in the
mid-1950s, when the nature of the gene was first elucidated,
and until very recently, sequencing was expensive and
time-consuming. "Now, with automated gene sequencers,
sequencing of dozens of isolates is easily done overnight,"
he says.
Sequencing revealed that the unvaccinated mice — which
lacked vaccine-induced antibodies — had no mutated influenza
viruses in their lungs. In contrast, the hemagglutinin gene
in virus isolated from vaccinated mice had mutated in a way
that increased the ability of the virus to adhere to the
receptors it uses to enter lung cells. Essentially, says Dr.
Yewdell, the virus can shield its hemagglutinin antigenic
sites from antibody attack by binding more tightly to its
receptor.
"The virus must strike the right balance, however," Dr.
Yewdell says. "Excessively sticky viruses may end up binding
to cells lining the nose or throat or to blood cells and may
not make it into lung cells. Also, newly formed viruses must
detach from infected cells before they can spread to the
next uninfected cell. Viruses that have mutated to be highly
adherent to the lung cell receptors may have difficulty
completing this critical step in the infection cycle."
Next, the researchers infected a new set of unvaccinated
mice with the high-affinity mutant virus strain that had
emerged in the first series of experiments. In the absence
of antibody pressure, the virus reverted to a low-affinity
form and was once again able to easily infect cells and
spread.
"We propose a model for antigenic drift in which high- and
low-affinity influenza virus mutants alternate," says Dr.
Yewdell. In adults — who have been exposed to many strains
of influenza in their lifetime and, correspondingly, have a
wide range of antibody responses — the virus is pressured to
increase its receptor affinity to escape antibody
neutralization. When such high-affinity mutants are passed
to people — such as children — who have not been exposed to
many influenza strains or who have not been vaccinated
against flu, receptor affinity decreases. People who have
not been exposed to multiple influenza virus strains or who
have never been vaccinated against influenza are said to be
immunologically naïve.
"Our model predicts that decreasing the immunologically
naïve population — by increasing the number of children
vaccinated against influenza, for example — could slow the
rate of antigenic drift and extend the duration of
effectiveness of seasonal influenza vaccines," he says.
1027 Older patients
with dementia at increased risk for flu mortality [Boston
MA]--An epidemiological study on pneumonia and
influenza (P&I) in adults age 65 and over reports that
patients with dementia are diagnosed with flu less
frequently, have shorter hospital stays, and have a fifty
percent higher rate of death than those without dementia.
The three-pronged study, which analyzed geographic and
demographic patterns of P&I and the relationship between P&I
and health care accessibility, was published online in
advance of print in Journal of the American Geriatrics
Society.
“The increased mortality of older patients with dementia
hospitalized for flu may be indicative of inadequacies in
health care quality and accessibility. It could be
beneficial to refine guidelines for the immunization,
testing, and treatment of flu in older patients with
dementia when planning for the possibility of a flu
pandemic,” said first and senior author Elena Naumova, PhD,
professor of public health and community medicine at Tufts
University School of Medicine.
Dementia, defined by the authors as cognitive impairment to
the extent that normal activity is impaired, causes unique
obstacles to the early diagnosis and treatment of flu.
Patients may have difficulty communicating symptoms and
medical complications due to poor oral hygiene or impaired
swallowing. Additionally, the authors believe that limited
access to health care services and inadequate testing
practices may contribute to the higher rates of mortality
and lower rates of diagnosis of flu seen in older patients
with dementia. A geographic analysis of the data showed that
P&I rates were highest among older adults in poor and rural
areas, where there is a lower concentration of health care
facilities.
“Limited access to specialized health care services can
delay diagnosis and treatment of the flu, causing it to
progress to pneumonia, the fifth leading cause of death
among the elderly. This study has helped us identify this
vulnerable population, and now further study is needed to
confirm the findings and assess the testing and vaccination
policies for older patients with dementia,” said Naumova.
Study data were obtained from the Centers for Medicaid and
Medicare Services (CMS), and covered a span of five years,
from 1998 to 2002. Of the 36 million hospitalization records
for adults aged 65 and older, more than six million records
documented a P&I diagnosis. Of these records showing a P&I
diagnosis, over 800,000 (13%) also showed dementia. The
demographic and geographic patterns of P&I hospitalizations
and their links with hospital accessibility were explored.
Pneumonia and influenza admissions, length of stay in a
hospital, and mortality rates among elderly with dementia
were compared to national estimates.
Elena Naumova is the director of the Tufts University
Initiative for the Forecasting and Modeling of Infectious
Diseases (Tufts InForMID), which works to improve biomedical
research by developing computational tools in order to
assist life science researchers, public health
professionals, and policy makers. The center is focused on
developing methodology for analysis of large databases to
enhance disease surveillance, exposure assessment, and
studies of aging.
Co-authors include Sara M. Parisi and Julia Wenger, now
graduates of the Master of Public Health program at Tufts
University School of Medicine; Denise Castronovo, MS,
Mapping Sustainability, LLC; Manisha Pandita, former
research assistant in the department of public health and
community medicine at Tufts University School of Medicine;
and Paula Minihan, PhD, assistant professor of public health
and community medicine, Tufts University School of Medicine.
This study was funded by the National Institute of Allergy
and Infectious Diseases and the National Institute of
Environmental Health Sciences, both part of the National
Institutes of Health.
Naumova EN, Parisi SM, Castronovo D, Pandita M, Wenger J,
and Minihan P. Journal of the American Geriatrics Society.
“Pneumonia and influenza hospitalizations in elderly people
with dementia.” Published online in advance of print,
October 26, 2009, doi: 10.1111/j.1532-5415.2009.02565.x.
1026 Latest analysis
confirms suboptimal vitamin D levels in millions of US
children [Boston MA]--Millions of children in the
United States between the ages of 1 and 11 may suffer from
suboptimal levels of vitamin D, according to a large
nationally representative study published in the November
issue of Pediatrics, accompanied by an editorial.
The study, led by Jonathan Mansbach, MD, at Children's
Hospital Boston, is the most up-to-date analysis of vitamin
D levels in U.S. children. It builds on the growing evidence
that levels have fallen below what's considered healthy, and
that black and Hispanic children are at particularly high
risk.
Both the optimal amount of vitamin D supplementation and the
healthy blood level of vitamin D are under heated debate in
the medical community. Currently, the American Academy of
Pediatrics recommends children should have vitamin D levels
of at least 50 nmol/L (20 ng/ml). However, other studies in
adults suggest that vitamin D levels should be at least 75
nmol/L (30 ng/ml), and possibly 100 nmol/L (40 ng/ml), to
lower the risk of heart disease and specific cancers.
Mansbach and collaborators from the University of Colorado
Denver and Massachusetts General Hospital used data from the
National Health and Nutrition Examination Survey (NHANES) to
look at vitamin D levels in a nationally representative
sample of roughly 5,000 children from 2001-2006.
Extrapolating to the entire U.S. population, their analysis
suggests that roughly 20 percent of all children fell below
the recommended 50 nmol/L. Moreover, more than two-thirds of
all children had levels below 75 nmol/L, including 80
percent of Hispanic children and 92 percent of non-Hispanic
black children.
"If 75 nmol/L or higher is eventually demonstrated to be the
healthy normal level of vitamin D, then there is much more
vitamin D deficiency in the U.S. than people realize,"
Mansbach says.
Mansbach and his co-authors suggest that all children take
vitamin D supplements, because of the generally low levels
that they found and the potential health benefits of
boosting vitamin D to normal levels. Vitamin D improves bone
health and prevents rickets in children, and recent studies
suggest that it also may prevent a host of common childhood
illnesses, including respiratory infections, childhood
wheezing, and winter-related eczema.
Although sun exposure generates healthy doses of vitamin D,
it can also cause skin cancer. Dermatologists and the AAP
recommend wearing sunblock, but this actually blocks our
skin's ability to make vitamin D. Furthermore, children with
more highly pigmented skin require much more sun exposure
than fair-skinned children to obtain healthy levels of
vitamin D. Vitamin D can also be obtained from certain
foods, like liver and fatty fish, but almost all children in
the U.S. don't consume these foods in high enough quantities
to match the vitamin D that could be provided by summer
sunshine or vitamin D supplements.
In the study, children taking multi-vitamins that included
vitamin D had higher levels overall, but this accounted for
less than half of all children. Mansbach recommends that all
children take vitamin D supplements, especially those living
in high latitudes, where the sun is scarce in the
wintertime.
"We need to perform randomized controlled trials to
understand if vitamin D actually improves these wide-ranging
health outcomes," Mansbach says. "At present, however, there
are a lot of studies demonstrating associations between low
levels of vitamin D and poor health. Therefore, we believe
many U.S. children would likely benefit from more vitamin
D."
This research was funded by the National Institutes of
Health.
1026 Vast majority of
physicians satisfied with hospital chaplain services
[Chicago IL]--A national survey of physicians'
experience with hospital chaplains found that the vast
majority of doctors were satisfied with the spiritual
services provided. Physicians in the Northeast and those
with a dim view of religion's effects on patients, however,
were less likely to be pleased.
The results of the survey – the largest, most representative
survey of physicians' attitudes about religion and
spirituality conducted to date – are published in a research
letter in the October 26 issue of the Archives of Internal
Medicine. George Fitchett, PhD, a chaplain at Rush
University Medical Center, is the study's lead author.
"Religion and spirituality are important resources for
coping with serious illnesses, but research indicates that
patients' needs in this regard often go unmet," Fitchett
said. "That's why it is important to understand how
physicians view chaplains. Doctors play a crucial role in
ensuring that patients get access to this kind of care."
The study was based on data from a random sample of
physicians of all specialties selected from the American
Medical Association Physician Masterfile. The survey
response rate was 63 percent.
Of the 1,102 physicians whose responses were included in the
study, 89 percent had some experience with chaplains. Of
these physicians, 90 percent were satisfied or very
satisfied with chaplains' services.
Those who were satisfied tended to be physicians who worked
in teaching hospitals; practiced medical subspecialties,
such as cardiology or oncology, or other specialties, such
as emergency medicine or neurology; endorsed the notion that
religion and spirituality can have a good effect on
patients; and believed it was acceptable to pray with a
patient whenever the physician sensed it would be
appropriate.
Those physicians who believed that religion and spirituality
had a negative impact on patients were more likely to be
dissatisfied with chaplains' services.
The survey also found that physicians in the Midwest were
more likely to be satisfied with chaplains than physicians
in the Northeast. The finding was unexplained because of
limitations in the data collected.
Other researchers involved in the study were Kenneth
Rasinski, PhD, from the University of Chicago; Wendy Cadge,
PhD, from Brandeis University; and Dr. Farr Curlin, from the
University of Chicago.
1026 Heart attacks
become more common but less often fatal in women [USC]--Heart
attacks appear to have become more common in middle-aged
women over the past two decades, but all women and
especially those younger than 55 have recently experienced a
greater increase than men in their chances of survival
following such a heart event, according to two reports in
the October 26 issue of Archives of Internal Medicine, one
of the JAMA/Archives journals.
Middle-aged women have historically had a lower overall risk
of heart events and stroke than men of a similar age,
according to background information in one of the articles.
However, a recent report showing higher stroke rates among
women than men in a sample representative of the U.S.
population appeared to reveal a new phenomenon and raised
the question of whether heart disease or heart attack were
also becoming more prevalent among women.
Amytis Towfighi, M.D., of the University of Southern
California, Los Angeles, and colleagues analyzed data from
U.S. adults age 35 to 54 who participated in the National
Health and Nutrition Examination Surveys (nationally
representative surveys conducted by the government) during
1988 to 1994 (4,326 participants) and 1999 to 2004 (4,075
participants). The researchers assessed how often men and
women had heart attacks and also compared their Framingham
coronary risk score, a measurement of heart disease risk
over 10 years that includes factors such as age, cholesterol
levels, blood pressure and smoking history.
In both study periods, men age 35 to 54 years had more heart
attacks than women in the same age group. However, the gap
narrowed in more recent years as heart attacks decreased in
prevalence among men and increased in prevalence among women
(2.5 percent of men and 0.7 percent of women reported a
history of heart attack in 1988-1994, whereas 2.2 percent of
men and 1 percent of women did so in 1999-2004).
Between the two time periods, the average Framingham
coronary risk score showed an improving trend among men but
decreased among women. In male participants, total
cholesterol levels remained stable, high-density lipoprotein
(HDL or "good" cholesterol) levels and systolic (top number)
blood pressure levels improved and smoking levels declined.
The only risk factor that improved among women was HDL
levels. Diabetes prevalence increased among both men and
women, likely due to insulin resistance and the obesity
epidemic in both sexes.
"Although men in their midlife years continue to have a
higher prevalence of myocardial infarction and a higher
10-year risk of hard coronary heart disease than women of
similar age, our study suggests that the risk is increasing
in women, while decreasing in men," the authors write.
"Therefore, intensification of efforts at screening for and
treating vascular risk factors in women in their midlife
years may be warranted."
In another report, Viola Vaccarino, M.D., Ph.D., of Emory
University School of Medicine, Atlanta, and colleagues
investigated trends in the rate of in-hospital deaths
following heart attack from June 1, 1994, through Dec. 31,
2006. Data were collected from 916,380 patients through the
National Registry of Myocardial Infarction.
In-hospital death rates decreased among all patients between
1994 and 2006, but decreased more markedly in women than in
men. The reduced risk of death was largest in women younger
than 55 years (a 52.9 percent reduction) and lowest in men
of the same age (33.3 percent). The absolute decrease in the
risk of death among patients younger than 55 was three times
larger in women (2.7 percent) than men (0.9 percent).
"A large part (93 percent) of this sharper decrease in
mortality of younger women compared with men in recent years
was because the risk status of women on admission improved
compared with that of men," the authors write. "Such
improvement may be due to better recognition and management
of coronary heart disease and its risk factors in women
before the acute myocardial infarction event, as suggested
by the narrowing sex difference in previous
revascularization [surgical treatment for heart disease]."
Editorial: Prevention Is Key for Women and Heart Disease
"Cardiovascular illnesses have been long neglected in their
role as the primary cause of mortality in women, both by
patients and physicians," write Sabine Oertelt-Prigione,
M.D., and Vera Regitz-Zagrosek, M.D., Ph.D., of Charité
Universitaetsmedizin, Berlin, in an accompanying editorial.
"Men are still believed to be at greater risk for myocardial
infarction and stroke and are thus more aggressively
informed, counseled and treated for these diseases."
"The improvements described by Towfighi et al and Vaccarino
et al are encouraging and indicate that we are on the right
track. However, much needs to be done, especially in
consideration of the increase in prevalence of risk factors
as obesity and type 2 diabetes mellitus in the general
population."
"As these studies show, increased and continuous vigorous
attention to the prevention of cardiovascular risk
factors—by healthy diet, regular physical activity and
avoidance of smoke and smoking—is necessary for both men and
women," they conclude.
1026 Weather patterns
help predict dengue fever outbreaks [Hong Kong China]--High
temperatures, humidity and low wind speed are associated
with high occurrence of dengue fever according to a study
published in the open access journal BMC Public Health.
Dengue fever is a viral disease transmitted by mosquitoes in
tropical and subtropical regions of the world. It is one of
the most significant insect-borne diseases found in humans,
with 2.5 billion people living in high-risk areas globally.
In recent years, the number of cases occurring has increased
dramatically. Being able to predict the trend of dengue
fever facilitates early public heath responses to minimise
morbidity and mortality.
A research team led by Qiyong Liu of the State Key
Laboratory for Infectious Disease Prevention and Control,
and China CDC, and Linwei Tian of the Stanley Ho Centre for
Emerging Infectious Diseases, School of Public Health and
Primary Care, Chinese University of Hong Kong, correlated
weather conditions, including minimum and maximum
temperature, wind velocity, humidity and rainfall with the
number of cases of dengue fever in the city of Guangzhou,
capital city of Guangdong Province, China, over a six year
period from 2001 until 2006
As dengue fever is a legally notifiable disease in China,
the researchers were able to retrieve the monthly incidence
of dengue fever from the Notifiable Infectious Disease
Report System in the China Centre for Disease Control and
Prevention. They correlated this with monthly weather data
obtained from the China Meteorological Data Sharing Service
System over the same period of time.
Higher minimum temperatures and lower wind speeds were
associated with the highest number of cases of dengue fever.
If the effects of humidity were factored into the
mathematical model, the model fit actual events even better.
The effects of minimum temperature and humidity on the
incidence of dengue fever were subject to a lag of about one
month, whereas the effects of wind velocity were apparent in
the same month.
The authors suggest that the effects of humidity and
temperature are likely to be related to mosquito survival;
low humidity and cooler temperatures decrease mosquito
survival. Wind speed affects mosquito flying, so high wind
velocities lead to lower density of mosquitoes. But the
authors point out "the transmission of dengue fever is more
complex, and is influenced by community intervention
measures, human behavioural influences on mosquito
population and human mosquito interaction," and conclude,
"future studies require studying mosquito populations."
1026 Study reveals high
death rates and short life expectancy among the homeless and
marginally housed [Toronto ON]--Homeless and
marginally housed people have much higher mortality and
shorter life expectancy than could be expected on the basis
of low income alone, concludes a study from Canada published
on bmj.com today.
Previous studies have found high levels of excess mortality
among the homeless compared with the general population, but
little information is available on death rates among
homeless and marginally housed people living in low-cost
collective dwellings, such as rooming houses and hotels.
So, researchers at St Michael's Hospital in Toronto and
Statistics Canada compared death rates and life expectancy
among a representative sample of homeless and marginally
housed people with rates in the poorest and richest income
sectors of the general population.
Using data from the 1991-2001 Canadian census, they tracked
15,000 homeless and marginally housed people across Canada
for 11 years.
Mortality rates among homeless and marginally housed people
were substantially higher than rates in the poorest income
groups, with the highest rates seen at younger ages.
Among those who were homeless and marginally housed, the
probability of survival to age 75 was 32% in men and 60% in
women. This compared to 51% and 72% among men and women in
the lowest income group in the general population.
For men, this equates to about the same chance of surviving
to age 75 as men in the general population of Canada in 1921
or men in Laos in 2006. For women, this equates to about the
same chance of surviving to age 75 as women in the general
population of Canada in 1956 or women in Guatemala in 2006.
Remaining life expectancy at age 25 among homeless and
marginally housed men was 42 years - 10 years lower than the
general population and six years lower than the poorest
income group.
For homeless and marginally housed women, remaining life
expectancy at age 25 was 52 years – seven years lower than
the general population, and five years lower than the
poorest income group.
A large part of this premature mortality is potentially
avoidable, say the authors. Many excess deaths were
attributable to alcohol and smoking-related diseases and to
violence and injuries, much of which might have been related
to substance abuse.
There were also many excess deaths related to mental
disorders and suicides.
This study shows that homeless and marginally housed people
living in shelters, rooming houses, and hotels have much
higher mortality and shorter life expectancy than could be
expected on the basis of low income alone, they conclude.
These findings emphasise the importance of considering
housing situation as a marker of socioeconomic disadvantage.
1026 Deadly stomach
infection rising in community settings [Rochester MN]--Mayo
Clinic researchers have found that a sometimes deadly
stomach bug, Clostridium difficile, is on the rise in
outpatient settings. Clostridium difficile is a serious
bacteria that can cause symptoms ranging from diarrhea to
life-threatening inflammation of the colon. These findings
were presented today at the 2009 American College of
Gastroenterology (ACG) Annual Meeting in San Diego.
Clostridium difficile, often called C. difficile or "C.
diff", is a bacterium that is resistant to some antibiotics
and is most often contracted by the elderly in hospitals and
nursing homes.
"Recent reports have shown increasing incidence and severity
of C. difficile infection — especially in the older
population," says Darrell Pardi, M.D., Mayo Clinic
gastroenterologist and senior author on the study. "Our
study examines why the cases are on the rise and who is
getting the infection."
In this population-based study, researchers studied 385
cases of C. difficile bacterial infection from 1991-2005 to
determine how many cases were hospital-acquired versus
community-acquired infections. Of the cases, 192 were
hospital-acquired and 35 were residents of nursing homes. Of
these hospital-acquired cases, the median age of infection
was 72 years; in contrast, 158 cases were community-acquired
and the median age was 50 years. Thirty-five percent of the
hospital infections had a severe illness compared to 22
percent of community infections who had a severe illness.
The patients with community-acquired infection were also
less likely than the hospital-acquired group to have been
exposed to antibiotics before their infection. Thus, many of
the community-acquired infections lacked the traditional
risk factors for infection, namely recent hospitalization
and exposure to antibiotics.
There were no differences between community- and
hospital-acquired infections in terms of what patients were
treated with (primarily metronidazole), response rates, or
recurrence rates after treatment.
"We are seeing more cases of C. difficile in the community,
but they tend to be less severe and in a younger
population," says Dr. Pardi. "The growing incidence of C.
difficile infection in both inpatient and outpatient
settings could be linked to the increasing usage of
antibiotics and to the possibility that C. difficile may be
getting resistant to some of our newer antibiotics."
There are hundreds of kinds of bacteria found normally in
the intestines. Many play beneficial roles in the body. When
a patient takes an antibiotic to treat an infection, it
often destroys beneficial bacteria as well as the bacteria
that are causing the illness. Without enough healthy
bacteria, dangerous pathogens such as C. difficile can
quickly grow out of control. Once it takes hold, C.
difficile can produce two virulent toxins that attack the
lining of the intestine.
"Doctors have gotten better at spotting C. difficile in
hospitals and nursing homes; however, now doctors and
patients need to be more aware that you can get this
infection as an outpatient and that a case of diarrhea or
abdominal cramps at home could become serious," says Dr.
Pardi.
According to the Centers for Disease Control and Prevention,
each year in the United States, C. difficile is responsible
for tens of thousands of diarrhea cases and at least 5,000
deaths.
1026 The pain of
torture can make the innocent seem guilty [Cambridge, MA]--The
rationale behind torture is that pain will make the guilty
confess, but a new study by researchers at Harvard
University finds that the pain of torture can make even the
innocent seem guilty.
Participants in the study met a woman suspected of cheating
to win money. The woman was then "tortured" by having her
hand immersed in ice water while study participants listened
to the session over an intercom. She never confessed to
anything, but the more she suffered during the torture, the
guiltier she was perceived to be.
The research, published in the "Journal of Experimental
Social Psychology," was conducted by Kurt Gray, graduate
student in psychology, and Daniel M. Wegner, professor of
psychology, both in Harvard's Faculty of Arts and Sciences.
"Our research suggests that torture may not uncover guilt so
much as lead to its perception," says Gray. "It is as though
people who know of the victim's pain must somehow convince
themselves that it was a good idea—and so come to believe
that the person who was tortured deserved it."
Not all torture victims appear guilty, however. When
participants in the study only listened to a recording of a
previous torture session—rather than taking part as
witnesses of ongoing torture—they saw the victim who
expressed more pain as less guilty. Gray explains the
different results as arising from different levels of
complicity.
"Those who feel complicit with the torture have a need to
justify the torture, and so link the victim's pain to
blame," says Gray. "On the other hand, those distant from
torture have no need to justify it and so can sympathize
with the suffering of the victim, linking pain to
innocence."
The study included 78 participants: half met the woman who
was apparently tortured (actually a confederate of the
experimenters who was, of course, not harmed at all), and
half did not. Participants were told that the study was
about moral behavior, and that the woman may have cheated by
taking more money than she deserved. The experimenter
suggested that a stressful situation might make a guilty
person confess, so participants listened for a confession
over a hidden intercom as she was subjected to the sham
"torture."
The confederate did not admit to cheating but reacted to
having her hand submerged in ice water with either
indifference or with whimpering and pleading. Participants
who had met her rated her as more guilty the more she
suffered. Those who did not meet her rated her as more
guilty when she felt less pain.
Gray suggests that these results offer an explanation for
the debate swirling around torture.
"Seeing others in pain can perpetuate ideological
differences about the justifiability of torture," says Gray.
"Those who initially advocate torture see those harmed as
guilty, unlike those who initially reject torture and its
methods."
The findings also shed light on the Abu Ghraib scandal,
where prison guards tortured Iraqi detainees. Prison guards,
who are close to the suffering of detainees, see detainees
as more guilty the more they suffer, unlike the more distant
general public.
The case is still open on whether torture actually makes
victims more likely to tell the truth. This research
suggests instead that the mere fact that someone was
tortured leads observers to think that the truth was found.
The research was supported by the Canadian Social Sciences
and Humanities Research Council and the Institute for Humane
Studies.
1026 Researchers
identify dominant chemical that attracts mosquitoes to
humans [UC Davis]--Scientists at the University
of California, Davis, have identified the dominant odor
naturally produced in humans and birds that attracts the
blood-feeding Culex mosquitoes, which transmit West Nile
virus and other life-threatening diseases.
The groundbreaking research, published this week in the
early online edition of the Proceedings of the National
Academy of Sciences, explains why mosquitoes shifted hosts
from birds to humans and paves the way for key developments
in mosquito and disease control.
Entomology professor Walter Leal and postdoctoral researcher
Zain Syed found that nonanal (sounds like NAWN-uh-nawl) is
the powerful semiochemical that triggers the mosquitoes'
keen sense of smell, directing them toward a blood meal. A
semiochemical is a chemical substance or mixture that
carries a message.
"Nonanal is how they find us," Leal said. "The antennae of
the Culex quinquefasciatus are highly developed to detect
even extremely low concentrations of nonanal." Mosquitoes
detect smells with the olfactory receptor neurons of their
antennae.
Birds, the main hosts of mosquitoes, serve as the reservoir
for the West Nile virus, Leal said. When infected mosquitoes
take a blood meal, they transmit the virus to their hosts,
which include birds, humans, horses, dogs, cats, bats,
chipmunks, skunks, squirrels and domestic rabbits. Since
1999, the U.S. Centers for Disease Control and Prevention
have recorded 29,397 human cases and 1,147 fatalities in the
United States alone.
The UC Davis researchers tested hundreds of naturally
occurring compounds emitted by people and birds. They
collected chemical odors from 16 adult human subjects,
representing multiple races and ethnic groups.
"We then determined the specificity and sensitivity of the
olfactory receptor neurons to the isolated compounds on the
antennae of the mosquitoes," Syed said.
Leal and Syed found that nonanal acts synergistically with
carbon dioxide, a known mosquito attractant. "We baited
mosquito traps with a combination of nonanal and carbon
dioxide and we were drawing in as many as 2,000 a night in
Yolo County, near Davis," Syed said. "Nonanal, in
combination with carbon dioxide, increased trap captures by
more than 50 percent, compared to traps baited with carbon
dioxide alone."
The UC Davis research was funded in part by the National
Institutes of Health; a cooperative research agreement with
Bedoukian Research, a supplier of specialty aroma and flavor
ingredients headquartered in Connecticut; and the National
Science Foundation.
1021 Researchers can
predict hurricane-related power outages [Baltimore MD]--Using
data from Hurricane Katrina and four other destructive
storms, researchers from Johns Hopkins and Texas A&M
universities say they have found a way to accurately predict
power outages in advance of a hurricane. Their approach
provides estimates of how many outages will occur across a
region as a hurricane is approaching.
The information provided by their computer models has the
potential to save utilities substantial amounts of money,
savings that can then be passed on to customers, the
researchers say. In addition, appropriate crew levels and
placements can help facilitate rapid restoration of power
after the storm.
The study was a collaborative effort involving Seth Guikema,
an assistant professor of geography and environmental
engineering at Johns Hopkins and formerly of Texas A&M;
Steven Quiring, an assistant professor of geography at Texas
A&M; and Seung-Ryong Han, who was Guikema's doctoral student
at Texas A&M and is now based at Korea University. Their
work, which was funded by a Gulf Coast utility company that
wishes to remain anonymous, is published in the current
issue of the journal Risk Analysis.
The research focused on two common challenges. When a
hurricane is approaching, an electric power provider must
decide how many repair crews to request from other
utilities, a decision that may cost the provider millions of
dollars. The utility also must decide where to locate these
crews within its service areas to enable fast and efficient
restoration of service after the hurricane ends. Having
accurate estimates, prior to the storm's arrival, of how
many outages will exist and where they will occur will allow
utilities to better plan their crew requests and crew
locations, the researchers say.
What makes the research team's computational approach unique
and increases its accuracy, Guikema and Quiring say, is the
combination of more detailed information about the storm,
the area it is impacting and the power system of the area,
together with more appropriate statistical models.
"If the power company overestimates, it has spent a lot of
unnecessary money," Quiring said. "If it underestimates, the
time needed to restore power can take several extra days or
longer, which is unacceptable to them and the people they
serve. So these companies need the best estimates possible,
and we think this study can help them make the best possible
informed decision."
In addition, more accurate models "provide a much better
basis for preparing for restoring power after the storm,"
Guikema said, adding that "the goal is to restore power
faster and save customers money."
In developing their computer model, the researchers looked
at damage data from five hurricanes: Dennis (1995), Danny
(1997), Georges (1998), Ivan (2004) and Katrina (2005). In
the areas studied, Ivan created 13,500 power outages;
Katrina, more than 10,000; Dennis, about 4,800; Georges,
1,075; and Danny, 620.
For the worst of these storms, some customers were without
power for up to 11 days. The research team collected
information about the locations of outages in these past
hurricanes, with an outage defined as permanent loss of
power to a set of customers due to activation of a
protective device in the power system.
The researchers also included information about the power
system in each area (poles, transformers, etc.), hurricane
wind speeds, wetness of the soil, long-term average
precipitation, the land use, local topography and other
related factors. This data was then used to train and
validate a statistical regression model called a Generalized
Additive Model, a particular form of model that can account
for nonlinear relationships between the variables.
1021 Major swine flu
outbreak at US Air Force Academy provided unique opportunity
to study virus behavior [San Diego CA]--With the
2009 influenza season upon us, characterization of the
epidemiology and duration of shedding for the nH1N1 virus is
critical. Investigators from the U.S. Air Force Academy and
the U.S. Air Force School of Aerospace Medicine Epidemiology
Consult Service capitalized on a unique opportunity to gain
valuable insights about the natural behavior of the nH1N1
virus, including shedding patterns, during a recent
large-scale swine flu outbreak at the U.S. Air Force Academy
(USAFA). Their results are reported in an article published
online on October 20, 2009 by the American Journal of
Preventive Medicine. It is the first published study of its
kind.
Findings from serial nasal washes indicated the presence of
viable virus shedding among about one quarter of confirmed
nH1N1 patients sampled on Day 7 from symptom onset. Further,
being afebrile and asymptomatic did not guarantee the
patient was no longer shedding viable nH1N1 virus; in fact,
19% of those who reported being symptom-free for greater
than 24 hours were still found to have viable virus
shedding. While viable virus shedding does not necessarily
mean the virus can be transmitted, these findings do
indicate that the virus may persist even after the
individual is feeling well and has returned to work.
Furthermore, the results of this study may assist
development of appropriate protocols for isolation in
high-risk settings or if the scale and/or severity of the
current nH1N1 situation increases. The current study also
provides groundwork to other investigators for further study
of the shedding characteristics of the virus.
In July, this novel H1N1 outbreak represented one of the
largest recognized nH1N1 clusters at a U.S. college to date.
Lead investigator Catherine Takacs Witkop, MD, MPH, of the
U.S. Air Force Academy, comments, "Characterizing virus–host
interactions and the epidemiology of nH1N1 is important in
both planning assumptions and in defining effective control
measures. Studies of seasonal influenza suggest that viral
shedding occurs for as long as 7 days after symptom onset.
No similar studies on shedding of nH1N1 have been published.
In addition, there are no published studies of the
epidemiology of nH1N1 infection among military training
populations or institutions of higher education."
On June 25, 2009, 1376 new basic cadet trainees (BCTs)
arrived at USAFA to begin a 6-week military training program
prior to their first academic year. Between July 6 and 7,
respiratory complaints increased and two cadets were
identified as positive for influenza A. Due to a high level
of suspicion that the responsible virus was nH1N1,
identification, treatment and containment efforts were
initiated immediately.
There were 134 confirmed and 33 suspect cases of nH1N1
infection identified with onset date from June 25 to July
24, 2009. Fever, cough and sore throat were the most
commonly reported symptoms. Among the at-risk BCTs, 11% were
infected during the outbreak period. Twenty-nine percent
(31/106) of samples in patients with temperature <100°F and
19% (11/58) of samples in patients reporting no symptoms for
at least 24 hours contained viable nH1N1 virus. Of 29
samples obtained 7 days from illness onset, 7 (24%)
contained viable nH1N1 virus.
A total of 228 cadets were placed in separated dorm areas
during the outbreak period. There were no confirmed or
suspect cases among healthcare personnel.
Investigators determined the outbreak was likely propagated
by a social mixing event, which has implications for
colleges and universities across the country. Measures
undertaken to stem the spread of the virus, quick response
and mitigation efforts enacted immediately upon outbreak
recognition, good communication and a public health campaign
contributed significantly to the subsequent rapid decline of
the outbreak.
Writing in the article, Dr. Witkop and co-authors state,
"The USAFA outbreak provided a unique opportunity to gain
valuable information about the natural behavior of the nH1N1
virus....Novel H1N1 is now endemic in all 50 U.S. states.
University- and college-based outbreaks of nH1N1 have
occurred and more can be expected this fall as students
gather from diverse geographic areas, reside in dorm
settings and attend mass gatherings such as football games,
pep rallies and student assemblies. The combination of
aggressive separation of ill BCTs, public health education
and prompt implementation of healthcare infection control
practices limited the duration and scope of the nH1N1
infection at USAFA. Comprehensive plans and rapid
implementation are critical. Isolation procedures
implemented at USAFA may not be practical in other
university settings; however, preparedness planning, public
health education activities and healthcare infection control
practices implemented at USAFA can be adopted in other
university settings."
The article is "Novel Influenza A (H1N1) Outbreak at the
U.S. Air Force Academy: Epidemiology and Viral Shedding
Duration" by Catherine Takacs Witkop, MD, MPH, Mark R.
Duffy, DVM, MPH, Elizabeth A. Macias, PhD, Thomas F.
Gibbons, PhD, James D. Escobar, MPH, Kristen N. Burwell, MPH
and Kenneth K. Knight, MD, MPH. Following advance online
publication on October 20, 2009 (DOI
10.1016/j.amepre.2009.10.005), the article will appear in
the American Journal of Preventive Medicine, Volume 38,
Issue 2 (February 2010) published by Elsevier.
1021 Calling it in: New
emergency medical service system may predict caller's fate
[Yokohama City, Japan]--Japanese researchers have
developed a computer program which may be able tell from an
emergency call if you are about to die. Research published
in the open access journal BMC Emergency Medicine shows that
a computer algorithm is able to predict the patient's risk
of dying at the time of the emergency call.
Kenji Ohshige and a team of researchers from the Yokohama
City University School of Medicine in Japan assessed the new
Yokohama computer-based triage emergency system from its
inception on 1st October 2008 until 31st March 2009,
collecting information from over 60,000 emergency calls. For
each call, triage information was entered into the computer
system, which then categorized patients according to the
severity of their condition. The researchers then compared
the computer-estimated threat of dying at the time of the
emergency call with the actual patients' condition upon
arrival at the hospital emergency department. They found
that the algorithm was effective in assessing the life risk
of a patient with over 80% sensitivity.
According to Ohshige, "A patient's life threat risk can be
quantitatively expressed at the moment of the emergency call
with a moderate level of accuracy. The algorithm for
estimating a patient's like threat risk should be improved
further as more data are collected."
Ambulance response time has risen rapidly with the increased
demand for this service in developed countries such as
Japan. This emphasises the need to prioritise ambulance
responses according to the severity of the patient's
condition. "As delayed response time reduces the number of
patients who survive from sudden cardiac arrest priority
dispatch of ambulances to patients in critical condition has
become a matter of importance", says Ohshige.
1021 Latest diabetes
figures paint grim global picture [Montreal QC]--The
International Diabetes Federation (IDF) released new data
today showing that a staggering 285 million people worldwide
have diabetes. The latest figures from the IDF Diabetes
Atlas indicate that people in low and middle-income
countries (LMCs) are bearing the brunt of the epidemic, and
that the disease is affecting far more people of working age
than previously believed.
In 1985, the best data available suggested that 30 million
people had diabetes worldwide. Fast-forward 15 years and the
numbers were revised to just over 150 million. Today, less
than 10 years on, the new figures – launched at the 20th
World Diabetes Congress in Montreal, Canada – put the number
closer to 300 million, with more than half aged between 20
and 60. IDF predicts that, if the current rate of growth
continues unchecked, the total number will exceed 435
million in 2030 – many more people than the current
population of North America.
Professor Jean Claude Mbanya, President of the International
Diabetes Federation, voiced concern: “The data from the
latest edition of the IDF Diabetes Atlas show that the
epidemic is out of control. We are losing ground in the
struggle to contain diabetes. No country is immune and no
country is fully equipped to repel this common enemy.”
Type 1 diabetes cannot be prevented. It is an autoimmune
disease in which the body destroys its own insulin-producing
cells. People with type 1 diabetes require daily injections
of insulin to survive. The majority of all diabetes is type
2 diabetes (85%-95%), which in many cases can be prevented.
People with type 2 diabetes cannot use the insulin they
produce effectively, but can often manage their condition
through exercise and diet, although many go on to require
medication, including insulin, to properly control blood
glucose levels. It is estimated 60% or more of type 2
diabetes could be prevented.
Both type 1 and type 2 diabetes represent a serious health
threat. Diabetes claims four million lives every year and is
a leading cause of blindness, kidney failure, heart attack,
stroke and amputation.
Diabetes explodes worldwide
Diabetes now affects seven percent of the world’s adult
population. The regions with the highest comparative
prevalence rates are North America, where 10.2 % of the
adult population have diabetes, followed by the Middle East
and North Africa Region with 9.3%. The regions with the
highest number of people living with diabetes are Western
Pacific, where some 77 million people have diabetes and
South East Asia with 59 million.
India is the country with the most people with diabetes,
with a current figure of 50.8 million, followed by China
with 43.2 million. Behind them the United States (26.8
million); the Russian Federation (9.6 million); Brazil (7.6
million); Germany (7.5 million); Pakistan (7.1 million);
Japan (7.1 million); Indonesia (7 million) and Mexico (6.8
million).
When it comes to the percentage of adult population living
with diabetes, the new data reveal the devastating impact of
diabetes across the Gulf Region, where five of the Gulf
States are among the top ten countries affected. The Pacific
island nation of Nauru has the world’s highest rate of
diabetes, with almost a third of its adult population
(30.9%) living with the disease. It is followed by the
United Arab Emirates (18.7%); Saudi Arabia (16.8%);
Mauritius (16.2%); Bahrain (15.4%); Reunion (15.3%); Kuwait
(14.6%); Oman (13.4%); Tonga (13.4%) and Malaysia (11.6%).
Increasing economic burden
Diabetes has become a development issue. In LMCs, it
threatens health and economic prosperity. IDF predicts that
diabetes will cost the world economy at least US$376 billion
in 2010, or 11.6% of total world healthcare expenditure. By
2030, this number is projected to exceed US$490 billion.
More than 80% of diabetes spending is in the world’s richest
countries and not in the poorer countries, where over 70
percent of people with diabetes now live.
The United States accounts for $198 billion or 52.7% of
total diabetes spending worldwide. India, which has the
largest diabetes population, spends US$2.8 billion or 1% of
the global total. In most LMCs, people with diabetes must
pay for their care out of their own pocket because public
medical services and insurance are lacking. The diagnosis of
diabetes in a low or middle-income country can often drag
entire families into poverty.
“The world needs to invest in integrated health systems that
can diagnose, treat, manage and prevent diabetes,” said
Professor Nigel Unwin, who leads the team of experts behind
the IDF Diabetes Atlas. “Governments also need to invest in
actions outside the formal health sector, particularly in
promoting healthier diets and physical activity, to reduce
obesity and the risk of type 2 diabetes. Without effective
prevention diabetes will overwhelm health systems and hinder
economic growth.”
Integrating plans for the prevention of diabetes into
national health systems and policy frameworks is an
important part of the response. IDF warns that many health
systems worldwide are not yet equipped to handle the extent
of the diabetes threat, and that failure to take action will
have serious consequences.
“The epidemic represents nothing short of a global health
emergency,” said IDF President Mbanya. “It is alarming that
world leaders stand by while the diabetes fuse slowly burns.
The serious impact on families, countries and economies
continues with little resistance. Governments, aid agencies
and the international community must take concerted action
to defuse the threat now, before the diabetes time bomb
explodes.”
1021 Illness often
undiscovered and undertreated among the uninsured [Boston
MA]--A new study shows uninsured American adults
with chronic illnesses like diabetes or high cholesterol
often go undiagnosed and undertreated, leading to an
increased risk of costly, disabling and even lethal
complications of their disease.
The study, published online today [Tuesday] in Health
Affairs, analyzed data from a recent national survey
conducted by the Centers for Disease Control and Prevention
(CDC). The researchers, based at Harvard Medical School and
the affiliated Cambridge Health Alliance, analyzed data on
15,976 U.S. non-elderly adults from the National Health and
Nutrition Examination Survey (NHANES), a CDC program,
between 1999 and 2006.
Respondents answered detailed questions about their health
and economic circumstances. Then doctors examined them and
ordered laboratory tests.
The study found that about half of all uninsured people with
diabetes (46 percent) or high cholesterol (52 percent) did
not know they had these diseases. In contrast, about
one-quarter of those with insurance were unaware of their
illnesses (23 percent for diabetes, 29.9 percent for high
cholesterol).
Undertreatment of disease followed similar patterns, with
the uninsured being more likely to be undertreated than
their insured counterparts: 58.3 percent vs. 51.4 percent
had their high blood pressure poorly controlled, and 77.5
percent vs. 60.4 percent had their high cholesterol
inadequately treated.
Surprisingly, being insured was not associated with a widely
used measure of diabetes control (a hemoglobin A1c level
below 7), a finding the authors attribute to the stringent
definition of good diabetes control used in the NHANES
survey. Even with excellent medical care, many diabetics
fail to achieve such low hemoglobin A1c levels. Using less
stringent hemoglobin A1c thresholds of 8 and 9, uninsured
adults had significantly worse blood sugar control than
their insured counterparts, the researchers found.
Lead author Dr. Andrew Wilper, who worked at Harvard when
the study was done and who now teaches at the University of
Washington Medical School, said: "Our study should lay to
rest the myth that the uninsured can get the care they need.
Millions have serious chronic conditions and don't even know
it. And they're not getting care that would prevent strokes,
heart attacks, amputations and kidney failure."
Referring to a study released in the American Journal of
Public Health last month, which has been widely quoted by
Sen. Max Baucus and others, he added: "Our previous work
demonstrated 45,000 deaths annually are linked to lack of
health insurance. Our new findings suggest a mechanism for
this increased risk of death among the uninsured. They're
not getting life-saving care."
Dr. Steffie Woolhandler, professor of medicine at Harvard
and study co-author, said: "The uninsured suffer the most,
but even Americans with insurance have shocking rates of
undertreatment, in part because high co-payments and
deductibles often make care and medications unaffordable. We
need to upgrade coverage for the insured, as well as
covering the uninsured. Only single-payer national health
insurance would make care affordable for the tens of
millions of Americans with chronic illnesses."
Dr. David Himmelstein, associate professor of medicine at
Harvard and study co-author, said: "The Senate Finance
Committee's bill would leave 25 million Americans uninsured
and unable to get the ongoing, routine care that could save
their lives and prevent disability. No other wealthy nation
tolerates this, yet Congress is turning its back on tens of
millions of Americans."
"Hypertension, diabetes and elevated cholesterol among
insured and uninsured U.S. adults," Andrew P. Wilper, M.D.,
M.P.H.; Steffie Woolhandler, M.D., M.P.H.; Karen Lasser,
M.D., M.P.H.; Danny McCormick, M.D., M.P.H.; David H. Bor,
M.D.; David U. Himmelstein, M.D. Health Affairs, Oct. 20,
2009 (online).
1021 Comparison finds
considerable differences on estimates of future physician
workforce supply [Hanover NH]--Compared with a
source of data often used regarding physician workforce
supply and projected changes, data from the U.S. Census
Bureau suggests that the future physician workforce may be
younger but fewer in number than previously projected,
according to a study in the October 21 issue of JAMA.
Recent projections have indicated that the supply of
physicians may soon decrease below recommended requirements,
with some projecting a shortfall as high as 200,000 by 2020.
"Although debate over potential shortages has focused
largely on the number and type of physicians needed in the
future, concerns have also been raised about data used in
physician supply estimates and projections," the authors
write.
The American Medical Association Physician Masterfile (Masterfile)
data, although frequently used by workforce analysts, are
believed to overestimate the number of active physicians at
older ages, attributed to delays in updating the Masterfile
data when a physician retires or experiences a change in
status, according to background information in the article.
Douglas O. Staiger, Ph.D., of Dartmouth College, Hanover,
N.H., and colleagues conducted an analysis of employment
trends of physicians using the Masterfile data and the U.S.
Census Bureau Current Population Survey (CPS), a data source
used extensively by the U.S. Department of Labor to estimate
current trends in employment. The researchers used data from
between 1979 and 2008. Physician supply through 2040 was
also projected using both data sources.
The researchers found that in an average year, the CPS
estimated 67,000 (10 percent ) fewer active physicians than
did the Masterfile during the sample period. Estimates from
the Masterfile and CPS data were similar for physicians
between the ages of 35 and 54 years, but differed markedly
at both younger and older ages. Older physicians accounted
almost entirely for the lower estimates of active physicians
in the CPS. During the sample period, on average, the CPS
estimated 22,000 (20 percent) fewer active physicians per
year ages 55 to 64 years than did the Masterfile, and
estimated 35,000 (51 percent) fewer active physicians per
year 65 years or older than the Masterfile. The CPS
estimated more young physicians (ages 25-34 years) than did
the Masterfile, with the difference increasing to an average
of 17,000 (12 percent) during the final 15 years.
"The CPS estimates of more young physicians were consistent
with historical growth observed in the number of first-year
residents, and the CPS estimates of fewer older physicians
were consistent with lower Medicare billing by older
physicians," the authors write.
Regarding projections for the future physician workforce
supply, both the CPS and the Masterfile data indicate that
the number of active physicians will increase by
approximately 20 percent between 2005 and 2020. However,
projections for 2020 using CPS data estimate nearly 100,000
(9 percent) fewer active physicians than projections using
the Masterfile data (957,000 vs. 1,050,000), and estimate
that a smaller proportion of active physicians will be 65
years or older.
"The CPS-based projection indicates that 71 percent of
active physicians will be younger than 55 years and only 9
percent will be older than 65 years, whereas the Masterfile-based
projection indicates that 61 percent of active physicians
will be younger than 55 years and 18 percent will be older
than 65 years," the researchers note.
"Although this analysis was restricted to physician supply,
projections of physician requirements also rely on estimates
of the current number of physicians as a starting point for
projections. Thus, without more accurate estimates of the
size and age distribution of the current workforce,
projections of physician supply, requirements, and potential
shortages may mislead policymakers as they try to anticipate
and prepare for the health care needs of the population,"
the authors conclude.
Editorial: How Many Physicians? How Much Does It Matter?
In an accompanying editorial, Thomas C. Ricketts, Ph.D.,
M.P.H., of the University of North Carolina, Cecil G. Sheps
Center for Health Services Research, Chapel Hill, N.C.,
writes on the importance of having accurate projections
regarding the physician workforce.
"The physician workforce is one of the most critical factors
that must be considered in current health care reform
efforts and discussions. Having accurate estimates for
determining not only the number of physicians, but also
current and future physician workforce requirements and
capabilities for delivering primary and specialty care, will
be essential for achieving and sustaining effective health
care reform."
1021 New immigrants
more likely to be homeless due to economic factors rather
than health issues [Toronto ON]--New immigrants
are more likely to cite economic and housing factors as
barriers that keep them homeless compared with native-born
individuals, according to a new study on the health of
homeless immigrants led by St. Michael's Hospital researcher
Dr. Stephen Hwang.
"Homeless people are in much poorer health than the general
population, but immigrants who are homeless tend to be
healthier than Canadian-born people who are homeless. This
is sometimes referred to as the 'healthy immigrant effect',"
explains Dr. Hwang. "We also found recent immigrants,
non-recent immigrants and Canadian-born individuals gave
significantly different responses regarding the single most
important thing keeping them homeless."
The study team interviewed 1,189 homeless people in Toronto,
Canada to examine the association between immigrant status
and current health. Participants were asked to identify the
single most important thing keeping them from getting out of
homelessness. The categories were: insufficient income, lack
of suitable/adequate housing, lack of employment, addiction
to alcohol and/or drugs, family or domestic instability,
mental health condition and all other reasons. The study was
published in the Journal of Epidemiology and Community
Health.
Key findings of the study include:
* Recent immigrants who are homeless were found to be
physically and mentally healthier and less likely to suffer
from chronic conditions and substance abuse problems than
native-born homeless individuals.
* 22% of Canadian-born individuals said mental illness,
domestic instability and addiction were reasons for their
homelessness
* 11 % of recent immigrants named the same factors.
The study also found the length of time since immigration is
a critical factor, as the health status of homeless
individuals who immigrated more than 10 years ago is not
significantly different from that of homeless Canadian-born
individuals.
"Previous studies have shown that recent immigrants face an
initial disadvantage in the labour market, earning wages
well below that of the native-born population," says Hwang.
"With economic issues being cited the main factor in recent
immigrant homelessness, strategies that focus on job skills,
training and employment for this group of individuals could
make a difference."
1021 Review:
Pneumococcal conjugate vaccines effective at preventing
child deaths [Washington DC]--A study published
in The Cochrane Review this month concludes that
pneumococcal conjugate vaccines (PCV), already known to
prevent invasive pneumococcal disease (IPD) and x-ray
defined pneumonia, was also effective against child deaths.
The findings were based on a
systematic review of the results of 6 randomized and
controlled trials conducted in the US, Africa, Philippines,
and Finland. Eighty percent of children were less likely to
develop vaccine-type IPD, 58% all-serotype IPD, and 27%
x-ray defined pneumonia than children who did not receive
the vaccine. Eleven percent of child deaths were also
prevented. In total, 113,044 children were included in the
six trials – 57,015 children in the PCV group and 56,029 in
the control group.
"Pneumococcal disease is driving a global health crisis,
particularly in the developing world," said Marilla G.
Lucero of the Research Institute for Tropical Medicine and
primary author of the study. "This study underscores the
value of vaccines in preventing this deadly disease and
saving children's lives."
Pneumococcal disease, or Streptoccoccus pneumoniae, is a
leading cause of pneumonia, meningitis, sepsis and other
life-threatening ailments. It takes the lives of 1.6 million
people each year, including more than 800,000 children
despite the existence of safe and effective vaccines to
prevent it. Ninety-five percent of child pneumococcal deaths
occur in the developing world, largely unreached by the
existing vaccines as yet.
WHO recommends that all countries prioritize introduction of
PCV, particularly those with high child mortality rates. In
2000, the United States became the first country to license
a 7-valent pneumococcal vaccine (PCV-7), which has virtually
eliminated severe pneumococcal disease caused by vaccine
serotypes in the U.S. Since then, 37 countries have
implemented universal or widespread use of PCV-7, nearly all
of which are in the industrialized world. New financial
mechanisms, including the GAVI Alliance's Advance Market
Commitment, are now in place to help low-income countries
prevent pneumococcal deaths in their own countries. Next
generation PCVs are expected to shortly become available and
will provide expanded serotype coverage of strains common in
the developing world.
"While early detection and treatment can save lives, this
review highlights the effectiveness of pneumococcal
conjugate vaccines for preventing pneumococcal disease
before it occurs," said Dr. Orin Levine, executive director
of PneumoADIP at the Johns Hopkins Bloomberg School of
Public Health. "Low-income countries can now have the
opportunity to introduce pneumococcal vaccine on an
unprecedented timetable and at prices their governments can
afford. We recommend that all countries eligible for GAVI
support apply now and take immediate steps to prioritize
prevention."
1021 Report examines
hidden costs of energy production and use [Washington DC]--A
new report from the National Research Council examines and,
when possible, estimates "hidden" costs of energy production
and use -- such as the damage air pollution imposes on human
health -- that are not reflected in market prices of coal,
oil, other energy sources, or the electricity and gasoline
produced from them.
The report estimates dollar
values for several major components of these costs. The
damages the committee was able to quantify were an estimated
$120 billion in the U.S. in 2005, a number that reflects
primarily health damages from air pollution associated with
electricity generation and motor vehicle transportation. The
figure does not include damages from climate change, harm to
ecosystems, effects of some air pollutants such as mercury,
and risks to national security, which the report examines
but does not monetize.
Requested by Congress, the report assesses what economists
call external effects caused by various energy sources over
their entire life cycle -- for example, not only the
pollution generated when gasoline is used to run a car but
also the pollution created by extracting and refining oil
and transporting fuel to gas stations. Because these effects
are not reflected in energy prices, government, businesses
and consumers may not realize the full impact of their
choices. When such market failures occur, a case can be made
for government interventions -- such as regulations, taxes
or tradable permits -- to address these external costs, the
report says.
The committee that wrote the report focused on monetizing
the damage of major air pollutants -- sulfur dioxide,
nitrogen oxides, ozone, and particulate matter – on human
health, grain crops and timber yields, buildings, and
recreation. When possible, it estimated both what the
damages were in 2005 (the latest year for which data were
available) and what they are likely to be in 2030, assuming
current policies continue and new policies already slated
for implementation are put in place.
The committee also separately derived a range of values for
damages from climate change; the wide range of possibilities
for these damages made it impossible to develop precise
estimates of cost. However, all model results available to
the committee indicate that climate-related damages caused
by each ton of CO2 emissions will be far worse in 2030 than
now; even if the total amount of annual emissions remains
steady, the damages caused by each ton would increase 50
percent to 80 percent.
DAMAGES FROM ELECTRICITY GENERATION
Coal accounts for about half the electricity produced in the
U.S. In 2005 the total annual external damages from sulfur
dioxide, nitrogen oxides, and particulate matter created by
burning coal at 406 coal-fired power plants, which produce
95 percent of the nation's coal-generated electricity, were
about $62 billion; these nonclimate damages average about
3.2 cents for every kilowatt-hour (kwh) of energy produced.
A relatively small number of plants -- 10 percent of the
total number -- accounted for 43 percent of the damages. By
2030, nonclimate damages are estimated to fall to 1.7 cents
per kwh.
Coal-fired power plants are the single largest source of
greenhouse gases in the U.S., emitting on average about a
ton of CO2 per megawatt-hour of electricity produced, the
report says. Climate-related monetary damages range from 0.1
cents to 10 cents per kilowatt-hour, based on previous
modeling studies.
Burning natural gas generated far less damage than coal,
both overall and per kilowatt-hour of electricity generated.
A sample of 498 natural gas fueled plants, which accounted
for 71 percent of gas-generated electricity, produced $740
million in total nonclimate damages in 2005, an average of
0.16 cents per kwh. As with coal, there was a vast
difference among plants; half the plants account for only 4
percent of the total nonclimate damages from air pollution,
while 10 percent produce 65 percent of the damages. By 2030,
nonclimate damages are estimated to fall to 0.11 cents per
kwh. Estimated climate damages from natural gas were half
that of coal, ranging from 0.05 cents to 5 cents per
kilowatt-hour.
The life-cycle damages of wind power, which produces just
over 1 percent of U.S. electricity but has large growth
potential, are small compared with those from coal and
natural gas. So are the damages associated with normal
operation of the nation's 104 nuclear reactors, which
provide almost 20 percent of the country's electricity. But
the life cycle of nuclear power does pose some risks; if
uranium mining activities contaminate ground or surface
water, for example, people could potentially be exposed to
radon or other radionuclides; this risk is borne mostly by
other nations, the report says, because the U.S. mines only
5 percent of the world's uranium. The potential risks from a
proposed long-term facility for storing high-level
radioactive waste need further evaluation before they can be
quantified. Life-cycle CO2 emissions from nuclear, wind,
biomass, and solar power appear to be negligible when
compared with fossil fuels.
DAMAGES FROM HEATING
The production of heat for buildings or industrial processes
accounts for about 30 percent of American energy demand.
Most of this heat energy comes from natural gas or, to a
lesser extent, the use of electricity; the total damages
from burning natural gas for heat were about $1.4 billion in
2005. The median damages in residential and commercial
buildings were about 11 cents per thousand cubic feet, and
the proportional harm did not vary much across regions.
Damages from heat in 2030 are likely to be about the same,
assuming the effects of additional sources to meet demand
are offset by lower-emitting sources.
DAMAGES FROM MOTOR VEHICLES AND FUELS
Transportation, which today relies almost exclusively on
oil, accounts for nearly 30 percent of U.S. energy demand.
In 2005 motor vehicles produced $56 billion in health and
other nonclimate-related damages, says the report. The
committee evaluated damages for a variety of types of
vehicles and fuels over their full life cycles, from
extracting and transporting the fuel to manufacturing and
operating the vehicle. In most cases, operating the vehicle
accounted for less than one-third of the quantifiable
nonclimate damages, the report found.
Damages per vehicle mile traveled were remarkably similar
among various combinations of fuels and technologies -- the
range was 1.2 cents to about 1.7 cents per mile traveled --
and it is important to be cautious in interpreting small
differences, the report says. Nonclimate-related damages for
corn grain ethanol were similar to or slightly worse than
gasoline, because of the energy needed to produce the corn
and convert it to fuel. In contrast, ethanol made from
herbaceous plants or corn stover -- which are not yet
commercially available -- had lower damages than most other
options.
Electric vehicles and grid-dependent (plug-in) hybrid
vehicles showed somewhat higher nonclimate damages than many
other technologies for both 2005 and 2030. Operating these
vehicles produces few or no emissions, but producing the
electricity to power them currently relies heavily on fossil
fuels; also, energy used in creating the battery and
electric motor adds up to 20 percent to the manufacturing
part of life-cycle damages.
Most vehicle and fuel combinations had similar levels of
greenhouse gas emissions in 2005. There are not substantial
changes estimated for those emissions in 2030; while
population and income growth are expected to drive up the
damages caused by each ton of emissions, implementation of
new fuel efficiency standards of 35.5 miles per gallon will
lower emissions and damages for every vehicle mile traveled.
Achieving significant reductions in greenhouse gas emissions
by 2030 will likely also require breakthrough technologies,
such as cost-effective carbon capture and storage or
conversion of advanced biofuels, the report says.
Both for 2005 and 2030, vehicles using gasoline made from
oil extracted from tar sands and those using diesel derived
from the Fischer-Tropsch process -- which converts coal,
methane, or biomass to liquid fuel -- had the highest
life-cycle greenhouse gas emissions. Vehicles using ethanol
made from corn stover or herbaceous feedstock such as
switchgrass had some of the lowest greenhouse gas emissions,
as did those powered by compressed natural gas.
Fully implementing federal rules on diesel fuel emissions,
which require vehicles beginning in the model year 2007 to
use low-sulfur diesel, is expected to substantially decrease
nonclimate damages from diesel by 2030 -- an indication of
how regulatory actions can significantly affect
energy-related damages, the committee said. Major
initiatives to further lower other emissions, improve energy
efficiency, or shift to a cleaner mix of energy sources
could reduce other damages as well, such as substantially
lowering the damages attributable to electric vehicles.
1021 Tsunami evacuation
buildings: another way to save lives in the Pacific
Northwest [Boulder CO]--Some time soon, a
powerful earthquake will trigger a massive tsunami that will
flood the Pacific Northwest, destroying homes and
threatening the lives of tens of thousands of people, says
Yumei Wang, a geotechnical engineer at the Oregon Department
of Geology and Mineral Industries in Portland.
The region's geology makes an earthquake-triggered tsunami
inevitable and imminent in geologic time, Wang says, yet
coastal towns and cities in the northwest are woefully
unprepared for such a large-scale natural disaster. In
response, she is working with public officials and
stakeholders to develop a series of tsunami evacuation
buildings up and down the northwest coast. They would be the
first buildings of their kind in the United States. And
construction, she urges, can't start soon enough.
"Unless we do this, we will have lots of people dying in a
tsunami," Wang says. "That's not how we want our people to
die."
Wang will present recommendations in a session titled, Risks
and Realities: Current Advances in Understanding Societal
Risk and Resilience to Natural Hazards, at this month's
Annual Meeting of the Geological Society of America in
Portland, Oregon.
A line of volcanoes from
northern California to British Columbia marks the eastern
edge of a fault system (called the Cascadia subduction
zone), where one plate is wedged under another. Those plates
shift like geological clockwork every few hundred years,
producing earthquakes that shake the region. The last major
quake along the Cascadia subduction zone occurred on January
26, 1700. It produced a tsunami that damaged coastal towns
as far away as Japan.
The region's next big earthquake could happen any day now,
Wang says, or it might not happen for several hundred years.
When the day comes, a tsunami—with inundation heights of 50
feet or more—could hit the northwest coast within 10 to 20
minutes.
The standard emergency response in cases like these is to
move people inland and uphill, but there are plenty of
communities where people simply won't be able to evacuate in
time, Wang says. The resort town of Seaside, Ore., for
example, is low-lying with inadequate roads and bridges.
Kids and the elderly are particularly vulnerable.
In Cannon Beach, Ore., Wang has started meeting with
officials to hold serious discussions on constructing the
first tsunami evacuation building in the U.S. The building,
a proposed rebuilding of the town's existing city hall,
would have to be made of reinforced concrete with a deep
foundation and strong columns, a post-tensioning structural
system to keep it upright, an 18-foot tall first floor, and
wave-dissipation structures in front and back, among many
other design details.
Tsunami evacuation buildings won't be cheap. Wang estimates
that the one in Cannon Beach would have an added cost of
between $1 million and $2 million. But the building would
provide a safe space that people could reach quickly and be
ready for emergency response and long term recovery. Getting
just one such building off the ground, Wang said, is a
critical first step towards creating a network of buildings
that will help save many thousands of lives.
1021 Study finds
mercury levels in children with autism and those developing
typically are the same [UC Davis]--In a large
population-based study published online today, researchers
at the UC Davis MIND Institute report that after adjusting
for a number of factors, typically developing children and
children with autism have similar levels of mercury in their
blood streams. Mercury is a heavy metal found in other
studies to adversely affect the developing nervous system.
The study, appearing in the journal Environmental Health
Perspectives, is the most rigorous examination to date of
blood-mercury levels in children with autism. The
researchers cautioned, however, that the study is not an
examination of whether mercury plays a role in causing the
disorder.
"We looked at blood-mercury levels in children who had
autism and children who did not have autism," said lead
study author Irva Hertz-Picciotto, an internationally known
MIND Institute researcher and professor of environmental and
occupational health. "The bottom line is that blood-mercury
levels in both populations were essentially the same.
However, this analysis did not address a causal role,
because we measured mercury after the diagnosis was made."
The research was conducted as part of the Northern
California-based Childhood Autism Risks from Genetics and
the Environment (CHARGE) Study, of which Hertz-Picciotto is
the principal investigator. The CHARGE Study is a large,
comprehensive, epidemiologic investigation designed to
identify factors associated with autism and discover clues
to its origins. CHARGE study participants include children
between 24 and 60 months who are diagnosed with autism, as
well as children with other developmental disorders and
typically developing controls.
The study looked at a wide variety of sources of mercury in
the participants' environments, including fish consumption,
personal-care products (such as nasal sprays or earwax
removal products, which may contain mercury) and the types
of vaccinations they received. The study also examined
whether children who have dental fillings made of the
silver-colored mercury-based amalgam and who grind their
teeth or chew gum had higher blood-mercury levels. In fact,
those children who both chew gum and have amalgams did have
higher blood-mercury levels.
But the consumption of fish — such as tuna and other ocean
fish and freshwater fish — was far and away the biggest and
most significant predictor of blood-mercury levels. Data on
most possible sources of mercury — fish consumption and
dental amalgams –— were collected by interviews with the
study subjects' parents. Information on vaccines was
obtained from the child's vaccination and medical records. A
few children had recently had a vaccine containing mercury,
and their blood-mercury levels were not elevated.
Of the 452 participants included in the research, 249 were
diagnosed with autism, 143 were developing typically and 60
had other developmental delays, such as Down syndrome. At
the outset, the children with autism appeared to have
significantly lower blood-mercury levels than the typically
developing children. But children with autism tend to be
picky eaters and, in this study, ate less fish. When
adjusted for their lower levels of fish consumption, their
blood-mercury concentrations were roughly the same as those
of children with typical development and very similar to
those found in a nationally representative sample of 1- to
5-year-old children.
Hertz-Picciotto said the CHARGE study is casting a wide net,
addressing an array of exposures that originate in the home
or the broader environment, as well as genes and gene
expression. Because so little is known about the causes of
autism, the researchers plan to look at everything from
household products to medical treatments, diet and
supplements, and even infections. Additionally, they will
explore interactions among multiple factors.
"Just as autism is complex, with great variation in severity
and presentation, it is highly likely that its causes will
be found to be equally complex. It's time to abandon the
idea that a single 'smoking gun' will emerge to explain why
so many children are developing autism. The evidence to date
suggests that, without taking account of both genetic
susceptibility and environmental factors, the story will
remain incomplete. Few studies, however, are taking this
kind of multi-faceted approach," Hertz-Picciotto said.
Other study authors include Peter Green, Lora Delwiche,
Robin Hansen, Cheryl Walker and Isaac Pessah, all of the
University of California, Davis.
The study was funded by the National Institute of
Environmental Health Sciences, the U.S. Environmental
Protection Agency through the Science to Achieve Results
(STAR) program and the UC Davis MIND Institute.
1021 Clots traveling
from lower veins may not be the cause of pulmonary embolism
in trauma patients [Boston MA]--A report from a
team of Massachusetts General Hospital (MGH) physicians
calls into question the longstanding belief that pulmonary
embolism (PE) – the life-threatening blockage of a major
blood vessel in the lungs – is caused in trauma patients by
a blood clot traveling from vessels deep within the legs or
lower torso. In their study utilizing advanced imaging
technologies, which appears in the October Archives of
Surgery, the MGH investigators found no evidence of deep
venous thrombosis (DVT) in most trauma patients with
pulmonary embolism.
"A consistent finding of previous studies – which was often
overlooked – was that no lower-extremity vein clots were
found in patients suffering pulmonary embolism," says George
Velmahos, MD, PhD, chief of the MGH Division of Trauma,
Emergency Surgery, and Surgical Critical Care, who led the
study. "But our surgical minds were so stuck in the dogma
that PE originates from lower-extremity DVT that even though
the data was there, we didn't pay attention to it."
Traditional thinking has been that pulmonary embolism
results when a deep venous thrombosis in the legs or pelvis
breaks off and travels through the bloodstream into the
lungs. If that were true, the authors note, pulmonary
embolism patients should still have evidence of the DVT,
since part of the original clot would remain attached to the
location where it formed. The earlier studies that did not
find DVTs in trauma patients with PE had utilized ultrasound
imaging, which is limited in its ability to locate deep
venous thrombosis, possibly missing any remaining clots.
The current investigation analyzed the results of
computed-tomography-based tests – CT pulmonary angiograms
for the lungs and for the lower extremities CT venography,
which is highly accurate in diagnosing clots in major blood
vessels. The researchers reviewed the records of 247 trauma
patients who had received both CT pulmonary angiograms and
CT venograms at MGH from 2004 through 2006. While 46
patients developed pulmonary embolism and 18 had deep venous
thrombosis, only 7 of the 46 PE patients also had evidence
of DVT. The known accuracy of CT venograms make it highly
unlikely, the authors note, that many patients had
undetected DVTs.
This report – believed to be the first to express doubts
about the accepted origin of pulmonary embolism – needs to
be confirmed by other investigators and also cannot be
extrapolated to the rare instances when PE develops in
otherwise healthy individuals. The authors' hypothesis – yet
to be tested – is that clots may form independently in the
lungs, and if the study's results hold up, they would imply
that current measures to prevent PE – including
blood-thinning drugs, mechanical compression of the legs and
the insertion of filters into the major vein that carries
blood from the lower extremities – are not effective.
"If it turns out that clots are forming primarily in the
lungs, it would revolutionize the way we think about PE and
they way we prevent and treat it," says Velmahos, who is the
John Francis Burke Professor of Surgery at Harvard Medical
School.
Additional authors of the Archives of Surgery report are
Konstantinos Spaniolas, MD, Malek Tabbara, MD, Marc de Moya,
MD, Alice Gervasini, RN, PhD, and Hasan Alam, MD; MGH
Trauma, Emergency Surgery, and Surgical Critical Care; and
Hani Abujudeh, MD, MGH Radiology.
1021 Violence between
couples is usually calculated, and does not result from loss
of control [Haifa, Israel]--Violence between
couples is usually the result of a calculated
decision-making process and the partner inflicting violence
will do so only as long as the price to be paid is not too
high. This is the conclusion of a new study by Dr. Eila
Perkis at the University of Haifa. "The violent partner
might conceive his or her behavior as a 'loss of control',
but the same individual, unsurprisingly, would not lose
control in this way with a boss or friends," she explains.
In this new study, carried out under the supervision of
Prof. Zvi Eisikovits and Dr. Zeev Winstok of the University
of Haifa's School of Social Work, Dr. Perkis examined
intimate violence based on the fact that in most cases the
offending partner is a law-abiding individual living a
normative life outside of the family unit. Dr. Perkis says
that in most cases the couple continues living together and
sustaining a shared family unit, so it is important that we
learn to understand the dynamics of such partnerships in
order to treat them.
First Dr. Perkis divided intimate violence into four levels
of severity: verbal aggression; threats of physical
aggression; moderate physical aggression; and severe
physical aggression. "These four levels follow one another
in an escalating sequence; someone who uses verbal violence
might well move on over time to threatening physical attack,
and from there it is only downhill towards acting on the
threat," she explains. Dr. Perkis warns however, that the
results of this study should not be correlated to cases of
murder, since the dynamics between couples in such cases are
different and such offenses are not included in the chain of
violent acts being examined.
The researcher found that acting on each type of violence is
calculated, such that the violence constitutes a tool for
solving conflict between the partners. "Neither of the
couple sits down and plans when he or she will swear or lash
out at the other, but there is a sort of silent agreement
standing between the two on what limits of violent behavior
are 'ok', where the red line is drawn, and where behavior
beyond that could be dangerous," she explains. She adds that
when speaking of one-sided physical violence, most often
carried out by men, the violent side understands that for a
slap, say, he will not pay a very heavy price, but for
harsher violence that is not included in the 'normative'
dynamic between them, he might well have to pay a higher
price and will therefore keep himself from such behavior.
"A 'heavy price' could be the
partner's leaving or reporting the incident to the police or
the workplace. As such, it can be said that violent behavior
is not the result of loss of control and both sides are
aware of where the red line is drawn, even if such an
agreement has never been spoken between them," she says.
According to Dr. Perkis, it is important to point out that
use of violence is not a normative behavior; it is illegal,
and of course, immoral. Therefore, it is only the violent
partner who is culpable for the act. Nevertheless, once we
understand that violence is being used as a tool for solving
conflict between a couple that is interested in staying
together, we can help them subdue such behavior by providing
them with better tools to cope with the source of tension
and conflict in their lives together.
"In couples therapy for partners who express the wish to
stay together, therapy must be focused on identifying
illegitimate motives, such as nonnormative tactics for
solving conflict, and assisting the couple in acknowledging
their ability to convert destructive patterns into effective
ones and ultimately to run their lives better," the
researcher concludes.
1021 Paradigm shift
needed to combat drug resistance - international human
migration needs to be factored into infectious disease
policy [Hamilton ON]--When people travel,
bacteria and other infectious agents travel with them. As
about a billion people cross international borders each
year, many more billions of the bugs come along for the
ride.
However, the trend is contributing to substantial domestic
and international public health threats and risks, as seen
with SARS and more recently with the H1N1 flu virus.
In a paper published today in Emerging Infectious Diseases (EID),
a journal of the U.S. Centers for Disease Control and
Prevention, a McMaster University infectious disease expert
explores the relationship between population mobility,
globalization and antimicrobial drug resistance.
In collaboration with a team of international scientists,
Douglas MacPherson, an associate professor in the Department
of Pathology and Molecular Medicine of the Michael G.
DeGroote School of Medicine, assesses the link between human
travel and the international movement of drug-resistant
infectious diseases around the world.
Citing published data, the authors conclude that population
mobility affects the spread and distribution of resistant
organisms. But despite this, it has not been considered a
primary factor in developing approaches for disease control.
The authors propose a paradigm shift is needed to tackle the
problem, as well as greater international collaboration and
standardization across borders.
"The movement of human beings is introducing many of the
greatest risks to our health and health systems today," said
MacPherson, a physician and medical microbiology specialist.
"For example, if you go down south on a Florida holiday and
break your leg and end up in a Florida hospital, when you
come home, you're going to be carrying institutional bugs
back to Hamilton and you're going to introduce that variety
of antimicrobial resistance into your local environment.
Mobile populations are probably the most common way of
moving drug-resistant organisms around the world."
Using H1N1 influenza and other infectious diseases as
examples, the EID paper concludes that the complexity of
human movement exceeds current international disease control
policies and practices.
The researchers suggest that an effective response requires
engagement at the local level, standardization of practices,
partnerships between a variety of sectors and rigorous
health information gathering along with threat and risk
assessment. They also recommend that mobile populations need
to be taken into consideration when modelling drug
resistance.
"It's not just about being reactive or responsive to the
problem. We now have the ability to be more proactive in
decision making, more integrative and more collaborative.
That's how we'll get to better solutions," MacPherson said.
The authors recommend a new approach be developed to
integrate population factors into health policy and
processes, which have traditionally focused on specific
diseases.
"A shift in the existing paradigm of pathogen-focused
policies and programs to include the 'human factor' in
health and disease would contribute to a healthier future
for everyone," MacPherson said.
The ideas contained in the Emerging Infectious Diseases
paper originated with the work of the Infectious Disease
Information Expert Committee of the Council of Experts of
the United States Pharmacopeia , an arm's length
organization working with the U.S. government that
establishes technical and analytic standards for all
prescriptions, over-the-counter medicines and dietary
supplements manufactured or sold in the United States and
many other countries around the world, including Canada.
MacPherson is the chair of the infectious disease committee
and a member of the Council of Experts.
1021 New mathematical
model more accurately diagnoses acute heart failure in
emergency rooms [Toronto ON]--Researchers at St.
Michael's Hospital have developed the first mathematical
model in cardiology and emergency medicine to more quickly
and reliably diagnose acute heart failure (AHF) in emergency
room patients. Research findings published in the Journal of
the American College of Cardiology, have been shown to help
physicians diagnose AHF with greater accuracy.
"In Canada, more than 100,000 people are hospitalized each
year for acute heart failure while an estimated $1.4 - 2.3
billion is spent to manage the disease," explains Dr. Brian
Steinhart, lead researcher and emergency medicine physician
at St. Michael's Hospital. "Our model aims to ensure early
correct diagnosis and treatment, which allows for shorter
emergency department stay for these patients and could lead
to improved health outcomes and better access to precious
emergency department resources."
According to researchers, the model uses natriuretic-peptide
levels (a peptide hormone released from heart muscle to help
regulate body fluids and blood pressure) and the clinician's
judgement to help diagnose patients whose history, physical
or chest X-ray may not clearly indicate AHF. Currently,
accurate clinical diagnosis of AHF in the emergency
department is less than 80 percent.
"In many cases, when a patient arrives in an emergency
department complaining of shortness of breath, physicians
are challenged to correctly diagnose patients," says Dr.
Steinhart, "Our model does not require extensive clinical
information, which makes it relatively simple-to-use. When
the result is greater than 80 percent probability for heart
failure, it suggests that the physician should treat for AHF
and when it is less than 20 percent, the physician should be
looking elsewhere for diagnosis."
The study developed the prediction model from the emergency
department experience of 534 patients with undifferentiated
shortness of breath enrolled in the Canadian Improved
Management of Patients with Congestive Heart Failure
(IMPROVE-CHF) trial.
Researchers and physicians involved in the trial include:
St. Michael's Hospital's Kevin Thorpe, Dr. Ahmed Bayoumi,
Dr. Gordon Moe and Dr. David Mazer, and Massachusetts
General Hospital and Harvard Medical School's Dr. James
Januzzi.
1021 Magnetic leaves
reveal most polluted byways [Boulder CO]--Tree
leaves may be powerful tools for monitoring air quality and
planning biking routes and walking paths, suggests a new
study by scientists at Western Washington University in
Bellingham. The research will be presented at this month's
Annual Meeting of the Geological Society of America in
Portland, Oregon.
Leaves along bus routes were up to 10 times more magnetic
than leaves on quieter streets, the study found. That
magnetism comes from tiny particles of pollution—such as
iron oxides from diesel exhaust—that float through the air
and either stick to leaves or grow right into them.
Geophysicist Bernie Housen and colleague Luigi Jovane
collected several leaves from 15 trees in and around
Bellingham. Five of the trees lay next to busy bus routes.
Five sat on parallel but much quieter side streets. Five
were in a rural area nearby.
Using two measurement techniques, Housen and Jovane found
that leaves along bus routes were between two and 8 times
more magnetic than leaves from nearby streets and between
four and 10 times more magnetic than rural leaves.
Inhaling particulate matter has been linked to a number of
negative health consequences, including breathing troubles
and even heart problems. Tiny particles bypass the airways
and get deep into the lung tissues.
The new study suggests that biking or walking along heavy
bus routes might be as bad for your health as you might
suspect when choking on exhaust fumes. That’s something
cities might want to consider as they plan new routes for
cyclists and pedestrians.
“I ride my bike to work every day,” Housen said. “I’ve
always wondered what the effects of diesel exhaust are on my
health.”
While many details remain to be worked out, the study also
suggests that collecting tree leaves can be a simple and
effective way to measure the load of particulate matter in
the air. European researchers have been exploring the idea
for a while, but this is one of the first studies to apply
the technique in the United States.
“Using trees is a nice, low-tech way to do these studies and
you don’t need to use fancy particle collectors,” Housen
said. “If it works, you could easily collect a lot of data
from a region. You could even have kids collect leaves. That
makes it a powerful tool to see variation of particulate
matter on a very detailed level.”
1021 New laryngoscope
could make difficult intubations easier [Augusta GA]--A
new tool developed by a Medical College of Georgia resident
and faculty member may make it easier to place assisted
breathing devices under difficult circumstances.
About two percent of patients that undergo the process,
called intubation, experience complications – regardless if
it's performed in an emergency situation or prior to
surgery.
During normal intubation, a physician stands behind a
patient's head and uses a metal scope to open the mouth and
guide a flexible plastic tube into the trachea. The tube is
used to maintain a patient's airway and provide a pathway
for mechanical ventilation if necessary.
"In some cases, you can't see the vocal cords, which you
have to go through to place the endotracheal tube, because
of some obstruction," says Dr. Richard Schwartz, chair of
the Department of Emergency Medicine in the MCG School of
Medicine.
Some diseases, such as head and neck cancer, can make
intubation harder. In other cases, anatomical variations,
such as shorter necks and bucked teeth, can make tube
placement more challenging, says Dr. Harsha Setty, a
third-year anesthesiology resident.
Difficult intubations can be traumatic for patients and lead
to problems such as cracked teeth, he says.
To make those intubations easier, Drs. Setty and Schwartz
developed the Video Rigid Flexible Laryngoscope.
The Video RIFL is composed of endotracheal tubes surrounding
a rigid cylindrical body featuring an illuminated LED camera
at one end and a video screen at the other. The light and
camera help guide the scope down the airway. The tube is
placed and released from the scope.
"Any obstructions are easier to see because of the camera
and lighted tip," Dr. Schwartz says. "The flexibility of the
tip also makes it easier to navigate. There is also less
physical pressure on the patient, so the risk of associated
trauma is reduced."
The device is the first of its kind to merge two
technologies – video and articulation, he says. It's being
used successfully at MCGHealth Medical Center and at other
hospitals in California, North Carolina, Washington and
Wisconsin.
While the device is being used primarily in operating and
emergency rooms right now, the potential range of uses is
broader, Dr.Schwartz says.
"It could be used in emergency rescue situations where
patients are airlifted by helicopters and intubation is
difficult because their heads are typically placed against a
wall," he says. "In those cases, rescue workers have to
intubate from the front and the camera on the RIFL makes
that easier."
Dr. Setty says there are also implications for education. "I
could project the camera image on a monitor to teach
students how to intubate in difficult situations," he says.
1021 Outfoxing pox:
Developing a new class of vaccine candidates [Arizona State
University]--In the annals of medicine, Edward
Jenner's 1796 vaccination of a young boy against smallpox,
using fluid from cowpox blisters, remains a landmark case.
In a new study, Kathryn Sykes, a researcher at Arizona State
University's Biodesign Institute and her colleagues have
taken a fresh look at cowpox. Their findings, appearing in
the advanced online issue of Virology, demonstrate that this
ancient pathogen still has much to teach us, and may hasten
development of novel vaccines against smallpox and other
pox-like diseases.
Sykes explains that poxviruses, in addition to their
importance for human health, provide an ideal framework for
investigating protective antigens—parts of the virus that
can be used to develop a vaccine—by means of modern,
high-throughput genomic and proteomic screening
technologies.
"If you study viruses like ebola or HIV, their genomes
contain a small number of genes—maybe just 3-9," she says,
noting that this is too small for the purposes of
demonstrating a capacity for high-throughput functional
screening. Other pathogens like malaria, which boast tens of
millions of nucleotides, are too large. "We wanted something
in the middle that could demonstrate our high-throughput
technologies but not blow us away before we had a few
protocols in place," she says. "Poxviruses are the
Goldilocks case. At around 220 genes, they are just right."
In the current study, Sykes' team used functional screening
of cowpox to identify new vaccine candidates against similar
viruses. These were compared with 4-pox—a vaccine comprised
of 4 protective genes from a close genetic relative of
cowpox called the vaccinia virus. The team found that the
identified antigens offered superior protection in a cowpox
challenge compared with the 4-pox vaccine. (See figure 1)
The 4-pox vaccine was developed by the U.S. Army Medical
Research Institute of Infectious Diseases (USAMRIID) as an
alternative to the licensed vaccine against smallpox, known
as Dryvax, (which is made from live vaccinia and presents
significant risk for those with suppressed immune systems).
By rapidly screening the whole viral genome, Sykes' group
attempts to isolate genes necessary for an effective
vaccine. This subunit vaccine approach is in contrast to
traditional vaccine methods, where scientists use a weakened
form of a live, whole-virus strain. "The dogma among old
fashioned vaccinologists is that you want to make a vaccine
that recreates the immune responses that happens upon
natural infection," Sykes explains. But pathogens like
poxviruses also contain elements that can help the virus
evade or in some cases, subvert the host's immune system.
Subunit vaccines make use of only those genomic segments
known to be immunogenic, provoking a robust immune response
without the danger of initiating disease.
The tricky part is identifying the effective subunits. Using
a process known as expression library immunization, the
entire cowpox genetic library was separated into pools and
tested in comparison with the 4-pox vaccine for protective
effect in a mouse model. In all, the team identified 9 new
protective components. Sykes stresses that the majority of
new candidates would not have been identified through
traditional methods, where scientists focus on a viral gene
because of its function or surface exposed location. "The
power of this technology is that it's assumption-free with
respect to what should be a vaccine candidate."
To further boost the immune response, Sykes recommends using
a gene gun to deliver the subunit vaccines, a process in
which protective antigens are shot directly into the
cytoplasm of immunogenic skin cells, (rather than injected
by needle into muscle cells, which are not themselves
immunogenically active). Such gene gun delivery provides a
highly effective mechanism for delivering antigens to the
immune system.
Sykes emphasizes that a single viral subunit will likely not
offer comprehensive protection. Rather, suites of antigens
must work together synergistically. Further high-throughput,
rapid vaccine development research will focus on identifying
such cooperative antigen groups. "We need to come up with
empirical ways of determining which antigens are working
together," Sykes says. "There's your highly effective
subunit vaccine."
The application of subunit component vaccine strategies for
other diseases, including tularemia, African swine fever
virus, and even cancer is also under investigation. "If you
think of a tumor cell as a pathogen, then you want to take
that tumor cell and treat it the same way we treated
cowpox—by screening all of its potential antigens and
testing them."
1021 News in red and
blue: Messages about social factors and health can backfire
[Ann Arbor MI]--Here's a health idea that
Democrats and Republicans agree on: when given information
on the genetic factors that cause diabetes, both parties
equally supported public health policies to prevent the
disease.
But a study designed by the University of Michigan showed
Republicans were less supportive of such policies after
reading news reports that people with diabetes got their
illness because of social or economic factors in which they
live, such as lack of neighborhood grocery stores or safe
places to exercise.
The social factors increased Democrats' support.
The study will appear online Thursday ahead of its December
publication in the American Journal of Public Health.
"When people are given the same information they can come
away with very different opinions," says Sarah E. Gollust,
Ph.D., a Robert Wood Johnson Foundation Health and Society
Scholar at the University of Pennsylvania who worked on the
study during her doctoral work at U-M.
Increasing public awareness of social factors that impact
health may not uniformly increase public support for action
because some groups simply do not believe they are credible,
authors write.
"Policymakers and journalists should be aware that social
values influence people's opinions about health policy, and
certain messages in the media might trigger these values,"
she says.
The findings contribute to evidence that Americans' opinions
about health policy are polarized by political party lines,
according to the study.
Gollust designed the study with Paula Lantz, Ph.D., a social
epidemiologist and chair of the Department of Health
Management and Policy at the U-M School of Public Health and
Peter A. Ubel, M.D., professor of internal medicine at the
University of Michigan and director of the U-M Center for
Behavioral and Decision Sciences in Medicine.
Study participants viewed news articles about type 2
diabetes on the Internet and then answered questions about
their opinions on health policy and their attitudes about
people with diabetes.
When each viewed an article on the links between social and
neighborhood factors and diabetes, 32 percent of Democrats
agreed with social factors' role on health compared to 16
percent of Republicans.
"If you are more liberally minded the 'neighborhood
explanation' can be motivating, but for people who are more
conservative politically, that message can backfire and make
them even less interested," says Ubel. "The same information
can polarize people."
Diabetes was merely used as an example of a common health
issue.
While type 2 diabetes is associated with health behaviors,
such as poor diet, lack of physical activity and obesity,
these behavioral factors can be influenced by social and
economic factors such as living in an unhealthy
neighborhood. Scientists have also identified numerous
genetic variants that increase susceptibility to type 2
diabetes.
So why focus on social factors? The goal of framing health
matters according to social factors is increasingly used to
shift attention to non-medical strategies to improve health.
The media also commonly discuss the prevalence of social
factors when describing health issues, but few studies have
been devoted to whether it shifts public opinion.
"The problem is these messages aren't going to have the same
effect on all people," Ubel says.
The authors do not suggest that news media avoid reporting
on social factors. Rather, advocates who want to mobilize
the public to support public health policies might consider
disseminating information to the media about both social
factors and individual behavioral causes to avoid triggering
resistance.
"Advocacy groups need to be very careful in thinking about
who their audience is and what framing will work best for
that audience," Ubel says. "Media should do a richer job of
helping people understand each of these different causes."
Authors: Sarah E. Gollust, Ph.D., Paula M. Lantz, Ph.D., and
Peter A. Ubel, M.D.
Citation: American Journal of Public Health, Vol. 99, No.
12, December 2009
Funding: Robert Wood Johnson Foundation Health and Society
Scholars Program at the University of Michigan and at the
University of Pennsylvania, the U-M Center for Behavioral
and Decision Sciences in Medicine, and the University of
Michigan Rackham Predoctoral Fellowship.
1021 Scientists find
'molecular trigger' for sudden death in epilepsy [Houston
TX]--The most common gene for a syndrome
associated with abnormal heart rhythms and sudden death
triggers epileptic seizures and could explain sudden
unexplained death in epilepsy, said researchers from Baylor
College of Medicine in a report that appears today in the
journal Science Translational Medicine.
The identification of this particular potassium channel
KvLQT in neurons of the central nervous system gives
scientists a clue about which epilepsy patients face the
greatest risk of dying unexpectedly, said Dr. Jeffrey
Noebels, the study's senior author and director of the Blue
Bird Circle Developmental Neurogenetics Laboratory at Baylor
College of Medicine. The channel has been identified in
heart muscle cells and now for the first time in brain or
nerve cells.
"Idiopathic (unexplained) epilepsy is one of neurology's
oldest mysteries. While most persons with epilepsy will have
a normal lifespan, our finding now points the way to a
simple and essential test to identify risk for sudden death
in persons with seizures of unknown origin. In these
patients, a routine cardiology evaluation consisting of an
EKG, and if indicated, a genetic screening test for this
family of genes can positively identify this new risk
factor," said Noebels.
"If the gene test is positive,
there are effective treatments for the heart irregularity,
including drugs known as beta blockers, as well as the use
of a cardiac pacemaker to prevent lethal arrhythmias."
As many as 18 percent of deaths in epilepsy come suddenly
without warning, devastating families.
"Living with epilepsy is difficult enough, but unexpectedly
dying from it, as happens in young adults with the disorder,
is one of the greatest fears a family must face," said Dr.
Alica Goldman, assistant professor in the BCM department of
neurology. Noebels is a professor in the departments of
neurology, neuroscience and molecular and human genetics at
BCM.
No one knew why young people with epilepsy died suddenly,
but Goldman built on previous work in Noebels' lab that
found that an ion channel gene thought to work only in the
heart was active in the brain as well. She examined five ion
channel genes linked to long QT syndrome, a disorder
associated with heart rhythm disorders and sudden death.
Long QT refers to an interval in electrocardiograms – the QT
interval, which is prolonged in this disorder. An ion
channel is a tiny pore in a membrane that controls the flow
of ions such as calcium and potassium in and out of a cell.
Goldman found that mice with a mutation in the gene that
encodes for the KvLQT1 ion channel had frequent epileptic
seizes as well as life-threatening heart rhythm
irregularities.
'This demonstrates the long-sought molecular link between
heart and brain in epilepsy," said Noebels.
Goldman is now screening epilepsy patients to determine
whether they have the same gene mutation.
Others who took part in this work include Ed Glasscock, Jong
Yoo, Tara Klassen and Tim Chen. Funding for the work came
from the Dana Foundation, the National Institutes of Health,
the American Heart Association, and Blue Bird Circle
Foundation of Houston.
1021 Is the person next
to you washing their hands with soap? [London School of
Hygiene and Tropical Medicine]--People are more
likely to wash their hands when they have been shamed into
it, according to a study by the London School of Hygiene &
Tropical Medicine.
The study, published in the American Journal of Public
Health, looked at responses to electronic hygiene messages
displayed in UK service station toilets.
A million people die every year from diarrhoeal disease and
respiratory infection. Handwashing with soap is the cheapest
and best way of controlling these diseases. It also prevents
the spread of flu, and hospital-acquired infections such as
Clostridium difficile. However, "it's difficult to know what
kind of message is most effective at changing this everyday
behaviour, so it's important to experimentally test what
works best in a real setting. That way you can save money
and make sure your programme will be effective prior to
rolling out any public health campaign at great expense"
says Robert Aunger, leader of the study.
A quarter of a million people were counted using the toilets
and their use of soap was monitored by on-line sensors. Only
32% of men washed their hands with soap whilst women were
twice as good, with 64% washing their hands.
A variety of messages, ranging from 'Water doesn't kill
germs, soap does' to 'Don't be a dirty soap dodger', were
flashed onto LED screens at the entrance of the toilets and
the effects of the messages on behaviour were measured. 'Is
the person next to you washing with soap?' was best overall,
showing how people respond to whether they thought others
were watching. There were intriguing differences in
behaviour by gender, with women responding to reminders,
while men tended to react best to messages that invoked
disgust, for example 'soap it off or eat it later'.
Gaby Judah, who ran the study said: "Our findings are
particularly important on Global Handwashing Day, when many
agencies concerned with improving health worldwide by
encouraging people to wash their hands with soap will be
looking to use best practice."
1021 Popular
antidepressant associated with a dramatic increase in
suicidal thoughts amongst men [Kings College, London UK]--Nortriptyline
has been found to cause a ten-fold increase in suicidal
thoughts in men when compared to its competitor escitalopram.
These findings are published in the open access journal BMC
Medicine.
The research was carried out by Dr. Nader Perroud from the
Institute of Psychiatry, Kings College London, who headed up
GENDEP, an international team. Dr Perroud said "Suicidal
thoughts and behaviours during antidepressant treatment have
prompted warnings by regulatory bodies". He continued "the
aim of our study was to investigate the emergence and
worsening of suicidal thoughts during treatment with two
different types of antidepressant."
Both escitalopram and nortriptyline have their effect
through the mood modulating neurotransmitter systems. The
former is a selective serotonin reuptake inhibitor (SSRI),
preventing serotonin from re-entering the cell and thereby
prolonging its effect on nerve synapses. The latter is a
tricyclic antidepressant that inhibits the reuptake of
noradrenaline, and to a lesser extent, that of serotonin.
The study was carried out on 811 individuals with moderate
to severe unipolar depression. Whilst an overall trend in
reduction of suicidal thoughts was observed, men who took
nortriptyline were found to have a 9.8-fold increase in
emerging suicidal thoughts and a 2.4-fold increase in
worsening suicidal thoughts compared to those who took
escitalopram.
Perroud concludes, "Our findings that treatment-emerging and
worsening suicidal thoughts may also be associated with
psychomotor activation triggered by antidepressants needs to
be investigated in future studies. The study also refutes
the idea that newer antidepressants such as the SSRIs are
worse than older medications in terms of increasing suicidal
thoughts."
1. Suicidal ideation during treatment of depression with
escitalopram and nortriptyline in Genome-Based Therapeutic
Drugs for Depression (GENDEP): a clinical trial
Nader Perroud, Rudolf Uher, Andrej Marusic, Marcella
Rietschel, Ole Mors, Neven Henigsberg, Joanna Hauser,
Wolfgang Maier, Daniel Souery, Anna Placentino, Aleksandra
Szczepankiewicz, Lisbeth Jorgensen, Jana Strohmaier, Astrid
Zobel, Caterina Giovannini, Amanda Elkin, Cerisse Gunasinghe,
Joanna Gray, Desmond Campbell, Bhanu Gupta, Anne E Farmer,
Peter McGuffin and Katherine J Aitchison
BMC Medicine (in press)
1021 Dying from
dementia - far greater access to palliative care required
[Indianapolis IN]-- A growing number of older
adults are dying from dementia. In an editorial in the
October 15, 2009 issue of the New England Journal of
Medicine, Greg Sachs, M.D., professor of medicine and
director of the Division of General Internal Medicine and
Geriatrics at the Indiana University School of Medicine and
a Regenstrief Institute investigator, notes that end-of-life
care for most older adults with dementia has not changed in
decades and urges that these individuals be provided far
greater access to palliative care, the management of pain
and other symptoms.
Dr. Sachs believes that more research on palliative care for
patients with dementia is needed to update public policy and
get lawmakers and insurance companies to recognize the need
to support and fund care which will improve the overall
health of older adults who can no longer speak for
themselves.
"Since individuals with advanced dementia cannot report
their symptoms, these symptoms often are untreated, leaving
them vulnerable to pain, difficulty breathing and various
other conditions. We shouldn't allow these people to suffer.
We should be providing palliative care to make them more
comfortable in the time they have left," said Dr. Sachs, who
is a geriatrician and medical ethicist.
While it is not easy, caregivers and medical personnel
should attempt to pick up on nonverbal clues of pain, such
as the individual holding the body in a certain way to avoid
a painful posture, or exhibiting swollen, tender joints, he
said. These observations, reported by a caregiver or found
on medical examination, may help the physician make the
patient more comfortable, and help identify underlying
conditions.
Palliative care involves a team-oriented approach to pain
management and medical treatment, as well as emotional
support tailored to the patient's needs. Palliative care
focuses on relieving symptoms such as pain, shortness of
breath, fatigue, nausea, loss of appetite and difficulty
sleeping. Hospice care provides palliative care but
palliative care can be administered regardless of prognosis
along with medical treatment and does not hasten death.
Dr. Sachs' editorial accompanies a Harvard University
observational study of 323 patients with advanced dementia
residing in 22 nursing homes which found that while few
suffered a sentinel event such as a stroke or a heart
attack, the survival of patients with advanced dementia was
usually less than a year, especially following the
occurrence of pneumonia, episodes of fever, or eating
problems.
Dr. Sachs leads the Indiana
Palliative Excellence in Alzheimer Care Efforts (IN-PEACE)
Program which is studying the feasibility of incorporating
an outpatient palliative care program for patients with
dementia into the primary care setting, where most older
adults receive their medical care. The program, supported by
a grant from the National Palliative Care Research Center,
provides improved symptom management, enhanced family
support, and assistance with difficult decision making.
1021 Fighting flu:
Stricter hand hygiene in schools only a short-term measure
[London School of Hygiene and Tropical Medicine]--Increased
hand hygiene in primary schools is only a short-term measure
in preventing infections such as H1N1 from spreading.
Researchers writing in the open access journal, BMC Public
Health, found stricter hand hygiene practices are difficult
to maintain in a school setting.
School children may be twice as likely to catch H1N1
influenza as adults, as such health policies often stress
hand hygiene among school children as one low cost
intervention that may prevent influenza from spreading.
A research team led by Wolf-Peter Schmidt at the London
School of Hygiene and Tropical Medicine, London, UK used
qualitative methods to explore teachers' and students' views
on different hand hygiene protocols, as well as interviewing
school nurses. Their pilot study in four East London primary
schools examined both practical issues and attitudes, and
included class exercises in hand washing or lining up to use
hand sanitizer.
The researchers found that staff are motivated to contribute
to hygiene education over and above what children learn from
their parents, provided that expectations are realistic for
the school environment. But very frequent and highly
monitored hand washing would be hard to keep up over the
longer term without the motivation of a major perceived
public health threat like the current influenza pandemic.
During a busy school day, time was a major factor in
deciding what level of hand hygiene could be achieved.
School nurses were more focused on reducing infection,
whereas teachers saw hygiene as an important education topic
– particularly among the younger age groups. Rinse-free
alcohol gel hand sanitizer was the fastest and least messy
option. But teachers highlighted to children that this was
only for situations where soap and water was in short
supply.
"Intensive hand hygiene interventions are feasible and
acceptable but only temporarily during a period of a
particular health threat like an influenza pandemic and only
if rinse-free hand sanitizers are used," according to
Schmidt.
"In many settings there may be
logistical issues in providing all schools with an adequate
supply," he added. "Hand hygiene is important in particular
for the prevention of gastro-intestinal infections. The
effect of hand hygiene on the spread of influenza is less
clear, but may be promoted as a precautionary measure, even
in the absence of evidence. Our study highlights the
practical issues of bringing improved hand hygiene to
scale."
1021 CT scans show
patients with severe cases of H1N1 are at risk for
developing acute pulmonary emboli [University of Michigan]--Researchers
utilizing computed tomography (CT) scans have found that
patients with severe cases of the H1N1 virus are at risk for
developing severe complications, including pulmonary emboli
(PE), according to a study to be published online Oct. 14,
2009, in the American Journal of Roentgenology. The study
will be published in the December issue of the AJR.
A pulmonary embolism occurs when one or more arteries in the
lungs become blocked. The condition can be life-threatening.
However, if treated aggressively, anti-coagulants (blood
thinners) can reduce the risk of death.
The study, performed at the University of Michigan Health
Service, included 66 patients diagnosed with the H1N1 flu.
Two study groups were formed. Group one consisted of 14
patients who were severely ill and required Intensive Care
Unit (ICU) admission. Group two consisted of 52 patients who
were not severely ill and did not require ICU admission.
All 66 patients underwent chest X-rays for the detection of
H1N1 abnormalities. Ten patients from the ICU group and five
patients from the largely outpatient group, underwent CT
scans. "Pulmonary Emboli were seen on CT in five of 14 ICU
patients," said Prachi P. Agarwal, M.D., lead author of the
study.
"Our study suggests that patients who are severely ill with
H1N1 are also at risk for developing PE, which should be
carefully sought for on contrast-enhanced CT scans," she
said.
"With the upcoming annual influenza season in the United
States, knowledge of the radiologic features of H1N1 is
important, as well as the virus's potential complications.
The majority of patients undergoing chest X-rays with H1N1
have normal radiographs. CT scans proved valuable in
identifying those patients at risk of developing more
serious complications as a possible result of the H1N1
virus, and for identifying a greater extent of disease than
is appreciated on chest radiographs," said Dr. Agarwal.
1017 Infectious disease
experts express concern over N95 recommendations [Society
for Healthcare Epidemiology of America]--Last
week's announcement by the Centers for Disease Control and
Prevention (CDC) that it is modifying its guidance regarding
measures that should be taken by healthcare workers who are
in contact with either confirmed or suspected cases of H1N1
was met with concern by the scientific community that had
submitted its recommendations to CDC.
CDC emphasizes a multipronged approach to protecting
healthcare workers from H1N1, including priority use of N95
fit-tested respirators. The Society for Healthcare
Epidemiology of America (SHEA) had urged CDC, based on
clinical experience and scientific evidence, to remove the
use of N95 respirators from its recommendations for routine
care in favor of the first-line use of surgical masks, as
one component of a cadre of prevention measures. Instead,
N95 respirators should be reserved for procedures associated
with a higher risk of aerosolization of the virus.
"Our position was and continues to be that N95s are neither
necessary nor practical in protecting healthcare workers and
patients against H1N1," said Mark Rupp, MD of the University
of Nebraska Medical Center and President of SHEA. "The best
science available leaves no doubt that the best way to
protect people is by vaccinating them."
The scientific community acknowledged that the CDC came
under intense pressure from labor unions to recommend the
use of N95 fit-tested respirators despite the fact that
respirators do not provide any added protection in clinical
situations against droplet transmissible diseases such as
H1N1. SHEA, whose membership is comprised of doctors and
nurses on the front lines caring for patients with the flu,
emphasizes the concern that continuing to recommend that
respirators be used in routine care has major implications
for both patient care and healthcare worker safety. "We
could actually put healthcare workers at greater risk by
further reducing an already short supply of a device that is
needed for high-risk procedures such as bronchoscopy by
using it for routine care," said Rupp.
As acknowledged by the CDC guidance, "It is important to
remember that protecting against the spread of H1N1, or any
type of flu, requires a multi-level approach, and the most
effective measure for protection is vaccination," said Rupp,
adding that "unfortunately this debate on respirators versus
masks has distracted hospitals and clinics from investing in
efforts that we know will pay off such as rigorous and
consistent application of basic infection control and
personal hygiene practices including adherence to cough
etiquette and hand hygiene, rapid identification and
separation of patients with the virus, and excluding sick
workers and visitors from the hospital."
"Along with scientists around the world, we will continue to
research H1N1 and its transmissibility," said Rupp. "We
understand the role of the CDC in providing reassurance
during a period of evolving evidence, and we urge the CDC to
continue to revisit its recommendations as new data becomes
available."
1014 Earlier flu
viruses provided some immunity to current H1N1 influenza [UC
Davis]--University of California, Davis,
researchers studying the 2009 H1N1 influenza virus, formerly
referred to as "swine flu," have identified a group of
immunologically important sites on the virus that are also
present in seasonal flu viruses that have been circulating
for years. These molecular sites appear to result in some
level of immunity to the new virus in people who were
exposed to the earlier influenza viruses.
More than a dozen structural sites, or epitopes, in the
virus may explain why many people over the age of 60, who
were likely exposed to similar viruses earlier in life,
carry antibodies or other type of immunity against the new
virus, immune responses that could be attributed to earlier
flu exposure and vaccinations.
Researchers Zheng Xing, a project scientist, and Carol
Cardona, a veterinarian and Cooperative Extension
specialist, both of the UC Davis School of Veterinary
Medicine, report their findings online in the journal of
Emerging Infectious Diseases. The report will appear in the
November print edition of the journal, published by the
Centers for Disease Control and Prevention.
"These findings indicate that human populations may have
some level of existing immunity to the pandemic H1N1
influenza and may explain why the 2009 H1N1-related symptoms
have been generally mild," Cardona said.
"Our hypothesis, based on the application of data collected
by other researchers, suggests that cell-mediated immunity,
as opposed to antibody-mediated immunity, may play a key
role in lowering the disease-causing ability, or
pathogenicity, of the 2009 H1N1 influenza," Xing added.
He noted that immune responses based on production of
specific cells, known as cytotoxic T-cells, have been
largely neglected in evaluating the efficacy of flu
vaccinations. In this type of immune response, the T-cells
and the antiviral chemicals that they secrete attack the
invading viruses.
About 2009 H1N1 influenza
The 2009 H1N1 virus is a new strain of influenza that first
appeared in the United States in April 2009. Early on, it
was referred to as "swine flu" because it was genetically
similar to influenza viruses that normally occur in pigs in
North America. Further study, however, revealed that the
virus actually included genes from viruses found in birds
and humans, as well as pigs.
At first, this H1N1 influenza virus apparently caused a high
number of deaths among patients in Mexico and among people
with certain pre-existing medical conditions. But as it has
progressed to become a pandemic or geographically widespread
virus, H1N1 has caused relatively mild symptoms and few
deaths.
One hallmark of this new influenza virus, according to the
Centers for Disease Control and Prevention, has been the
presence of pre-existing antibodies against the virus in
about one third of H1N1 2009 patients over the age of 60, a
phenomenon that suggested some levels of immunity may have
existed to the new pandemic H1N1 virus. The UC Davis
research
To probe this phenomenon, the UC Davis researchers surveyed
data from earlier studies of epitopes known to exist on
different strains of seasonal influenza A. They found that
these epitopes, present in other seasonal H1N1 influenza
strains around the world and capable of triggering an immune
response, were also present in the strains of H1N1 2009 that
were found in California, Texas and New York.
Interestingly, although previous H1N1 viruses seem to have
produced a protective antibody response in exposed people,
these antibodies largely did not provide cross-protection
for individuals infected with the H1N1 2009 strain of
influenza. The researchers theorize that, rather than
stimulating protective antibodies, the epitopes of the new
H1N1 2009 virus produced an immune response by triggering
production of cytotoxic T-cells, which boost a person's
immune defenses by killing infected cells and attacking the
invading viruses.
Humans can mount two types of immune responses. One type is
produced when the invading virus triggers production of
protective antibodies that circulate in the bloodstream, and
the other type, described above, is known as a cell-mediated
immune response. It is produced when the invading virus
triggers the activation of cytotoxic T-cells, a process that
helps clear the virus from the body. Evidence from earlier
studies suggests that cytotoxic T-cell immune immunity can
be caused by either an active viral infection or by
vaccination against such a virus.
Implications for avian influenza
The researchers note that about 80 percent of the epitopes
found in seasonal influenza and flu vaccine viruses are also
present in the highly pathogenic H5N1, or avian influenza,
virus. They suggest that these epitopes may have protected
some individuals infected with the highly pathogenic H5N1
virus through cytotoxic T-cell immunity.
However, the H5N1 virus rapidly reproduces itself and
spreads so quickly within vital organs that the body may not
be able to launch protective immunity, thus accounting for
the high fatality rate of avian influenza.
Furthermore, only a fraction of the human population can
recognize the specific epitopes necessary to cause the
appropriate protective immune response, which may explain
why the H1N1 2009 virus, as well as avian influenza, may
vary in severity from person to person.
Xing and Cardona propose that immunity acquired from
seasonal influenza or flu vaccinations may provide partial
protection for patients infected with the avian influenza
virus due to the shared epitopes essential for cytotoxic
T-cell immunity.
This is supported by statistics from the World Health
Organization indicating that there have been fewer avian
influenza infections in people 40 years and older than there
were in people under that age, and that the fatality rate of
avian influenza was just 32 percent in the older age group
but 59 percent in the younger group.
The researchers, therefore, suggest that repeated exposure
to seasonal influenza viruses or flu vaccinations may have
resulted in cytotoxic T-cell immunity to avian influenza,
and that the same type of immunity may also have developed
in people exposed to the H1N1 virus.
Funding for this study was provided by grants from the
Department of Homeland Security's National Center for
Foreign Animal and Zoonotic Disease Defense, and by the UC
Davis Center for California Food Animal Health.
1014 Flu surveillance
boosts control, treatment options [University of Alabama at
Birmingham]--Because pandemics unfold in
unpredictable ways, surveillance of travel-related illness
is among the most powerful tools health officials and
doctors can use to detect and respond to new pathogens like
the novel H1N1 influenza, says the physician who heads the
University of Alabama at Birmingham (UAB) Travelers' Clinic.
"Being able to track disease outbreaks in real time enables
you to know, in real-time, what works and what doesn't work
in terms of treatment," says David Freedman, M.D., director
of the clinic.
Freedman is also co-director of GeoSentinel, a global online
network of 48 travel- and tropical-medicine clinics spread
across several continents. The network is a partnership
between UAB, the International Society of Travel Medicine,
the Centers for Disease Control and Prevention (CDC) and
other groups – and an important part of that surveillance
toolkit.
"GeoSentinel is showing us travelers and mobile populations
getting the flu," Freedman says. "We are tracking which
countries and places have intense enough transmission that
they are then exporting flu and potentially seeding other
countries.
"Today, if a GeoSentinel-linked doctor in Singapore has 10
infected patients and treats them a certain way that works
well, that information can be disseminated on the same day,
as well," he says.
The H1N1 flu virus was first identified in Mexico and
quickly spread through human infection to more than 70
countries. H1N1 disease cases began immediately showing up
as clickable dots on the GeoSentinel secure Web site in
April of this year, Freedman says.
Unlike traditional surveillance maps, the GeoSentinel shows
locations where someone got sick during travel, as opposed
to where they live or where they may be recuperating.
Tracking and understanding the patterns of H1N1's spread
remains crucial as more dots show up on the GeoSentinel map,
Freedman says. Member clinics log on to the network and
submit disease cases through a standardized Internet form,
which links to global positioning. Qualified researchers,
doctors and others use those reports for pandemic modeling
and monitoring, and to gain a big-picture look at disease
transmission.
"The most striking thing is how rapidly the swine flu
spread," Freedman says. "Although the H1N1 virus is fairly
mild compared to a lot of other novel flu viruses, it is
very contagious. Back in 1918 and 1919 when we had the great
flu epidemic, it took six months or more to spread across
the world.
"The new H1N1 swine flu spread across the world in six
weeks."
One important pattern to emerge through GeoSentinel
monitoring was naming North America as the early source for
spreading H1N1 person-to-person, Freedman says. The initial
surveillance data was continuously shared with public-health
groups, governmental agencies and doctors who needed to
respond swiftly to the pathogen.
"With the speed of modern travel, and the fact that our
countries draw visitors from a lot of different
nationalities, the ingredients for a pandemic were there.
Americans were top of the list for exporting this disease,"
he says.
1014 H1N1 critical
illness can occur rapidly; predominantly affects young
patients [JAMA]--Critical illness among Canadian
patients with 2009 influenza A(H1N1) occurred rapidly after
hospital admission, often in young adults, and was
associated with severely low levels of oxygen in the blood,
multi-system organ failure, a need for prolonged mechanical
ventilation, and frequent use of rescue therapies, according
to a study to appear in the November 4 issue of JAMA. This
study is being published early online to coincide with its
presentation at a meeting of the European Society of
Intensive Care Medicine.
Infection with the 2009 influenza A(H1N1) virus has been
reported in virtually every country in the world. The World
Health Organization declared the first phase six (phase
indicating widespread human infection) global influenza
pandemic of the century on June 11, 2009. The largest number
of confirmed cases occurred in North America between March
and July 2009, according to background information in the
article.
Anand Kumar, M.D., of the Health Sciences Centre and St.
Boniface Hospital, Winnipeg, Manitoba, Canada, and
colleagues with the Canadian Critical Care Trials Group H1N1
Collaborative conducted an observational study of critically
ill patients with 2009 influenza A(H1N1) in 38 adult and
pediatric intensive care units (ICUs) in Canada between
April 16 and August 12, 2009. The study focused on the death
rate at 28 and 90 days, as well as the frequency and
duration of mechanical ventilation and the duration of ICU
stay.
The researchers found that a total of 168 patients had
confirmed or probable 2009 influenza A(H1N1) infection and
became critically ill during this time period, and 24 (14.3
percent) died within the first 28 days from the onset of
critical illness. Five more patients died within 90 days.
The average age of the patients with confirmed or probable
2009 influenza A(H1N1) was 32.3 years, 113 were female (67.3
percent), and 50 were children (29.8 percent).
"Our data suggest that severe disease and mortality in the
current outbreak is concentrated in relatively healthy
adolescents and adults between the ages of 10 and 60 years,
a pattern reminiscent of the W-shaped curve [rise and fall
in the population mortality rate for the disease,
corresponding to age at death] previously seen only during
the 1918 H1N1 Spanish pandemic," the authors write.
Patients with 2009 influenza A(H1N1) infection-related
critical illness experienced symptoms for a median
(midpoint) of four days before entering the hospital, but
worsened rapidly and required care in the ICU within one or
two days. Shock and multi-system organ failure were common,
and 136 patients (81 percent) received mechanical
ventilation, with the median duration being 12 days. The
average ICU stay was 12 days. Lung rescue therapies included
neuromuscular blockade, inhaled nitric oxide and
high-frequency oscillatory ventilation.
"In conclusion, we have demonstrated that 2009 influenza
A(H1N1) infection-related critical illness predominantly
affects young patients with few major comorbidities and is
associated with severe hypoxemic respiratory failure, often
requiring prolonged mechanical ventilation and rescue
therapies," the authors write. "With such therapy, we found
that most patients can be supported through their critical
illness."
Editorial: Preparing for the Sickest Patients With 2009
Influenza A(H1N1)
In an accompanying editorial, Douglas B. White, M.D., M.A.S.,
and JAMA Contributing Editor Derek C. Angus, M.D., M.P.H.,
of the University of Pittsburgh School of Medicine, write
that many U.S. hospitals may not have adequate numbers of
physicians or staffing structures to facilitate timely
treatment of the most seriously ill patients with 2009
influenza A(H1N1).
"Hospitals must develop explicit policies to equitably
determine who will and will not receive life support should
absolute scarcity occur," they write. "Any deaths from 2009
influenza A(H1N1) will be regrettable, but those that result
from insufficient planning and inadequate preparation will
be especially tragic," they conclude.
1014 Critical illness
from 2009 H1N1 in Mexico associated with high fatality rate
[JAMA]--Critical illness from 2009 influenza
A(H1N1) in Mexico occurred among young patients, was
associated with severe acute respiratory distress syndrome
and shock, and had a fatality rate of about 40 percent,
according to a study to appear in the November 4 issue of
JAMA. This study is being published early online to coincide
with its presentation at a meeting of the European Society
of Intensive Care Medicine.
Novel 2009 influenza A(H1N1) was first reported in the
southwestern United States and Mexico in March 2009. Between
March 18 and June 1, 2009, 5,029 cases and 97 documented
deaths occurred in Mexico. The population and health care
system in Mexico City experienced the first and greatest
early burden of critical illness, according to background
information in the article.
Guillermo Domínguez-Cherit, M.D. of Instituto Nacional de
Ciencias Médicas y Nutrición "Salvador Zubirán," Mexico
City, and colleagues conducted an observational study of
critically ill patients at six hospitals in Mexico that
treated the majority of such patients with confirmed,
probable, or suspected 2009 influenza A(H1N1) between March
24 and June 1, 2009. The study focused on the death rate,
rate of critical illness and mechanical ventilation, and
length of stay in the hospital and the intensive care unit.
Among 899 patients admitted to hospitals with confirmed,
probable, or suspected 2009 influenza A(H1N1), 58 became
critically ill. The critically ill patients had a median
(midpoint) age of 44 years. Most were treated with
antibiotics, and 45 patients were treated with
anti-influenza drugs known as neuraminidase inhibitors,
including oseltamivir and zanamivir. Fifty-four patients
required mechanical ventilation.
"Our analysis of critically ill patients with 2009 influenza
A(H1N1) reveals that this disease affected a young patient
group," the authors write. "Fever and respiratory symptoms
were harbingers of disease in almost all cases. There was a
relatively long period of illness prior to presentation to
the hospital, followed by a short period of acute and severe
respiratory deterioration."
By 60 days, 24 of the critically ill patients (41.4 percent)
died. Nineteen patients died within the first two weeks
after becoming critically ill.
"Patients who died had greater initial severity of illness,
worse hypoxemia [abnormally low levels of oxygen in the
blood], higher creatinine kinase levels, higher creatinine
levels, and ongoing organ dysfunction," the authors report.
"Early recognition of disease by the consistent symptoms of
fever and a respiratory illness during times of outbreak,
with prompt medical attention including neuraminidase
inhibitors and aggressive support of oxygenation failure and
subsequent organ dysfunction, may provide opportunities to
mitigate the progression of illness and mortality observed
in Mexico," they conclude.
1014 ECMO saves lives:
Swine flu study [Monash University]--A research
team has warned medical experts in the Northern Hemisphere
not to underestimate the serious impact of the H1N1 (Swine
flu) virus with a new report showing that many patients who
were critically ill with the virus required prolonged life
support treatment with heart-lung machines.
The latest report, released today in the Journal of American
Medical Association (JAMA) revealed the extent to which
doctors in Australia and New Zealand used extracorporeal
membrane oxygenation (ECMO) during the height of the
pandemic during June to August 2009.
ECMO is the most advanced and invasive form of life support
available for lung failure and has previously been used
rarely. This winter, 68 patients suffering severe acute
respiratory distress syndrome (ARDS) - a major symptom of
the H1N1 virus - were treated with ECMO.
At the time of the report, 54 of the 68 patients had
survived and 14 (21 per cent) had died. Six patients
remained in ICU, including two who were still receiving ECMO.
Sixteen patients were still in hospital but had moved out of
ICU, and 32 had been discharged from the hospital.
ECMO takes blood from the body through large plastic tubes
and circulates it through a system that adds oxygen. ECMO is
generally used for a limited time because of the risks of
bleeding, clotting, infection and organ failure. ARDS is a
very severe condition where the lungs fail due to the rapid
accumulation of fluid within the lungs.
The team was led by Monash University researcher Dr Andrew
Davies, Senior Research Fellow at the Australian and New
Zealand Intensive Care Research Centre, who said the H1N1
patients admitted to ICU's were suffering symptoms of
respiratory failure and there seemed no choice but to use
ECMO to try and save their lives.
"We had not used ECMO machines to treat swine flu patients
before because the disease was new to us – but now we know
the treatment works and despite the severity of patients'
symptoms, most survived," Dr Davies said.
The average duration of ECMO treatment was ten days and the
patients stayed in the hospital for an average of 39 days.
The research team - Australia and New Zealand Extracorporeal
Membrane Oxygenation (ANZ ECMO) Influenza Investigators -
conducted the observational study in 15 intensive care units
(ICUs) in Australia and New Zealand between June 1 and
August 31, 2009.
The researchers looked at a range of factors including
degree of lung dysfunction in patients, how many patients
were admitted, the duration of treatment and survival.
Dr David Gattas, Intensive Care Specialist at the Royal
Prince Alfred Hospital in Sydney said the research
information would better prepare ICU's in the Northern
Hemisphere for the patients who develop the more severe
cases of the virus.
"The findings of the study should be widely read in the
Northern Hemisphere and we hope this knowledge will help
medical teams who may have to make fast decisions about
starting advanced life supports such as ECMO. Many of these
severely affected flu victims can survive," Dr Gattas said.
1014 Should noninvasive
ventilation be considered a high-risk procedure during an
epidemic? [CMAJ]--Contrary to current policies
recommending that non-invasive ventilation be avoided during
an infectious outbreak, the author of a commentary in CMAJ
(Canadian Medical Association Journal) argues that it should
be used expeditiously in this setting.
Noninvasive ventilation uses a mask interface to ventilate
the lungs of patients in respiratory failure, rather than a
tube inserted into the trachea. Because suitable candidates
for noninvasive ventilation avoid complications associated
with endotracheal intubation, they have better outcomes
compared to similar patients who are ventilated invasively.
Prohibitions against noninvasive ventilation were
implemented during the SARS (severe acute respiratory
syndrome) outbreak in 2003 because it was thought that flow
from the mask increased the risk of infectious transmission
to staff. Since then, the World Health Organization, the
United Kingdom's National Health Agency, the Hong Kong Lung
Association, the American Association of Respiratory Care
and Ontario's Provincial Infectious Diseases Advisory
Committee have published guidelines that treat noninvasive
ventilation as a high-risk procedure.
"During the SARS epidemic, the suggestion that noninvasive
ventilation may increase the risk of disease transmission
was considered sufficient justification to avoid its use.
However in the 6 years since then, no convincing evidence
has substantiated that theory. On the other hand,
noninvasive ventilation has been proven to save the lives of
some patients in acute respiratory failure", writes John
McCracken, a respiratory therapist at Peterborough Regional
Health Centre in Peterborough Ontario Canada.
"It is in no one's best interest for patients to undergo
endotracheal intubation in cases where it could be avoided.
In light of the available evidence, the precautionary
principle would suggest that it is imprudent for
policymakers to await scientific certainty. Noninvasive
ventilation can be accomplished using simple portable
equipment. "If the demand for sophisticated ICU ventilators
threatens to exceed supply during an infectious outbreak,
the expeditious use of noninvasive ventilation would help
conserve the equipment for those who need it most,"
concludes the author.
1014 Over half of cot
deaths occur while co-sleeping [BMJ]--More than
half of sudden unexplained infant deaths occur while the
infant is sharing a bed or a sofa with a parent
(co-sleeping) and may be related to parents drinking alcohol
or taking drugs, suggests a study published on bmj.com
today.
Although the rate of cot death in the UK has fallen
dramatically since the early 1990s, specific advice to avoid
dangerous co-sleeping arrangements is needed to help reduce
these deaths even further, say the researchers.
The term sudden infant death syndrome (SIDS) was introduced
in 1969 as a recognised category of natural death that
carried no implication of blame for bereaved parents.
Since then, a lot has been learnt about risk factors, and
parents are now advised to reduce the risk of death by
placing infants on their back to sleep, placing infants in
the "feet to foot" position at the bottom of the cot, and
keeping infants in a smoke-free environment.
But it is not clear which risk messages have been taken on
board in different social or cultural groups, and little is
known about the emergence of new or previously unrecognised
risk factors.
So a team of researchers at the Universities of Bristol and
Warwick studied all unexpected infant deaths from birth to
two years in the southwest region of England from January
2003 to December 2006.
To investigate a possible link between SIDS and
socioeconomic deprivation, they compared these deaths with a
control group at 'high risk' for SIDS (young, socially
deprived mothers who smoked) as well as a randomly selected
control group.
Parents were interviewed shortly after the death and
information was collected on alcohol and drug use. A
detailed investigation of the scene and circumstances of
death was also conducted by trained professionals.
Of the 80 SIDS deaths analysed, more than half (54%)
occurred whilst co-sleeping compared to 20% co-sleeping rate
amongst both control groups.
Much of this risk may be explained by the combination of
parental alcohol or drug use prior to co-sleeping (31%
compared with 3% random controls), and the high proportion
of co-sleeping deaths on a sofa (17% compared with 1% random
controls), say the authors.
A fifth of SIDS infants were found with a pillow for the
last sleep and a quarter were swaddled, suggesting
potentially new risk factors emerging.
The risk factors were similar whichever group the SIDS cases
were compared with, suggesting that these risk factors for
SIDS apply to all sections of the community and are not just
a consequence of social deprivation.
Some of the risk reduction messages seem to be getting
across and may have contributed to the continued fall in the
SIDS rate, say the authors. However, the majority of the
co-sleeping SIDS deaths occurred in a hazardous sleeping
environment. The safest place for an infant to sleep is in a
cot beside the parental bed in the first six months of life,
they write.
Parents need to be advised to never put themselves in a
situation where they might fall asleep with a young infant
on a sofa. They also need to be reminded that they should
never co-sleep with an infant in any environment if they
have been drinking or taking drugs.
We have learnt that SIDS is largely preventable, says Edwin
Mitchell, Professor of Child Health Research at the
University of Auckland, in an accompanying editorial. It is
important to monitor parents' knowledge and infant care
practices to inform health education and promotion.
Implementing what we already know has the potential to
eliminate SIDS, the challenge now is how to change
behaviour, he concludes.
1014 Canadian blood
supply future uncertain as population ages: Study [McMaster
University]--The Canadian blood supply relies
heavily on a small number of donors—with young adults
donating at higher rates—which may prove problematic as the
population ages, according to a new study from McMaster
University.
The research, published in open access format in the
International Journal of Health Geographics, examined what
specific factors had an impact on blood donation in this
country.
"Like other countries, Canada's population is aging and the
implications of this need to be better understood from the
perspective of blood supply," says Antonio Páez, lead
researcher and assistant professor in the department of
Geography & Earth Sciences at McMaster University. "So while
younger people are more likely to donate, they are also a
declining share of Canada's population."
Almost every single Canadian will require donor blood at
some point in their lifetime, but less than 4% of eligible
donors donate, explains Páez.
The team of researchers used records from Canadian Blood
Services, the national charitable organization charged with
overseeing the safety of the blood supply, which operates 40
permanent collection sites and more than 20,000 donor
clinics annually.
The study found those aged 15 to 24 were the most likely to
donate, while those who are typically more entrenched in the
workforce—aged 25 to 54—were the least likely to donate
blood.
Similarly, immigrants and the wealthy were less likely to
donate, while English-speaking Canadians, highly educated
individuals or those employed in health-related occupations
were more likely to give blood. Researchers also found that
those living in small cities or towns were far more likely
to donate than people who live in larger, metropolitan
cities.
"Blood products are an essential component of modern
medicine and necessary to support many life-saving and
life-prolonging procedures. To achieve sustainable levels of
donations, there needs to be targeted campaigns to encourage
a greater number of Canadians to consider blood donation,"
says Páez.
According to researchers, 25% of Canadians believe there are
some risks associated with giving blood, but an aggressive
education campaign would help expand the donor database,
which is estimated at about 12.5 million eligible donors.
The study was funded by Canada's Social Sciences and
Humanities Research Council, Canada Blood Services and
Environics Analytics. The complete study can be viewed at
http://www.ij-healthgeographics.com/content/8/1/56.
1014 H1N1 simulation
modeling shows rapid vaccine rollout effective in reducing
infection rates [Canadian Medical Association Journal]--Early
action, especially rapid rollout of vaccines, is extremely
effective in reducing the attack rate of the H1N1 influenza
virus, according to a simulation model of a pandemic
outbreak reported in a new study in CMAJ (Canadian Medical
Association Journal).
The article presents a simulation model that projects how
many people will be infected under different disease control
strategies. The model simulated a pandemic outbreak based on
demographic information from London, a mid-sized city in
Ontario, Canada as well as epidemiologic influenza pandemic
data. It looked at the impact of vaccination timing, school
closures and antiviral drug treatment strategies as well as
the effect of pre-existing immunity.
The authors simulated a large range of possible scenarios
that may play out in reality, to determine whether any
general conclusions could be drawn. The model captures how
vaccination not only protects vaccinated individuals but can
also help the healthcare system to cope by flattening the
peak of the outbreak and delaying the peak. The model
provides mathematical predictions for how and when that
could happen.
The H1N1 pandemic has required decision-makers to set policy
in the face of significant uncertainties, and simulation
models can be used to help them decide on the best strategy
to mitigate the spread of infection.
"The results of our pandemic influenza simulation model
suggest that vaccination can have a disproportionately large
impact on reducing the attack rate in a "fall wave,"
although delays can significantly erode its effectiveness,"
write Dr. Marija Zivkovic Gojovic and coauthors.
As well, the model predicts that school closures would be
effective. However, the authors note there are important
social costs of school closures that they did not examine in
the analysis. The study did not attempt to predict
influenza-related deaths, and did not assess vaccination
strategies targeted to high risk groups or specific age
groups, such as school age children.
The model was developed by researchers from the University
of Toronto, the Ontario Agency for Health Protection and
Promotion and the Research Institute of the Hospital for
Sick Children in Toronto; and University of Guelph in
Guelph, Ontario.
1010 NIH prepares to
launch 2009 H1N1 influenza vaccine trial in people with
asthma [NIH]--The National Institutes of Health
is preparing to launch the first government-sponsored
clinical trial to determine what dose of the 2009 H1N1
influenza vaccine is needed to induce a protective immune
response in people with asthma, especially those with severe
disease. The study is cosponsored by the National Institute
of Allergy and Infectious Diseases (NIAID) and the National
Heart, Lung, and Blood Institute (NHLBI), both part of NIH.
"People with severe asthma often take high doses of
glucocorticoids that can suppress their immune system,
placing them at greater risk for infection and possibly
serious disease caused by 2009 H1N1 influenza virus," says
NIAID Director Anthony S. Fauci, M.D. "We need to determine
the optimal dose of 2009 H1N1 influenza vaccine that can be
safely administered to this at-risk population and whether
one or two doses are needed to produce an immune response
that is predictive of protection."
The study plan has been submitted to the Food and Drug
Administration for review. With FDA allowing it to proceed,
the clinical trial will be conducted at seven sites across
the United States that participate in NHLBI's Severe Asthma
Research Program.
This program already has a well-characterized group of
participants with mild, moderate or severe asthma who may be
eligible for this new study. These groups are largely
distinguished by the amount and frequency of glucocorticoids
needed to control asthma symptoms. People with mild disease
may not need glucocorticoids, or may require low doses of
inhaled glucocorticoids; those with moderate asthma need low
to moderate doses of inhaled glucocorticoids; and those with
severe asthma need high doses of inhaled glucocorticoids and
frequently use oral glucocorticoids as well.
Individuals who already have been infected with 2009 H1N1
influenza or have received a 2009 H1N1 influenza vaccination
will not be eligible for the study.
"The results of this study will have immediate implications
for individuals with severe asthma as well as those who have
milder asthma," says NHLBI Director Elizabeth G. Nabel, M.D.
Early results from other clinical trials of 2009 H1N1
influenza vaccines in healthy adults have shown that a
single 15-microgram dose of 2009 H1N1 influenza vaccine
without adjuvant is well tolerated and induces a strong
immune response in most participants. The same vaccine also
generates an immune response that is expected to be
protective in healthy children ages 10 to 17 years. Ongoing
trials are comparing the immune response to one and two
doses of 15- or 30-micrograms of vaccine given three weeks
apart in various populations.
The Centers for Disease Control and Prevention has
recommended that certain at-risk populations receive the new
H1N1 vaccine as a priority before the general population.
These target populations include pregnant women, health care
providers and individuals with underlying chronic medical
conditions, including asthma.
People who have severe asthma may be particularly at risk
for infection with the 2009 H1N1 influenza virus. A report
published in 2004 suggested that some people who took high
doses of glucocorticoids to treat their asthma may receive
less protection from influenza vaccines against some strains
of influenza. Early in the 2009 H1N1 flu outbreak a CDC
review of hospital records found that people with asthma
have a four-fold increased risk of being hospitalized with
infection compared to the general population.
The study will enroll approximately 350 people with mild,
moderate and severe asthma. Participants will be organized
into two groups: those with mild or moderate asthma and
those with severe asthma. Half of the participants in each
group will receive a 15-microgram dose of vaccine, and the
other half a 30-microgram dose. Three weeks later, each
participant will receive a second dose of the same amount.
The strength of the immune response induced by the vaccine
will be determined in blood samples by measuring the level
of antibodies against 2009 H1N1 flu virus.
Safety data will be collected and examined throughout the
course of the study by trial investigators and by an
independent safety monitoring committee. Participants will
be monitored for any side effects they may experience
because of the vaccine, as well as asthma attacks that occur
during the study period.
The vaccine to be used in the trial, manufactured by
Novartis, contains inactivated 2009 H1N1 influenza virus and
therefore cannot cause anyone to become infected with the
virus.
The trial will be conducted at the following locations:
* Cleveland Clinic, Ohio
* Emory University, Atlanta
* University of Pittsburgh Asthma Institute
* University of Virginia, Charlottesville
* University of Wisconsin, Madison
* Wake Forest University, Winston-Salem, N.C.
* Washington University School of Medicine, St. Louis
Detailed information about this study can be found on the
ClinicalTrials.gov Web site at
http://clinicaltrials.gov/ct2/results?term=H1N1+AND+asthma.
1010 NIH launches 2009
H1N1 influenza vaccine trials in HIV-infected pregnant women
[NIH]--The first clinical trials to test whether
the 2009 H1N1 influenza vaccine can safely elicit a
protective immune response in pregnant women launched
yesterday, and a trial to conduct the same test in
HIV-infected children and youth will begin next week. The
International Maternal Pediatric Adolescent AIDS Clinical
Trials Group is conducting the studies, which are sponsored
and funded by the National Institute of Allergy and
Infectious Diseases (NIAID) and the Eunice Kennedy Shriver
National Institute of Child Health and Human Development (NICHD),
both part of the National Institutes of Health.
"These studies are important because HIV infection and
pregnancy both increase the risk for a poor immune response
to the normal 15-microgram dose of seasonal influenza
vaccine given to the general population," says NIAID
Director Anthony S. Fauci, M.D. "Moreover, children, young
people and pregnant women are at higher risk for more severe
illness from the 2009 H1N1 influenza virus than other
groups, and HIV-infected individuals in these populations
may be particularly vulnerable."
"Because of the increased vulnerability of these
populations, these trials are testing whether doses of
licensed 2009 H1N1 influenza vaccine that are higher than
doses being tested in other groups can safely elicit
protective immune responses in HIV-infected children, youth
and pregnant women," adds Lynne Mofenson, M.D., chief of the
Pediatric, Adolescent and Maternal AIDS Branch in NICHD.
One trial will enroll 130 HIV-infected pregnant women ages
18 to 39 years who are in their second or third trimester
(14 to 34 weeks) of pregnancy. The other trial will enroll
140 children and youth aged 4 to 24 years who were infected
with HIV at birth.
Thirty-five sites and eight sub-sites across the United
States and Puerto Rico are eligible to conduct the trials.
Each volunteer will receive two 30-microgram doses of 2009
H1N1 influenza vaccine 21 days apart. (In contrast, the
NIAID studies of 2009 H1N1 influenza vaccine in
HIV-uninfected children, youth and pregnant women are
testing doses of 15 and 30 micrograms.)
Safety data will be collected and monitored closely by the
study investigators and an independent safety monitoring
committee. The strength and longevity of the immune response
elicited by the vaccine will be gauged in several ways.
The study team will take blood samples from the pregnant
women after each dose and three and six months after
delivery to measure the concentration of antibodies the
women produce against 2009 H1N1 influenza virus and how
strong that antibody response remains over time. After the
women give birth, study staff will sample umbilical cord
blood to measure the concentration of maternal antibodies
against the H1N1 virus that were transferred to the infants
through the placenta. The study team also will collect small
blood samples from the infants at 3 and 6 months of age to
measure their level of maternally derived antibody
protection from the virus over time. The infants will not
receive vaccine.
Similarly, in children and young people, the strength and
longevity of the immune response will be gauged by testing
blood samples taken 21 days after the first dose, 10 days
after the second dose, and six months after entering the
study.
The vaccine, manufactured by Novartis Vaccines and
Diagnostics, contains inactivated 2009 H1N1 influenza virus,
so it is impossible to become infected with the virus by
receiving the vaccine. The vaccine does not contain
adjuvant, a substance added to some vaccines to improve the
body's response to vaccine.
Research on seasonal influenza vaccine and vaccines for
other diseases in HIV-infected and other populations suggest
that higher doses of vaccine tend to elicit stronger immune
responses. These stronger responses, in turn, increase the
concentration of protective antibodies in the bloodstream,
which likely is beneficial to both the vaccinated individual
and, if pregnant, to her fetus. This is the rationale for
testing whether higher doses of licensed 2009 H1N1 influenza
vaccine elicit a protective immune response in HIV-infected
individuals and whether that protection is transferred to
the fetuses of vaccinated pregnant women.
For more information about NIAID-sponsored clinical trials
in HIV-infected pregnant women, children and youth, see
http://www3.niaid.nih.gov/news/QA/H1N1trialsHIVpedspreg.htm.
1010 Lessons learned
from H1N1 virus pandemic - High impact on ICU beds [Monash
University]--A comprehensive study has revealed,
for the first time, the impact of swine flu on the health of
the general public in Australia and New Zealand.
The lessons learned in Intensive Care Units (ICUs) across
the two countries on the impact of the H1N1 (swine flu)
virus are being shared with countries in the Northern
Hemisphere to help them prepare for their upcoming flu
season.
The three-month study, conducted at the height of the
pandemic between June and August, reveals that 722 patients
were admitted to ICUs and that at the peak of the epidemic
up to 20 per cent of ICU beds were occupied by patients with
swine flu infection.
The study was co-coordinated by the Monash University-based
Australian and New Zealand Intensive Care Research Centre (ANZIC-RC).
The study involved all ICUs in Australia and New Zealand
with the affected patients being treated in 109 of these
units. The study was conducted utilising the resources of
the Australian and New Zealand Intensive Care Society
Clinical Trials Group (ANZICS CTG).
Dr Ian Seppelt, a specialist in Intensive Care Medicine and
based at Sydney's Nepean Hospital, said the impact of the
virus on ICUs across Australia and New Zealand was dramatic.
"Intensive Care Units specialise in the management of
patients with life-threatening illness and the surge of
patients with H1N1 placed substantial strain on staff and
resources. The most severely affected patients had pneumonia
affecting both lungs that was caused by the virus. The
number of patients admitted to ICUs with this complication
represented a 600 per cent increase compared to previous
years," Dr Seppelt said.
Clinical Associate Professor Steve Webb, from the Intensive
Care Unit at Royal Perth Hospital, was another key
researcher on the project and said the information, which
surfaced from the study will benefit other countries about
to head into their winter flu season.
"Unlike previous 'seasonal' influenza strains, which impact
heavily on elderly people and people with severe coexisting
medical conditions, the H1N1 virus affected a different
profile. Critical illness due to swine flu was most common
in infants and middle aged people; with pregnant patients,
the overweight, and indigenous patients particularly
affected. Overall, about one-third of patients admitted to
an ICU because of swine flu had no underlying health
problems. " Associate Professor Webb said.
Professor Rinaldo Bellomo, Foundation Chair of the ANZICS
CTG and Director of Intensive Care Research at Austin
Health, Melbourne said the results of the study would be
shared with health authorities in other countries to assist
them better prepare for their flu season.
"We have come through our flu season and our assessment of
the impact of the H1N1 strain will assist them prepare for
any outbreak. The H1N1 virus has taken hold in many
countries already, but many countries in the Northern
Hemisphere will benefit from the lessons we have learned,"
Professor Rinaldo Bellomo said.
"Fortunately a vaccine is now available to prevent the
complications of swine flu and it is important that all
members of the community and especially those with risk
factors, consider being vaccinated," he said.
1010 US must focus on
protecting critical computer networks from cyber attack
[RAND]--Because it will be difficult to prevent
cyber attacks on critical civilian and military computer
networks by threatening to punish attackers, the United
States must focus its efforts on defending these networks
from cyber attack, according to a new RAND Corporation
study.
The study finds that the United States and other nations
that rely on externally accessible computer networks—such as
ones used for electric power, telephone service, banking,
and military command and control—as a foundation for their
military and economic power are subject to cyber attack.
"Adversaries in future wars are likely to go after each
other's information systems using computer hacking," said
Martin C. Libicki, the report's lead author and senior
management scientist at RAND, a nonprofit research
organization. "The lessons from traditional warfare cannot
be adapted to apply to attacks on computer networks.
Cyberspace must be addressed in its own terms."
Working against connected but weakly protected computer
systems, hackers can steal information, make the systems
malfunction by sending them false commands and corrupt the
systems with bogus information.
In most instances, the damage from cyber attacks is
temporary and repeated attacks lead the victim to develop
systems that are more difficult to penetrate. The RAND study
finds that military cyber attacks are most effective when
part of a specific combat operation—such as silencing a
surface-to-air missile system protecting an important
target—rather than as part of a core element in a long,
drawn out military or strategic campaign.
Libicki says it is difficult to determine how destructive a
cyber attack would be. Damage estimates from recent cyber
attacks within the United States range from a few billion
dollars to hundreds of billions of dollars a year.
The study indicates that cyber warfare is ambiguous, and
that it is rarely clear what attacks can damage deliberately
or collaterally, or even determine afterward what damage was
done. The identity of the attacker may be little more than
guesswork, which makes it hard to know when someone has
stopped attacking. The cyber attacker's motivation,
especially outside physical combat, may be equally unclear.
The weapons of cyber war are amorphous, which eliminates
using traditional approaches to arms control. Because
military networks mostly use the same hardware and software
as civilian networks, they have similar vulnerabilities.
"This is not an enterprise where means and ends can be
calibrated to one another," Libicki said. "As a result, it
is ill-suited for strategic warfare."
Because offensive cyber warfare is more useful in bothering,
but not disarming, an adversary, Libicki does not recommend
the United States make strategic cyber warfare a priority
investment. He says similar caution is needed for deterring
cyber warfare attacks, as it is difficult to attribute a
given attack to a specific adversary, and the lack of an
ability to counterattack is a significant barrier.
Instead, Libicki says the United States may first want to
pursue diplomatic, economic and prosecutorial efforts
against cyber attackers.
The study, "Cyberdeterrence and Cyberwar," was prepared by
RAND Project AIR FORCE, a federally funded research and
development center for studies and analysis aimed at
providing independent policy alternatives for the U.S. Air
Force.
1010 Major healthcare
challenges persist for DC children despite high rates of
health insurance coverage [Children's National Medical
Center/ RAND Health]--Despite high rates of
health insurance coverage among children in the District of
Columbia, children's access to health care is inadequate and
poses a significant health problem for the city's young
residents, particularly those who are publicly insured,
according to a RAND Corporation study issued today.
The study, conducted by RAND Health and funded by Children's
National Medical Center, assesses health and health care
among the more than 100,000 youth residing in Washington,
D.C. Researchers suggest that health promotion efforts must
focus on a partnership involving numerous private and public
sector organizations that serve children, including schools,
community-based organizations and child care centers.
The District of Columbia leads the nation in children with
health coverage, with only 3.5 percent estimated to be
uninsured in 2007. Nationally, an estimated 9.1 percent of
children lack health insurance.
"But having health insurance in the District of Columbia
does not automatically translate into access to health
care," said Anita Chandra, the report's lead author and a
behavioral scientist at RAND.
Access problems appear especially profound for children who
have publicly funded insurance. The study finds that rates
of well-child care among publicly insured children are
substantially below national norms and more than one in four
publicly insured children in the District receives care at a
hospital emergency department at least once a year.
The study is the first to comprehensively focus on
children's health issues and examine not only the health
service delivery system, but the communities in which
children live in the District of Columbia. Researchers aim
to provide a foundation for District policymakers to examine
children's health issues, as well as assist the Children's
National Medical Center in allocating its community benefit
resources.
The study finds that numerous barriers prevent residents
from getting primary and specialty health care in
non-hospital settings. One major factor is the uneven
distribution of primary and specialty care providers across
the District. Other barriers cited by District residents in
the study include a perceived lack of provider understanding
of cultural and neighborhood issues, as well as a limited
availability of health care providers who speak languages
other than English. The study also finds that particular
health conditions and health behaviors require special
attention because of their prevalence and potential
severity. Although children are generally healthier than
adults, researchers identified several chronic health
conditions that are prevalent among District youth,
including asthma, sickle cell anemia, HIV/AIDS and obesity.
"Children with asthma, in particular, are substantial users
of hospital-based care," said Carole Roan Gresenz, a study
co-author and senior economist at RAND. "District of
Columbia leaders will want to focus on services that will
help children manage their asthma and other chronic
conditions before they end up in the emergency department or
hospital."
Researchers find that socioeconomic, environment and safety
conditions also are crucial issues facing District youth.
Though the rate of children in poverty in the District has
declined in recent years, the percentage of children who
live in poverty in the District remains higher than the
national percentage (23 percent versus 18 percent).
Safety and violence are particularly important issues. The
rate of dating violence in the District increased from 11
percent to 17 percent from 2005 to 2007, and rates of child
abuse and neglect are twice the national average. As a
result, far more children are in the District's foster care
system than the national average.
The study includes a unique synthesis of information from
previous research, including vital statistic reports and
studies of school nursing and school mental health programs,
along with original data analysis of existing survey and
administrative information. The research also included
information obtained from focus groups with parents,
adolescents and health care providers.
The report's key recommendations include:
* Develop and apply strategies that will increase children's
access to primary and specialty care. This includes
increasing the network of providers through better and
faster reimbursement, and incentives such as support for
electronic health record implementation.
* Focus attention on children with the most prevalent
chronic illnesses: asthma, sickle cell anemia, HIV/AIDS and
obesity. Early preventive care will help children manage
their conditions before they need the hospital or emergency
department.
* Give more attention to prevention and wellness programs
across sectors. This would include violence prevention
programs that address school safety issues, emotional
wellness programs and sexual health interventions that
combine discussions of risky sexual activity with life
skills training.
"This report is an unprecedented review of
pediatric-specific issues in the District," said Jacqueline
D. Bowens, executive vice president at Children's National
Medical Center. "Based on these findings, Children's
National may take the lead on new issues, collaborate on
others, and then play a supporting role on social and
infrastructure development factors that ultimately affect
children's health."
The study, "Health and Health Care Among District of
Columbia Youth," can be found at www.rand.org. Other authors
of the report are Janice Blanchard, Alison Evans Cuellar,
Teague Ruder, Alex Chen and Emily Gillen.
1010 Injury and hazards
in home health care nursing are a growing concern [Columbia
University's Mailman School of Public Health]--Patients
continue to enter home healthcare ''sicker and quicker,"
often with complex health problems that may require
extensive nursing care. This increases the risk of
needlestick injuries in home healthcare nurses. While very
few studies have focused on the risks of home healthcare, it
is the fastest growing healthcare sector in the U.S.
In a recent study, led by
researchers at Columbia University Mailman School of Public
Health, the rate of needlestick-type injuries was 7.6 per
100 nurses. At this rate, the scientists estimate that there
are nearly 10,000 such injuries each year in home care
nurses. The findings, reported in the paper, "The Prevalence
and Risk Factors for Percutaneous Injuries in Registered
Nurses in the Home Health Care Sector," were published in
the September 2009 issue of American Journal of Infection
Control.
According to lead author Robyn Gershon, DrPH, professor of
clinical Sociomedical Sciences at the Mailman School of
Public Health and principal investigator, "although
professionally and personally rewarding for many, home care
nursing can be both physically and emotionally demanding.
Our study findings suggest that home healthcare work may be
dangerous for nurses who work in this setting. These types
of injuries are serious as they can result in infection with
bloodborne pathogens, such as hepatitis and HIV."
A critical finding of this study was the statistical
correlation between needlesticks and exposure to stressful
conditions in the patients' household. Nurses reporting
household stressors, such as cigarette smoke, unsanitary
conditions, air pollution, and vermin, were nearly twice as
likely to report needlestick injuries. Most significant was
the fact that home healthcare nurses exposed to violence in
their patients' households were nearly three and a half
times more likely to also report needlestick injuries,
according to the study.
The home healthcare sector is a very important part of the
nation's healthcare infrastructure with over 1.3 million
workers in the field, including roughly 125,000 RNs. Many
procedures previously performed only in the hospital are now
routinely performed in the home.
Over 700 home healthcare RNs from across New York State were
recruited for this study, which was funded by the National
Institute for Occupational Safety and Health (NIOSH), the
Centers for Disease Control and Prevention (CDC).
The provision of a safe work environment in the home
healthcare sector is complicated by the fact that worker
safety in this setting is largely unregulated. Certain OSHA
regulations do not apply to workers employed in individual
households. However, home healthcare agencies accredited by
the Joint Commission must be in compliance with certain
infection control and other standards. Protecting workers
from violence in the healthcare setting is an ongoing and
well recognized challenge according to Dr. Gershon, "These
results indicate that household hazards in general, and home
care violence in particular, needs addressing."
"Many of the unsafe conditions identified in this study can
also increase risk of harm to patients," said Dr. Gershon.
She further noted that as healthcare increasingly moves out
from the acute care setting and into the home setting,
efforts to improve the health and safety of workers in this
sector is critical, with benefits to home health care
workers and patients alike.
"Dr. Gershon's research on home healthcare and how it
affects elderly patients and caregivers alike is key to
helping us evaluate the ways to ensure that both frail older
adults and their home health providers remain as safe and
healthy in the home setting as possible," says Linda Fried,
MD, MPH, dean of the Mailman School of Public Health. "This
research is especially important since we know that 20% of
the U.S. population will be over 65 years old by the year
2030." Dr. Fried is an epidemiologist and geriatrician whose
career has been dedicated to the science of healthy aging.
The study was supported by Centers for Disease Control and
Prevention/National Institute of Occupational Safety and
Health (5 R01 OH008215-03).
1010 Insured
African-Americans more likely to use emergency room than
other insured groups [UCLA]--Health insurance,
and the access it provides to a primary care physician,
should reduce the use of a major driver of health care
costs: the emergency room.
Yet in a policy brief released today by the UCLA Center for
Health Policy Research, researchers found that in
California, privately insured African Americans enrolled in
HMOs are far more likely to use the ER and to delay getting
needed prescription drugs than HMO-insured members of other
racial and ethnic groups. The research was funded by the
California Office of the Patient Advocate.
It's not that African Americans fail to see their doctors,
researchers say. In fact, of all HMO enrollees, African
Americans were the most likely to report seeing a doctor in
the past year, according to the authors of the brief,
"African-Americans in Commercial HMOs Are More Likely to
Delay Prescription Drugs and Use the Emergency Room."
Patient income and illness did not predict ER or
prescription drug use either. Researchers found greater ER
use and delays in getting prescription drugs even among
African American HMO enrollees who were generally healthy
and had higher incomes.
While the reasons behind the ER use and drug delays among
African Americans are the subject of future research, lead
author Dylan Roby, a research scientist with the UCLA Center
for Health Policy Research, said the data suggests that the
way health maintenance organizations or their contracted
physicians provide care — and the way patients respond to
that care — may create obstacles to timely primary care, as
well as foster excessive use of the emergency room and
delays in getting needed medications.
African Americans Depend on HMOs
More than two-thirds of insured African Americans in
California are enrolled in HMOs (67.3 percent, or 1.35
million), compared with 64.7 percent (4.5 million) of
insured Latinos and 51.6 percent (8 million) of whites.
Using data from the 2007 California Health Interview Survey
(CHIS), researchers found that African American patients
enrolled in commercial HMO plans were more likely to delay
getting needed prescription drugs. Those enrolled in
commercial Kaiser Permanente plans were more likely to use
the ER, they said.
"It's troubling, because it suggests that even if you are
insured and well-off, you still may not be getting the care
you need," Roby said. "It also suggests that HMOs that are
designed to provide preventive care and to make sure people
have their medications are not able to do so."
Kaiser Permanente is the most popular HMO among African
Americans, with one-fourth of all insured African Americans
enrolled in the Oakland-based insurance carrier. Despite HMO
emphasis on preventive care, however, more than a quarter
(25.4 percent) of all privately insured African Americans
enrolled in a Kaiser Permanente plan used the emergency room
in the past year — in contrast to 14 percent of Asian
American enrollees and 17.5 percent of Latinos.
The reasons could range from the relative affordability of
emergency-room services to the ease of accessing those
services, Roby said.
"If it takes days or weeks to get an appointment with your
doctor and just hours to be seen in the ER, people might
make the easier choice, especially if it is convenient and
affordable," he said. "On the other hand, if someone knows
their local ER is overcrowded and expensive, they may be
more likely to wait and see their own doctor."
Delaying Needed Medicine
Privately insured African American HMO enrollees also were
notably more likely to delay getting needed prescription
drugs. Prescription drug delays were about 10 percent higher
for privately insured African Americans enrolled in
non-Kaiser commercial HMO plans than for whites in
comparable commercial plans.
Costs, geography and the pharmacy benefits offered by a
given HMO may all inhibit the timely purchase of
prescription drugs.
"We need to think about how the cost of prescriptions and
delays in getting needed medications are compromising health
status and quality of life," Roby said.
The research helps health advocates in California identify
key health and health care issues for African American HMO
members, said Sandra Perez, director of the California
Office of the Patient Advocate. "This is the first step in
understanding how HMOs can close the gaps in the quality of
care and access they provide to their members."
Roby recommended an education campaign for both patient and
provider that would address appropriate use of the ER and
primary care services, as well as the importance of
medication adherence and getting prescribed medications and
refills.
"African American HMO members need to be empowered to find a
doctor they are comfortable with, while health plans need to
make a greater effort to connect patients with that doctor,"
Roby said.
The policy brief was supported by a grant from the
California Office of the Patient Advocate as part of a
targeted educational outreach program.
1010 New study finds
high rates of childhood exposure to violence and abuse in US
[University of New Hampshire]--A new study from
the University of New Hampshire finds that U.S. children are
routinely exposed to even more violence and abuse than has
been previously recognized, with nearly half experiencing a
physical assault in the study year.
"Children experience far more violence, abuse and crime than
do adults," said David Finkelhor, director of the UNH Crimes
against Children Research Center and the study director. "If
life were this dangerous for ordinary grown-ups, we'd never
tolerate it."
The research was sponsored by the U.S. Department of Justice
(DOJ), Office of Juvenile Justice and Delinquency Prevention
(OJJDP) and supported by the Centers for Disease Control and
Prevention (CDC). The research results are presented in the
journal Pediatrics and an Office of Justice Programs/OJJDP
bulletin titled "Children's Exposure to Violence: A
Comprehensive National Survey."
UNH researchers asked a national sample of U.S. children and
their caregivers about a far broader range of exposures than
has been done in the past.
According to the research, three out of five children were
exposed to violence, abuse or a criminal victimization in
the last year, including 46 percent who had been physically
assaulted, 10 percent who had been maltreated by a
caregiver, 6 percent who had been sexually victimized, and
10 percent who had witnessed an assault within their family.
The authors contend that earlier studies of violence
exposure only inquired about individual crimes – looking
only at bullying or child maltreatment or sexual abuse. In
contrast, this study asked about all such exposures as well
as additional ones that are rarely, if ever, covered such as
dating violence and witnessing domestic violence.
The study found that more than a third of the children had
had two or more different kinds of exposures in the past
year and 11 percent had five or more.
"Studies have missed the fact that there are a surprisingly
large group of very repeatedly and variously victimized kids
whom we should be doing a better job to help and protect,"
Finkelhor said.
The researchers urge teachers, police, doctors, counselors,
and parents to ask children about a broader range of
possible victimization experiences, especially children who
had been identified as victims already. They also call for
new efforts to create safer schools, homes and other youth
environments.
The study was conducted in 2008 and involved interviews with
caregivers and youth about the experiences of a nationally
representative sample of 4,549 children ages 0-17. In
addition to Finkelhor, the authors include Heather Turner,
professor of sociology at UNH, Richard Ormrod, research
professor of geography at UNH, and Sherry Hamby, research
associate professor of psychology at Sewanee, the University
of the South.
1010 Draft NIST report
on Cowboys facility collapse released for comment [National
Institute of Standards and Technology]--A
fabric-covered, steel frame practice facility owned by the
National Football League's Dallas Cowboys collapsed under
wind loads significantly less than those required under
applicable design standards, according to a report released
on October 6 for public comment by the Commerce Department's
National Institute of Standards and Technology (NIST).
Located in Irving, Texas, the facility collapsed on May 2,
2009, during a severe thunderstorm. Twelve people were
injured, one seriously.
Based on the national standards for determining loads and
for designing structural steel buildings, NIST researchers
studying the Cowboys facility found that the May 2 wind load
demands on the building's framework—a series of identical,
rib-like steel frames supporting a tensioned fabric
covering—were greater than the capacity of the frame to
resist those loads.
Assumptions and approaches used in the design of the Cowboys
facility led to the differences between the values
originally calculated for the wind load demand and
structural frame capacity compared to those derived by the
NIST researchers. For instance, the NIST researchers
included internal wind pressure due to the presence of vents
and multiple doors in their wind load calculations because
they classified the building as "partially enclosed" rather
than "fully enclosed" as stated in the design documents. The
NIST researchers also determined that the building's fabric
could not be relied upon to provide lateral bracing
(additional perpendicular support) to the frames in contrast
to what was stated in the design documents and that the
expected wind resistance of the structure did not account
for bending effects in some members of the frame.
"Our investigation found that
the facility collapsed under a wind load that a building of
this type would be expected to withstand," said study leader
John Gross. "As a result of our findings, NIST is
recommending that fabric-covered steel frame structures be
evaluated to ensure the adequate performance of the
structural framing system under design wind loads."
The NIST report recommends that such evaluations determine
whether or not: (1) the fabric covering provides lateral
bracing for structural frames considering its potential for
tearing; (2) the building should be considered partially
enclosed or fully enclosed based on the openings that may be
present around the building's perimeter; and (3) the failure
of one or a few frame members may propagate, leading to a
partial or total collapse of the structure.
Shortly after the Cowboys facility's collapse, NIST sent a
reconnaissance team of three structural engineers to assess
the failed structure and wind damage in the surrounding
area, and collect relevant data such as plans,
specifications and design calculations. Using the data
acquired during the reconnaissance, the NIST study team
developed a computer model of a typical structural frame
used in the practice facility and then studied the frame's
ability to resist forces under two wind conditions: the wind
loads based on the design standard wind speed of 90 miles
per hour and the actual wind loads based on conditions at
the time of the collapse.
NIST worked with the National Oceanic and Atmospheric
Administration's (NOAA) National Severe Storms Laboratory to
estimate the wind conditions at the time of collapse. The
researchers determined that, at the time of collapse, the
wind was blowing predominantly from west to east,
perpendicular to the long side of the building. Maximum wind
speed gusts at the time of collapse were estimated to be in
the range of 55 to 65 miles per hour—well below the design
wind speed of 90 miles per hour in the national standard for
wind loads. The center of a microburst (a small, intense
downdraft which results in a localized area of strong winds)
associated with the May 2 thunderstorm was located about one
mile southwest of the structure at the time of collapse.
According to the NIST and NOAA researchers, the wind field
in the vicinity of the Cowboys facility at the time of
collapse was consistent with design standards and not
unusual.
Based on their study of the wind conditions at the time of
collapse and the structural response, the NIST researchers
determined the following likely collapse sequence:
* Buckling of the inner chord (inner side of the roof truss)
of a frame in a section of the roof on the east side
resulted in the formation of a kink in the frame.
* Failures of the east and west "knees" (connections between
the side walls and the roof) allowed the frame to sway
eastward with the wind.
* Compressive failure of the east side at the roof's highest
point (ridge) led to fractures of the nearby inner and outer
chords in the vicinity of the ridge.
* A progression of frame failures throughout the structure
resulted in total structural collapse.
The draft report is available online at
www.bfrl.nist.gov/investigations/investigations.htm.
NIST welcomes comments on the draft report and
recommendation. Comments must be received by noon Eastern
Standard Time on Nov. 6, 2009. Comments may be submitted in
writing via e-mail to
structuralsafety@nist.gov;
fax to (301) 869-6275; or surface mail to the attention of
Stephen Cauffman, NIST, 100 Bureau Dr., Stop 8611,
Gaithersburg, Md. 20899-8611.
Once the final report is published, NIST will brief and
provide technical support on the recommendation to the
American Society of Civil Engineers (ASCE) committee
currently developing a building standard specifically for
tensioned fabric structures. NIST also will brief the
appropriate committee of the International Code Council
(ICC) on the study's recommendation for use in improving
provisions in ICC's model building code.
1010 For safer
emergencies, give your power generator some space [National
Institute of Standards and Technology]--To subdue
the steaming heat of hurricanes or to thaw out during a
blizzard, gasoline-powered, portable generators are a
lifeline during weather emergencies when homes are cut off
without electricity. But these generators emit poisonous
carbon monoxide—a single generator can produce a hundred
times more of the colorless, odorless gas than a modern
car's exhaust.
New research from the National
Institute of Standards and Technology (NIST) shows that to
prevent potentially dangerous levels of carbon monoxide,
users may need to keep generators farther from the house
than previously believed—perhaps as much as 25 feet.
Up to half of the incidents of non-fatal carbon monoxide
(CO) poisoning reported in the 2004 and 2005 hurricane
seasons involved generators run within 7 feet of the home,
according to the U.S. Centers for Disease Control and
Prevention (CDC).
Carbon monoxide can enter a house through a number of
airflow paths, such as a door or window left open to
accommodate the extension cord that brings power from the
generator into the house. While some guidance recommends 10
feet from open windows as a safe operating distance, NIST
researcher Steven Emmerich says the "safe" operating
distance depends on the house, the weather conditions and
the unit. A generator's carbon monoxide output is usually
higher than an automobile's, he says, because most
generators do not have the sophisticated emission controls
that cars do.
"People need to be aware that generators are potentially
deadly and they need to educate themselves on proper use,"
Emmerich says. With funding from CDC, NIST researchers are
gathering reliable data to support future CDC guidance.
NIST building researchers simulated multiple scenarios of a
portable generator operating outside of a one-story house,
using both a test structure and two different computer
models—the NIST-developed CONTAM indoor air quality model
and a computational fluid dynamics model.
The simulations included factors that could be controlled by
humans, such as generator location, exhaust direction and
window-opening size, and environmental factors such as wind,
temperature and house dimensions. In the simulations the
generator was placed at various distances from the house and
tested under different weather conditions.
"We found that for the house modeled in this study,"
researcher Leon Wang says, "a generator position 15 feet
away from open windows was not far enough to prevent carbon
monoxide entry into the house."
Winds perpendicular to the open window resulted in more
carbon monoxide entry than winds at an angle, and lower wind
speeds generally allowed more carbon monoxide in the house.
"Slow, stagnant wind seems to be the worst case because it
leads to the carbon monoxide lingering by the windows," Wang
explains. Researchers determined that placing the generator
outside of the airflow recirculation regions near the open
windows reduced carbon monoxide entry.
In the next phase of the study NIST will model a two-story
house that researchers believe will interact with the wind
differently. NIST researchers also have worked with the
Consumer Product Safety Commission on related work. (See: "NIST
to Study Hazards of Portable Gasoline-Powered Generators,"
NIST Tech Beat, March 5, 2008.)
The generator study can be downloaded at
http://fire.nist.gov/bfrlpubs/build09/PDF/b09009.pdf.
* L. Wang and S.J. Emmerich. Modeling the Effects of Outdoor
Gasoline Powered Generator Use on Indoor Carbon Monoxide
Exposures. (NIST Technical Note 1637,) 2009.
1010 The high cost of
treating alcohol-impaired drivers [Injury Prevention Center
at Rhode Island Hospital]--The costs of drinking
and driving are all too apparent, with alcohol involved in
41 percent of all motor vehicle crash fatalities in 2006. In
addition to the mortality and morbidity associated with
drinking and driving, the economic impact of alcohol
impaired driving is considerable, estimated at $51 billion,
with medical costs accounting for 15 percent of that figure.
Now a new study from the Injury Prevention Center at Rhode
Island Hospital has found that even minimally injured
alcohol-impaired drivers account for higher emergency
department (ED) costs than other drivers.
Their study appears in the Volume 54, No. 4 October 2009
edition of Annals of Emergency Medicine and is currently
available online in advance of publication. An editorial on
the study also appears in the journal.
Treatment of injuries from motor vehicle crashes accounts
for four percent of the 120 million ED visits in the United
States each year. It is estimated that alcohol is involved
in as many as one in eight of these crashes, bringing the
total to 600,000 cases each year. Alcohol complicates the
clinical assessment of patients within an ED as the
patient's perception of pain may be blunted and a period of
observation may be warranted until the patient is judged to
be coherent enough for an accurate examination.
In the past, research into the cost of treating alcohol
impaired drivers focused on the inpatient population.
Researchers at the Injury Prevention Center at Rhode Island
Hospital led by emergency medicine physician Michael Lee,
MD, felt that this was an incomplete representation of the
medical costs of drinking and driving as it is estimated
that up to 80 percent of alcohol impaired drivers treated in
EDs are discharged to home and are not admitted.
The researchers performed a retrospective study of 1,618
patients who had alcohol in their systemand were treated in
an urban Level I trauma center and discharged home directly
from the ED. The patients ranged in age from 21 to 65.
The study found that the median charges for patients under
the influence of alcohol were higher by $4,538. Lee notes,
"A large percentage of that cost can be directly correlated
to a higher frequency of and costlier diagnostic imaging
studies. Imaging itself represents 69 percent of the charge
differential." In addition, the median length of stay for
alcohol-positive patients was higher by 3.3 hours when
compared to alcohol-negative patients.
Lee says, "While an alcohol-impaired driver may be treated
for only minor injuries and discharged to home, there is
still a considerably higher cost to treat that patient in an
ED. Further, the time spent on them with a longer length of
stay results in delays for other patients who need care in
an ED."
Lee concludes, "The magnitudes are striking for this
minimally injured population. This represents a burden of
alcohol-impaired driving that was underreported in the
past."
Other researchers working with Lee include Michael Mello,
MD, director of the Injury Prevention Center at Rhode Island
Hospital and Steven Reinert, MS, of Lifespan's information
systems department.
1010 Intensive care
units poorly equipped to care for the dying [Sahlgrenska
Academy]--Almost half of the patients who die in
intensive care units die within 24 hours, but the
environment is not equipped to provide good end-of-life
care. Most relatives are nevertheless happy with the care
given, shows a thesis from the Sahlgrenska Academy.
An intensive care unit (ICU) is designed primarily to save
lives rather than provide end-of-life care. When a patient
dies on an ICU, this often follows a sudden illness or
trauma, and neither the patient nor relatives are prepared
for death.
"The location and environment in which people die mean a lot
not only for the person who is dying but also for those who
are to look after them and those who must learn to live
without them," says nurse Isabell Fridh, who wrote the
thesis.
Her thesis shows that Swedish ICUs are often unable to care
for dying patients in separate rooms. The waiting rooms to
which relatives are sent are often too few and too small.
Most units do not have a care programme for end-of-life
care, and many also have no procedures in place for
supporting relatives after a death, which is standard
practice at hospices. The results also show that almost half
of the patients (in the study) died within 24 hours after
admittance (to intensive care), and 40% of these did not
have any relatives present at the time of death.
"This may seem to paint a bleak picture, but the truth is
that most of the relatives I interviewed for my thesis
thought that the care given was a positive experience
despite their sense of loss," says Fridh. "Many feel that
their loved one benefited from all available medical
resources and that everything that could be done to save
their life was indeed done."
Relatives rarely complain about the physical environment,
but they do not like to be separated from the patient
against their will, and greatly appreciate being able to
spend that last bit of time with their loved one in a
private room.
Isabell Fridh also interviewed ICU nurses, who do their
utmost to care for dying patients even where the environment
is not well suited to it. Nurses use the available medical
technology to alleviate patients' suffering and try hard to
provide privacy and give relatives a lasting sense that
their loved one's death was peaceful and dignified.
1010 Research gives new
meaning to 'green' cross code [University of Leeds]--Pedestrians
could reduce the amount of traffic pollution they breathe in
simply by crossing the street, according to the latest
research from the University of Leeds.
The research, led by Professor of Environmental Modelling
Alison Tomlin from Leeds' Faculty of Engineering, has shown
that air pollution levels change dramatically within small
geographical areas dependent on wind patterns, the location
of traffic queues and the position and shapes of the
surrounding buildings.
The findings showed that pollution hotspots tend to
accumulate on the leeward side of the street, (the sheltered
side) in relation to the wind's direction at roof-top level.
They also revealed that that carbon monoxide levels were up
to four times lower in parallel side streets compared to the
main road.
The team monitored traffic flow and carbon monoxide (CO)
levels over an eight week period at one of the busiest
junctions in the UK - the intersection between Marylebone
Road and Gloucester Place in West London.
"CO levels were highly variable over remarkably short
distances," says Professor Tomlin. "As you'd expect, the
junction itself showed high levels caused by queuing
traffic, but with some wind patterns these hotspots moved
further down the street. However, the leeward side of the
street had consistently higher concentrations of carbon
monoxide than the windward side. The same trends would be
expected for other traffic related pollutants such as
ultrafine particles and nitrogen dioxide."
"Most people would expect pollution levels to be slightly
lower away from the main body of traffic, but our figures
show a very significant difference," she says.
"Pollution can be trapped within the street where it is
emitted by recirculating winds. If it escapes to above
roof-top level, it doesn't tend to be mixed back into
neighbouring streets very strongly. It would be worth
cyclists and pedestrians rethinking their regular routes, as
they can massively reduce their pollution exposure by moving
just one street away from the main traffic thoroughfares."
The research also has significance for local authorities and
other bodies monitoring air quality levels in urban areas.
Currently every city has a number of sites monitoring
pollution levels to ensure compliance with EU standards, but
Professor Tomlin says these may need to be looked at in
relation to the other factors identified by the research to
ensure an accurate spatial picture.
"Monitoring stations tend to be sited in what are expected
to be pollution hotspots, but our research has shown that
hotspots move depending on meteorological conditions,
particularly wind direction," says Professor Tomlin. "We
need to develop models which take these factors into
account, so that the data from monitoring sites can be
accurately analysed to provide a true reflection of air
quality across the whole of an urban area."
The research is published in the latest issue of Atmospheric
Environment and has been funded by the Engineering and
Physical Sciences Research Council (EPSRC) and the Natural
Environment Research Council (NERC).
1010 New technology
detects chemical weapons in seconds [Queen's University
Belfast]--Scientists at Queen's University
Belfast are developing new sensors to detect chemical agents
and illegal drugs which will help in the fight against the
threat of terrorist attacks.
The devices will use special gel pads to 'swipe' an
individual or crime scene to gather a sample which is then
analysed by a scanning instrument that can detect the
presence of chemicals within seconds. This will allow
better, faster decisions to be made in response to terrorist
threats.
The scanning instrument will use Raman Spectroscopy which
involves shining a laser beam onto the suspected sample and
measuring the energy of light that scatters from it to
determine what chemical compound is present. It is so
sophisticated it can measure particles of a miniscule scale
making detection faster and more accurate.
Normally this type of spectroscopy is not sensitive enough
to detect low concentrations of chemicals, so here the
sample is mixed with nanoscale silver particles which
amplify the signals of compounds allowing even the smallest
trace to be detected.
Dr Steven Bell from Queen's University Belfast who is
leading the research said:
"Although we are still in the middle of the project we have
finished much of the preliminary work and are now at the
exciting stage where we put the various strands together to
produce the integrated sensor device. For the future, we
hope to be able to capitalise on this research and expand
the range of chemicals and drugs which these sensors are
able to detect."
It is hoped the new sensors will also be the basis for
developing 'breathalyzer' instruments that could be of
particular use for roadside drugs testing in much the same
way as the police take breathalyzer samples to detect
alcohol.
At present, police officers are only able to use a Field
Impairment Test to determine if a person is driving under
the influence of drugs. The accuracy of this method has been
questioned because of concerns that it is easy to cheat.
To ensure the technology is relevant, senior staff members
from FSNI (Forensic Science Northern Ireland) will give
significant input into the operational aspects of the
technology and give feedback as to how it might be used in
practice by the wider user community.
Stan Brown, Chief Executive of FSNI said:
"We consider the work being carried out by researchers at
Queen's University extremely important and potentially very
useful in driving forward the effectiveness, efficiency and
speed of forensic science practice. The combination of
leading edge research and hands-on experience of FSNI's
practitioners has already proven very fruitful and is likely
to lead to significant developments in forensic
methodologies across a range of specialisms."
In the future this technology could have a number of
important applications and according to Dr Bell: "There are
numerous areas, from medical diagnostics to environmental
monitoring, where the ability to use simple field tests to
detect traces of important indicator compounds would be
invaluable."
The research is being led by Dr Steven Bell of the School of
Chemistry and Chemical Engineering at Queen's University of
Belfast in collaboration with colleagues from the School of
Pharmacy at Queen's University and Forensic Science Northern
Ireland.
Since 1999 this collaboration has been focused on developing
new Raman and SERS methods for analysis of illicit drugs,
paints, fibres, materials and other physical evidence. It
has already led to routine use of Raman methods within FSNI
laboratories for drugs intelligence and a more extensive
programme for integrating Raman methods into a broad range
of casework is already underway. This new project will take
the next step and move this research out of the laboratory
and into the field.
1010 Tracing ultra-fine
dust [Fraunhofer Institute for Laser Technology ILT in
Aachen]--Fine particle emissions have been the
subject of heated debate for years. People who live near
industrial plants see the smoke being discharged into the
atmosphere and wonder how harmful it is. But visible
emissions are not always the most harmful. The highest risk
is posed by fine dust particles which can easily penetrate
the human organism. These ultra-fine particles are difficult
to measure, however, because they are less than 100
nanometers in diameter.
Research scientists at the Fraunhofer Institute for Laser
Technology ILT in Aachen have developed a technique by which
the composition of such particles can be precisely analyzed.
"The statutory limit values
for fine particle emissions are based on the total particle
weight," explains Dr. Cord Fricke-Begemann, project manager
at the ILT.
"Large particles are, however,
much heavier than small ones. Weight measurements do not
provide any information on the quantity of ultra-fine
particles in the fine dust, but they are often more harmful
than the larger particles."
The measurement technique developed by the research
scientists consists of two steps. A gas stream separates the
particles into size classes before they are collected on
filters. Their composition is then examined by means of
laser emission spectroscopy.
"We are therefore able to
identify harmful heavy and transition metals, such as zinc,
in the fine dust, and also to ascertain the particle size at
which they become particularly enriched," explains Fricke-Begemann.
A key aspect of the method is
that it delivers the results in less than 20 minutes. What's
more, it can work at a high throughput rate and enables
measurements to be taken directly on site – e.g. in steel
plants. Emission values can be measured and monitored in
real time during production thanks to a further development
of the technique in which the particles are continuously
drawn off via an air tube and analyzed.
All industrial plants produce fine dust emissions, and every
process leaves behind a characteristic "fingerprint" of the
particle composition and size distribution. With their
measurement method the scientists can test the air in nearby
residential areas and identify where the particles are from.
They can also help to develop strategies for reducing
emissions from the plants concerned.
1010 Air pollution may
trigger appendicitis [University of Toronto/ Health Canada]--A
new study in CMAJ (Canadian Medical Association Journal)
suggests that air pollution may trigger appendicitis in
adults.
The study, conducted by researchers at the University of
Calgary, University of Toronto and Health Canada, looked at
5191 adults admitted to hospital in Calgary, Alberta,
Canada. Fifty-two per cent of admissions occurred between
April and September, the warmest months of the year in
Canada during which people are more likely to be outside.
The dominant theory of the cause of appendicitis has been
obstruction of the appendix opening, but this theory does
not explain the trends of appendicitis in developed and
developing countries. Appendicitis cases increased
dramatically in industrialized countries in the 19th and
early 20th centuries, then decreased in the middle and late
20th century, coinciding with legislation to improve air
quality. The incidence of appendicitis has been growing in
developing countries as they become more industrialized.
Using Environment Canada's air pollution data for Calgary,
the researchers determined the levels of ozone, nitrogen
dioxide and other air-borne pollutants along with
temperature. They found correlations between high levels of
ozone and nitrogen dioxide and the incidence of appendicitis
between age groups and genders. More men than women were
found to have the condition.
"For unexplained reasons, men are more likely than women to
have appendicitis," write Dr. Gilaad Kaplan of the
University of Calgary and coauthors. "Men may be more
susceptible to the effects of outdoor air pollution because
they are more likely to be employed in outdoor occupations,"
although they note that misclassifications of data could
explain some of the difference.
While it is not known how air pollution may increase the
risk of appendicitis, the authors suggest pollutants may
trigger inflammatory responses. They recommend further
studies to determine the link.
1010 Keeping children
safe: Rethinking design [University of Toronto/ The Hospital
for Sick Children]--Injury is the leading cause
of death for children over the age of 1 in industrialized
countries and improving the safety of the manmade (built)
environment will benefit children's health, according to an
article in CMAJ (Canadian Medical Association Journal).
Injury accounts for about 40% of childhood deaths in
industrialized countries and is even higher in developing
countries. It often involves failure to negotiate a manmade
environment. Death rates from injury in affluent countries
is 15.3 per 100,000 boys and 10 per 100,000 for girls among
children 14 and younger. In developing countries, the rates
are 50.5 per 100,000 boys and 43.5 per 100,000 girls.
In 2002, 371,000 boys and 289,000 girls worldwide died of
injury, with more than 180,000 – mostly pedestrians – killed
by traffic.
In addition to causing injury and death, unsafe environments
are barriers to physical activity that is important to life
long health. Changes such as speed control, traffic light
phasing, fencing spaces and enhancing pedestrian visibility
can reduce injuries by 50 to 75% in specific locations and
25% in wider areas. By making traffic safer for children, it
increases the likelihood they will walk to school and can
derive health benefits from physical activity. In fact, 50%
of Canadian children never walk to school compared with only
17% who do most of the time.
"By giving priority to automotive over pedestrian
transportation we have allowed road traffic to become the
leading cause of death among our children," writes Dr.
Andrew Howard of the University of Toronto and The Hospital
for Sick Children (SickKids). "North American children are
increasingly sedentary," and urban sprawl is linked to
higher rates of traffic injury and obesity.
Other ways to modify the built environment include
appropriate playground equipment that minimizes injuries
while encouraging activity. Falls from climbing equipment
are 5 times more likely to result in severe fractures than
falls from a standing height. Evidence shows that
playgrounds that did not comply with standards from the
Canadian Standards Association (CSA) had twice the rate of
injury of compliant playgrounds, although these standards
are voluntary without regulatory authority for most Canadian
playgrounds.
Fencing around pools to limit deaths from drowning and
modification of homes and apartments to prevent falls from
windows are other examples of changes to physical
surroundings that can save children's lives.
"Our built environment influences our children's levels of
activity, their physical health and their risk for injury,"
writes Dr. Howard. "Intelligent planning, particularly with
consideration for urban design and traffic engineering to
emphasize safe walking and cycling, has enormous potential
to improve the health and safety of children now and across
the lifespan."
1010 Costs of expanding
health care coverage partly offset by future Medicare
savings [Harvard Medical School]--Expanding
health coverage might not cost as much as policymakers
assume.
New findings from researchers at Harvard Medical School
demonstrate that individuals who were either continuously or
intermittently uninsured between the ages of 51 and 64 cost
Medicare more than those who had continuous insurance
coverage in the years prior to Medicare eligibility.
On average, those who were previously uninsured cost
Medicare an additional $1,000 annually per person when
compared with those who had been consistently covered. These
increased costs were due primarily to complications
resulting from cardiovascular disease and diabetes and from
apparently delayed surgeries for arthritis.
Had these middle-aged adults been consistently covered, they
would have likely cost Medicare less.
"Providing health insurance coverage to older uninsured
adults may not cost as much as previously thought," says
lead author J. Michael McWilliams, Harvard Medical School
assistant professor of health care policy and medicine and a
practicing internist at Brigham and Women's Hospital.
The study, published early online in the Annals of Internal
Medicine, was funded by the Commonwealth Fund, a private
foundation supporting independent research on health policy
reform and a high performance health system.
In order to get a comprehensive picture of how coverage
before age 65—or a lack thereof—affects Medicare spending
after age 65, McWilliams and colleagues, including senior
author John Ayanian, professor of healthcare policy and
medicine at Harvard Medical School and Brigham and Women's
Hospital and professor of health policy and management at
the Harvard School of Public Health, looked at two sources
of linked national data.
First, they analyzed information from the Health and
Retirement Study, a nationally representative longitudinal
survey that collected health insurance and other information
from a large sample of adults. Starting in 1992, when
members of this sample group were between the ages of 51 and
61, survey information was collected every two years until
2006, tracking each person's transition into Medicare. From
these data they identified two separate groups, one group of
2951 adults who had been continuously insured before
becoming eligible for Medicare at age 65, and another group
of 1616 adults who were either intermittently or
continuously uninsured before age 65.
Next, they analyzed Medicare claims data for these same
individuals from age 65 until age 74, using rigorous
statistical methods to ensure that the two groups of adults
were evenly balanced for all recorded demographic and health
characteristics before age 65.
Not only did they find that the previously uninsured cost
the Medicare system substantially more than the previously
insured (on average, $5796 versus $4773 per person
annually), but they found that nearly two thirds of this
increase was due to potentially preventable hospitalizations
and delayed elective procedures.
"The bulk of the higher spending was explained by chronic
conditions we know how to treat, which makes perfect
clinical sense," says McWilliams. "When uninsured adults do
not receive adequate care for hypertension, heart disease,
and diabetes before age 65, they develop complications that
require costlier care after age 65."
For example, after age 65 previously uninsured adults with
cardiovascular disease or diabetes had a 48 percent higher
risk of hospitalization for complications related to these
conditions, complications such as heart attacks, heart
failure, and strokes. Those who lacked insurance prior to
Medicare and had arthritis were also 86 percent more likely
to be hospitalized for hip and knee replacements, suggesting
they delayed these surgeries that relieve pain and enhance
quality of life until they gained Medicare coverage.
"The debate over health reform has focused on its costs
rather than its benefits. This important study shows that
closing the gaps in health insurance coverage for older
adults can have important benefits in controlling chronic
conditions early on—contributing to better health and lower
cost once they reach age 65 and qualify for Medicare," said
Commonwealth Fund President Karen Davis. "These findings
point to the urgent need to act on comprehensive health
reform to ensure secure and stable coverage for all
Americans, and slow the rise in health care costs for
employers, families, and government."
The researchers estimate that filling in the coverage gaps
for adults who are uninsured between ages 51 to 64 would
cost $197 billion due to greater health care utilization.
However, this increase in healthcare for this same group
would potentially reduce subsequent Medicare spending by $98
billion. Thus, the overall net cost would be $99 billion.
According to Ayanian, "This study suggests that not only are
there substantial health benefits to expanding coverage, but
that the economic cost may not be as steep as previously
thought. These potential economic benefits to the Medicare
program are important to consider when evaluating proposals
to expand coverage before age 65."
Written by David Cameron
Full Citation
Annals of Internal Medicine, early online publication Oct 5,
2009
"Medicare Spending for Previously Uninsured Adults"
J. Michael McWilliams, M.D., Ph.D.
Ellen Meara, Ph.D.
Alan M. Zaslavsky, Ph.D.
John Z. Ayanian, M.D., M.P.P.
From the Department of Health Care Policy, Harvard Medical
School (J.M.M., E.M., A.M.Z., J.Z.A.), Boston, MA; Division
of General Internal Medicine and Primary Care, Department of
Medicine, Brigham and Women's Hospital and Harvard Medical
School (J.M.M., J.Z.A), Boston, MA; National Bureau of
Economic Research (E.M.), Cambridge, MA; and Department of
Health Policy and Management, Harvard School of Public
Health (J.Z.A.), Boston, MA.
1010 Analyses of flu
pandemics project savings from earlier vaccinations
[Stanford University Medical Center]--In a city
the size of New York, starting a vaccination campaign a few
weeks earlier could save almost 600 lives and over $150
million, according to a study by scientists at the Stanford
University School of Medicine.
The study, to be published online Oct. 6 in the Annals of
Internal Medicine, modeled a pandemic in a hypothetical
urban area with a population and demographic characteristics
mirroring New York City's.
It concluded that under a very broad range of assumptions,
vaccinating this October would save more money and lives
than in November, and that vaccinating at either time was
better than no campaign at all. An October campaign would
avert 2,051 deaths and save $469 million, while a November
campaign would prevent 1,468 deaths and save $302 million
relative to doing nothing.
"To put it simply, the most cost-saving and life-saving
strategy is to vaccinate as many people as possible as soon
as possible," said the study's first author, Nayer Khazeni,
MD, an instructor of medicine in pulmonary and critical
care. She is also an associate at Stanford's Center for
Health Policy and Center for Primary Care and Outcomes
Research.
Citing New York City's 1976 mass-vaccination program against
swine flu, the investigators presumed that a substantial
fraction of the city's population could be reached in a
10-day campaign. Their sophisticated mathematical model
incorporated numerous alternative assumptions regarding the
new viral strain's lethality and transmission rate, the
vaccine's effectiveness and side-effect profile and the
likelihood that people would limit their social contacts as
cases multiplied.
Public health officials have noted that it may not be
possible to provide H1N1 vaccine on a mass scale in October.
Earlier in the summer, up to 120 million doses of vaccine
were expected to be ready in mid-October, enough to
inoculate 40 percent of the U.S. population. Although the
projected number of doses available by then has been scaled
back to 45 million, enough for 15 percent of the U.S
population, the study makes a compelling case for the
benefits of vaccinating sooner rather than later.
Avoiding hospitalizations, for instance, provides a huge
financial payoff, according to the study's senior author
Douglas Owens, MD, senior investigator at the Veterans
Affairs Palo Alto Health Care System and professor of
medicine and of health research and policy at the medical
school. "A two-week stay in an intensive care unit could
cost well over $50,000," said Owens. "You can vaccinate a
lot of people for that much."
To date, H1N1 vaccines appear to have no serious side
effects. But even when the researchers programmed their
mathematical model with an assumption of substantial vaccine
side effects, they found that far more lives and dollars
would be saved than lost by a mass-vaccination campaign. For
example, under the conservative assumption that the H1N1
vaccine's safety profile would closely resemble that of the
one used in the national swine-flu vaccination campaign of
1976, side effects would cause only two deaths in a city the
size of New York City if 40 percent of the population were
vaccinated.
"That's about 0.1 percent of the lives that would be saved,"
Khazeni noted. "And even if vaccine side effects occurred
far more often, many lives would still be saved by the
campaign for every life lost due to side effects."
The Stanford investigators' mathematical model-developed by
co-author David Hutton, a graduate student in management
science and engineering under Owens' direction-can be used
to look at other scenarios that might become relevant in the
future. For example, a new vaccination strategy would be
needed to cope with a pandemic caused by the H5N1 strain of
influenza, commonly referred to as avian flu. That extremely
virulent strain was, until the onset of the H1N1 pandemic
early this year, the primary concern of public-health
authorities anticipating an influenza pandemic. All it would
take to ignite a dangerous pandemic is a random mutation
that substantially increased H5N1's transmissibility among
humans.
A hypothetical vaccination campaign targeting the H5N1 viral
strain is the subject of a second study, also undertaken by
Khazeni and Owens and their Stanford colleagues, appearing
simultaneously in the same journal. This study models the
efficacy of an H5N1-directed public-health campaign, once
again in a municipality resembling New York City, and
examines the extensive stockpiling of vaccines and antiviral
drugs (such as Tamiflu and Relenza) and their widespread
distribution for preventive use at the onset of a local
outbreak.
Unlike the H1N1 vaccine, studies show, a vaccine targeting
the H5N1 strain would require two vaccine doses and would
need an immune response-boosting substance called an
adjuvant in order to induce strong human immune responses.
The adjuvant would also lower the required individual dose
size by as much as 45-fold, thereby multiplying total
available doses by that amount.
Supplies of adjuvant and antivirals in the federal
government's Strategic National Stockpile should be
expanded, Khazeni said. Those stockpiles would not only be
useful against H5N1, but could also be directed toward use
against other influenza strains with pandemic potential that
may arise at any time.
Added Owens: "Just because we've had H1N1 doesn't mean we
won't have something else."
Funding for the study was provided by the Agency for
Healthcare Research and Quality, the National Institute on
Drug Abuse, the Department of Veterans Affairs and Stanford
University. Its other Stanford co-author is Alan Garber, MD,
PhD, staff physician at the Veteran's Affairs Palo Alto
Health Care System and the Henry J. Kaiser Jr. professor and
director of the Center for Health Policy and the Center for
Primary Care and Outcomes Research. A researcher at Weill
Cornell Medical College in New York was the other co-author.
1010 Child burn
injuries down significantly yet alarming number of children
still being injured [Nationwide Children's Hospital]--In
the next 60 seconds, another child will be on his/her way to
the hospital to be treated for serious burns; it happens
more than 300 times a day in this country.* Now, one of the
largest studies ever done on burn injuries in kids is out
from experts at Nationwide Children's Hospital and the
results are mixed: while overall injuries are down, there
are some kids who are still at serious risk.
Lily McKinney has always loved spending time in the kitchen;
whenever anyone is cooking she's willing to do anything to
help. But in an instant, Lilly's eagerness to help ended up
getting her hurt.
"My husband was checking on the lasagna that was in the oven
and she snuck right around him and just put her hands right
on the oven door," says Lilly's mother Danette McKinney.
Lilly was left with second-degree burns on both hands. She
spent a night in the hospital and weeks in bandages. It's
kids like Lilly that are still getting burned at a
surprising rate, according to the study.
"We found that kids under age six were actually injured the
most, representing about 60 percent of all burn-related
injuries," says Lara McKenzie, PhD, a researcher at
Nationwide Children's Hospital.
Dr. McKenzie found that while burn injuries have dropped 31
percent overall since 1990, the numbers are still
disproportionately high in children under six years of age.
Over the 17-year study period, there were more than 2
million burn-related injuries in this age group, or about
120,000 burns annually.
"For younger children, particularly kids under six, have
thinner skin than older children or adults, and they'll
actually burn faster, even when exposure time is short,"
says McKenzie.
Dr. McKenzie, who is also with
Ohio State, says many hazards are at eye-level in this age
group and in toddlers, their new-found mobility often
catches parents off-guard.
"I think we tend to overestimate the reach and ability of
children, especially young children and toddlers. They can
really reach a lot of surfaces and different hazards," she
says.
Experts suggest you sit on the floor in danger zones in your
house, like the kitchen, to see your home from your kids'
perspective. Seeing the world from their eyes, they say, can
help open your eyes to dangers you may not have noticed.
Burns are a common cause of
pediatric injury worldwide, typically resulting from hot
water, flames, hot surfaces, chemicals and electrical
appliances. A recent study conducted by the Center for
Injury Research and Policy of The Research Institute at
Nationwide Children's Hospital, found that from 1990-2006
more than 2 million children younger than 21 were treated in
hospital emergency departments for burn-related injuries.
The good news that resulted from the 17-year study period is
that researchers saw a 31 percent decrease in the rate of
burn-related injuries. The bad news is that children are
still being injured from burns – about 120,000 each year.
"The decrease in the burn-related injury rate over the study
period is notable," said study author Lara McKenzie, PhD,
principal investigator at the Center for Injury Research and
Policy at Nationwide Children's Hospital. "However, the
disproportionately high number of injuries and the severity
of these burns to young children is still cause for
concern."
Data from the study, being released online October 5 and
appearing in the November issue of Pediatrics, show that
children younger than 6 accounted for more than half of all
burn-related injuries. Among that age group, most injuries
occurred in the home, and the majority (60 percent) resulted
from thermal burns. The hands and fingers were the most
frequently injured body parts (36 percent), followed by the
head and face (21 percent).
Dr. McKenzie, also a faculty member of The Ohio State
University College of Medicine, said that reasons why
younger children suffered a majority of burn-related
injuries during the study period may be due to parents
underestimating the reach ability of toddlers, and the fact
that younger children have thinner skin.
"Parents should be aware of the capability of reach that
their toddler may have," continued Dr. McKenzie. "Items that
seem out of reach for young children may not be. That risk
should be eliminated. Also, young children, especially those
under age 6, have thinner skin, and the severity of a burn
can be greater for them even at a reduced exposure time."
Parents can help protect their children from burns by
setting the water heater thermostat to no higher than 120
degrees Fahrenheit, keeping kids away from the stove,
locking up chemicals and covering unused electrical outlets.
Parents should prohibit young children from operating
microwaves or other electrical appliances, preparing hot
food or drinks, and playing near the kitchen during food
preparation.
"Burn-related injuries are potentially preventable with
better education, warnings and instructions on consumer
products," said Dr. McKenzie. "Increased efforts are needed
to improve burn prevention strategies and target households
with young children."
Data for this study were collected from the National
Electronic Injury Surveillance System (NEISS), which is
operated by the U.S. Consumer Product Safety Commission. The
NEISS dataset provides information on consumer
product-related and sports and recreation-related injuries
treated in hospital emergency departments across the
country.
Sources: *Pediatric Burn Injuries Treated in Emergency
Departments in the United States: 1990-2006; Pediatrics,
Vol. 124 No. 5, November 2009.
1010 Battery ingestion
not uncommon in children; caregivers and physicians need
education [American Academy of Otolaryngology]--Ten
years of case studies at a pediatric hospital and a thorough
literature review have shown that it is not uncommon for
children to ingest small "button" batteries, either through
swallowing or inserting the batteries into their noses.
In a paper presented at the 2009 American Academy of
Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF)
Annual Meeting & OTO EXPO in San Diego, researchers revealed
that a significant lack of knowledge about the dangers of
button batteries exists in the lay population and in
healthcare providers.
Button batteries are miniature disc batteries that are
typically used to power hearing aids, watches, calculators,
and many commonly used items, including small toys and
musical greeting cards. Each year, more than 3,000 people of
all ages in the U.S. unintentionally swallow these
batteries, according to the National Capital Poison Center
in Washington, DC. Sixty-two percent of battery ingestions
involve children under the age of 5, with a peak incidence
in 1- and 2-year-olds.
While many children who ingest button batteries recover with
few long-term health issues, some develop long-term
complications that significantly deteriorate quality of
life, such as tracheostomy-tube or gastrostomy-tube
dependence, vocal paralysis, and septal perforation with
saddle nose deformity. The authors say expeditious
identification and treatment of button battery ingestion is
crucial, for which continuing education must be provided to
pediatricians, primary care, urgent care, and emergency room
care providers, and otolaryngologists.
The authors also concluded that increased public awareness
is necessary to diminish the incidence of such ingestions.
Industry changes, including improved packaging and button
battery markings, will also be fundamental to this process.
Title: Button battery ingestion in the pediatric population
Presenters: Dale Amanda Tylor, MD and Seth Pransky, MD
1010 Global death toll:
1 million premature babies every year [March of Dimes
Foundation]--More than one million infants die
each year because they are born too early, according to the
just released White Paper, The Global and Regional Toll of
Preterm Birth.
The new White Paper shows that in 2005, an estimated 13
million babies worldwide were born preterm -- defined as
birth at less than 37 full weeks of gestation. That is
almost 10 percent of total births worldwide. About one
million deaths in the first month of life (or 28 percent of
total newborn deaths) are attributable to preterm birth.
According to the White Paper, the highest preterm birth
rates in the world are found in Africa, followed by North
America (United States and Canada combined).
These data are being presented at the 4th International
Conference on Birth Defects and Disabilities in the
Developing World to be held in early October in New Delhi,
India.
"Premature births are an enormous global problem that is
exacting a huge toll emotionally, physically, and
financially on families, medical systems and economies,"
says Dr. Jennifer L. Howse, president of the March of Dimes.
"In the United States alone, the annual cost of caring for
preterm babies and their associated health problems tops $26
billion annually.
"If world leaders are serious about reaching the United
Nation's Millennium Development Goals to reduce child
mortality and improve maternal health, then strategies and
funding for reducing death and disability related to preterm
birth must receive priority," Dr. Howse adds.
An Uneven Global Problem
The new White Paper uses data published recently in The
Bulletin of the World Health Organization (WHO). The March
of Dimes says the WHO Bulletin figures are conservative
–counting only singleton preterm births, for example– and
likely underestimates the true magnitude of the worldwide
crisis of preterm birth.
Worldwide, the preterm birth rate is estimated at 9.6
percent –representing about 12.9 million babies. Though all
countries are affected, the global distribution is uneven:
the toll of preterm birth is particularly severe for Africa
and Asia, where more than 85 percent of all preterm births
occur. Comparison of preterm birth rates across world
regions finds the highest rate in Africa -- 11.9 percent or
about 4 million babies each year; followed by (in descending
order) North America, Asia, Latin America and the Caribbean,
Oceania (Australia and New Zealand combined), and Europe.
See chart below for more information.
Increase in Preterm Births
Wherever trend data are available, rates of preterm birth
are increasing. For example, the rate of preterm birth in
the U.S. has increased 36 percent in the past 25 years. Key
factors contributing to this increase include a rise in the
number of pregnancies in women over age 35; the growing use
of assisted reproduction techniques, leading to an increase
in the number of twin and higher order multiple births; and
the rise in the number of late preterm births (defined as
between 34 and 36 weeks gestation).
Babies who survive a preterm birth face the risk of serious
lifelong health problems including cerebral palsy,
blindness, hearing loss, learning disabilities, and other
chronic conditions. Even infants born late preterm have a
greater risk of re-hospitalization, breathing problems,
feeding difficulties, temperature instability (hypothermia),
jaundice and delayed brain development.
Underlying Causes and Risk Factors
There are some known risk factors for preterm birth that can
be identified before or during pregnancy. For example, women
who have already had one preterm baby are at greater risk.
Some preterm births may be preventable by addressing known
modifiable risk factors, including:
* Nutrition and body weight;
* Existing medical conditions such as high blood pressure
and diabetes;
* Alcohol and tobacco use, and secondhand smoke;
* Early elective inductions and elective Cesarean delivery.
However, at present, there is no reliable way to prevent or
delay preterm birth, says Christopher P. Howson, Ph.D., vice
president for Global Programs of the March of Dimes. "While
much can be done right now to reduce death and disability
from preterm birth even in low-resource settings, we need to
know more about the underlying causes of premature birth in
order to develop effective prevention strategies," he says.
The March of Dimes and the other authors of the white paper
call for greater efforts to inform health professionals,
policy makers, women of childbearing age, and others about
the worldwide toll of preterm birth and opportunities for
prevention and for care of women with high-risk pregnancies
and their babies.
Preterm Births: Why Don't They Count?
Few countries currently have good health statistics and
information systems or birth surveillance registries, the
authors of the white paper say, so data on the number of
preterm births and related deaths are limited at best.
"This was a first attempt to estimate the worldwide scale of
the problem," says Mario Merialdi, M.D., of WHO's Department
of Reproductive Health and Research, one of the editors of
the White Paper and an author of the study published in The
Bulletin of WHO. "As a first step, it is necessary to
improve data on the extent of the problem." He says WHO
currently is improving its database on preterm birth in
order to support decision-making in this area.
Another challenge, the authors of the white paper say, is
that there is no internationally accepted classification of
preterm birth or glossary of terms. "We need to at least
adopt common definitions and agree on what is a preterm
baby," says Joy E. Lawn, MRCP, of Saving Newborn Lives/Save
the Children USA.
Dr. Lawn says there also is an urgent need for more country
and regional data on the prevalence of acute and long-term
health problems and impairment caused by preterm birth.
Data gathering and research for the White Paper and the 2010
forthcoming March of Dimes Global Report on Preterm Birth is
supported by the March of Dimes, the World Health
Organization's Department of Reproductive Health and
Research, Save the Children USA, and the Partnership for
Maternal, Newborn, and Child Health, a global partnership
with 260 members.
Editors of the White Paper were Dr. Howson; Dr. Lawn; Dr.
Merialdi; and Jennifer H. Requejo, Ph.D., of the Partnership
for Maternal, Newborn and Child Health and the Institute for
International Programs at the Johns Hopkins Bloomberg School
of Public Health.
Beck S, Wojdyla D, Say L,
Betran AP, Merialdi M, Requejo JH, Rubens C, Menon R, Van
Look P. 2009. WHO systematic review on maternal mortality
and morbidity: The global burden of preterm birth. The
Bulletin of the World Health Organization.
* See also Hamilton BE, Martin JA, Ventura SJ. 2007. Births:
Preliminary data for 2007. National vital statistics
reports, Web release; vol. 57 no. 12. Hyattsville, MD:
National Center for Health Statistics.
1003 Survey finds just
40 percent of adults 'absolutely certain' they will get H1N1
vaccine [Harvard School of Public Health]--In a
new survey, Harvard School of Public Health (HSPH)
researchers found that just 40% of adults are "absolutely
certain" they will get the H1N1 vaccine for themselves, and
51% of parents are "absolutely certain" that they will get
the vaccine for their children. The survey examined the
reasoning among those who said they would not get the
vaccine or might not. This is the latest in a series of
surveys of public views concerning the H1N1 flu outbreak
undertaken by the Harvard Opinion Research Program at HSPH.
The polling was done September 14-20, 2009.
Public Mixed on Getting Vaccine, but Interest May Jump If
Outbreak Is Severe
About six in ten adults are not "absolutely certain" they
will get the H1N1 vaccine for themselves, including 41% who
say they will not get it, 6% who say they don't know if they
will get it, and 11% who say they are planning to get it but
may change their mind. About four in ten parents (44%) are
not "absolutely certain" that they will get the vaccine for
their children, including 21% who will not get it, 7% who
don't know, and 16% who say they are planning to get it but
may change their mind.
If there were people in their community who were sick or
dying from H1N1, roughly six in ten adults (59%) who say
they do not think they'll get the vaccine would change their
mind and get it for themselves. About the same percentage of
parents (60%) who say they do not think they'll get the
vaccine for their children would change their minds if H1N1
was causing sickness or death in their community.
"These findings suggest that public health officials need to
be prepared for a surge in demand for the H1N1 vaccine if
the H1N1 flu becomes more severe," said Robert J. Blendon,
Professor of Health Policy and Political Analysis at HSPH.
Major Reasons for Not Getting Vaccine or Being Unsure
Those who were not "absolutely certain" they will get the
H1N1 vaccine cited the following as the top "major" reasons
for their thinking: (1) they are concerned about getting
side effects from the vaccine (30%); (2) they don't think
they are at risk of getting a serious case of the illness
(28%); and (3) they think they could get medication to treat
H1N1 if they do get sick (26%). The top "major" reasons
cited by parents who are not "absolutely sure" they will get
the vaccine are that (1) they are concerned about side
effects of the vaccine (38%); (2) they are concerned that
their children could get other illnesses from the vaccine
(33%); and (3) they do not trust public health officials to
provide correct information about the safety of the vaccine
(31%).
"There's still a lot of uncertainty about what people will
ultimately do in terms of getting the vaccine. If public
health officials want to encourage a larger number of people
to get vaccinated this fall, they will need to address the
public's concerns in the coming weeks," said Blendon.
Safety Concerns
At this point in time, only about a third (33%) of the
public sees the H1N1 vaccine as very safe "generally for
most people to take." By comparison, the figure is 57% for
the seasonal flu vaccine. A smaller fraction of the public
thinks the H1N1 vaccine is very safe for particular groups
to take, including children ages 6 months to 2 years (18%)
and pregnant women (13%). The Centers for Disease Control is
encouraging these groups, among others, to get the vaccine
as early as possible.
Concerns About Outbreak on the Rise
Public concern about a fall or winter outbreak of H1N1 has
risen since June. Roughly three-quarters of the public (76%)
believe there will be widespread cases of H1N1 this fall or
winter with people getting very sick, which is an increase
from June when only 59% felt the same way. More people are
also now concerned that they or someone in their immediate
family will get sick from H1N1 during the next 12 months
(52% in later September, as compared to 38% in June).
Roughly two-thirds of people (64%) think that public health
officials' concerns about a possible outbreak have been
justified, while one third (31%) think that they have been
overblown.
This poll is part of a series of polls about the way that
Americans and their institutions are responding to the H1N1
flu outbreak. The first three focus on the American public,
and the fourth focuses on views of businesses across the
United States.
Methodology
This poll is part of an on-going series of surveys focused
on the public and biological security by the Harvard Opinion
Research Program (HORP) at Harvard School of Public Health.
The study was designed and analyzed by researchers at the
Harvard School of Public Health (HSPH). The project director
is Robert J. Blendon of the Harvard School of Public Health.
The research team also includes Gillian K. SteelFisher, John
M. Benson, and Kathleen J. Weldon of the Harvard School of
Public Health, and Melissa J. Herrmann of SSRS/ICR.
Fieldwork was conducted via telephone (including both
landline and cell phone) for HORP by SSRS/ICR of Media (PA)
September 14-20, 2009.
The survey was conducted with a representative national
sample of 1,042 adults age 18 and over, including
oversamples of non-Hispanic African Americans and Hispanics.
Altogether, 144 non-Hispanic African Americans and 126
Hispanics were interviewed. In the overall results, these
groups were weighted to their actual proportion of the total
adult population.
The margin of error for the total sample is plus or minus
3.7 percentage points. Possible sources of non-sampling
error include non-response bias, as well as question wording
and ordering effects. Non-response in telephone surveys
produces some known biases in survey-derived estimates
because participation tends to vary for different subgroups
of the population. To compensate for these known biases,
sample data are weighted to the most recent Census data
available from the Current Population Survey for gender,
age, race, education, region, and number of adults in the
household. Other techniques, including random-digit dialing,
replicate subsamples, and systematic respondent selection
within households, are used to ensure that the sample is
representative.
1003 How to limit risk
of climate catastrophe [MIT]--A new analysis of
climate risk, published by researchers at MIT and elsewhere,
shows that even moderate carbon-reduction policies now can
substantially lower the risk of future climate change. It
also shows that quick, global emissions reductions would be
required in order to provide a good chance of avoiding a
temperature increase of more than 2 degrees Celsius above
the pre-industrial level — a widely discussed target. But
without prompt action, they found, extreme changes could
soon become much more difficult, if not impossible, to
control.
Ron Prinn, co-director of MIT's Joint Program on the Science
and Policy of Global Change and a co-author of the new
study, says that "our results show we still have around a
50-50 chance of stabilizing the climate" at a level of no
more than a few tenths above the 2 degree target. However,
that will require global emissions, which are now growing,
to start downward almost immediately. That result could be
achieved if the aggressive emissions targets in current U.S.
climate bills were met, and matched by other wealthy
countries, and if China and other large developing countries
followed suit with only a decade or two delay. That 2 degree
C increase is a level that is considered likely to prevent
some of the most catastrophic potential effects of climate
change, such as major increases in global sea level and
disruption of agriculture and natural ecosystems.
"The nature of the problem is one of minimizing risk,"
explains Mort Webster, assistant professor of engineering
systems, who was the lead author of the new report. That's
why looking at the probabilities of various outcomes, rather
than focusing on the average outcome in a given climate
model, "is both more scientifically correct, and a more
useful way to think about it."
Too often, he says, the public discussion over climate
change policies gets framed as a debate between the most
extreme views on each side, as "the world is ending
tomorrow, versus it's all a myth," he says. "Neither of
those is scientifically correct or socially useful."
"It's a tradeoff between risks," he says. "There's the risk
of extreme climate change but there's also a risk of higher
costs. As scientists, we don't choose what's the right level
of risk for society, but we show what the risks are either
way."
The new study, published online by the Joint Program in
September, builds on one released earlier this year that
looked at the probabilities of various climate outcomes in
the event that no emissions-control policies at all were
implemented — and found high odds of extreme temperature
increases that could devastate human societies. This one
examined the difference that would be made to those odds,
under four different versions of possible
emissions-reduction policies.
Both studies used the MIT Integrated Global Systems Model, a
detailed computer simulation of global economic activity and
climate processes that has been developed and refined by the
Joint Program on the Science and Policy of Global Change
since the early 1990s. The new research involved hundreds of
runs of the model with each run using slight variations in
input parameters, selected so that each run has about an
equal probability of being correct based on present
observations and knowledge. Other research groups have
estimated the probabilities of various outcomes, based on
variations in the physical response of the climate system
itself. But the MIT model is the only one that interactively
includes detailed treatment of possible changes in human
activities as well — such as the degree of economic growth,
with its associated energy use, in different countries.
Quantifying the odds
By taking a probabilistic approach, using many different
runs of the climate model, this approach gives a more
realistic assessment of the range of possible outcomes,
Webster says. "One of the common mistakes in the
[scientific] literature," he says, "is to take several
different climate models, each of which gives a 'best guess'
of temperature outcomes, and take that as the uncertainty
range. But that's not right. The range of uncertainty is
actually much wider."
Because this study produced a direct estimate of
probabilities by running 400 different probability-weighted
simulations for each policy case, looking at the actual
range of uncertainty for each of the many factors that go
into the model, and how they interact. By doing so, it
produced more realistic estimates of the likelihood of
various outcomes than other procedures — and the resulting
odds are often significantly worse. For example, an earlier
study by Tom Wigley of the National Center for Atmospheric
Research estimated that the Level 1 emissions control policy
— the least-restrictive of the standards studied -would
reduce by 50 percent the odds of a temperature increase of
more than 2 degrees C, but the more detailed analysis in the
new study finds only a 20 percent chance of avoiding such an
increase.
One interesting finding the team made is that even
relatively modest emissions-control policies can have a big
impact on the odds of the most damaging climate outcomes.
For any given climate model scenario, there is always a
probability distribution of possible outcomes, and it turns
out that in all the scenarios, the policy options have a
much greater impact in reducing the most extreme outcomes
than they do on the most likely outcomes.
For example, under the strongest of the four policy options,
the average projected outcome was a 1.7 degrees C reduction
of the expected temperature increase in 2100, but for the
most extreme projected increase (with 5 percent probability
of occurring) there was a 3.2 degree C reduction. And that's
especially significant, the authors say, because the most
damaging effects of climate change increase drastically with
higher temperature, in a very non-linear way.
"These results illustrate that even relatively loose
constraints on emissions reduce greatly the chance of an
extreme temperature increase, which is associated with the
greatest damage," the report concludes.
Webster emphasizes that "this is a problem of risk
management," and says that while the technical aspects of
the models are complex, the results provide information
that's not much different from decisions that people face
every day. People understand that by using their seat belts
and having a car with airbags they are reducing the risks of
driving, but that doesn't mean they can't still be injured
or killed. "No, but the risk goes down. That's the return on
your decision. It's not something that's so unfamiliar to
people. We may make sure to buy a car with airbags, but we
don't refuse to leave the house. That's the nature of the
kind of tradeoffs we have to make as a society."
1003 Half-million
low-income elderly affected by sweeping cuts to state safety
net [UCLA]--An 81-year-old San Francisco woman
with dementia, little money and an equally aged caregiver
sister who is suffering from cancer.
A 72-year-old Riverside woman with Alzheimer's who cannot be
left safely on her own, forcing her son to cut back his
working hours to care for her.
A 78-year-old Los Angeles man with Alzheimer's whose
daughter will have to quit her job to take care of him if
day care services are cut.
These are some of the hundreds of thousands of low-income
seniors who are likely to lose income — and some of the tens
of thousands who will also lose some or all of the in-home
and supportive care they rely on — as budget cuts resulting
from California's 2009 fiscal crisis go into effect starting
Oct. 1, according to a new study by the UCLA Center for
Health Policy Research.
Among the most vulnerable: seniors with Alzheimer's disease
whose families rely on state-funded Alzheimer's centers that
will soon lose all of their state funding. Also impacted are
low-income seniors with disabilities, who often rely on a
web of safety-net programs that both supplement their
incomes and give them access to free or subsidized in-home
care, say the authors of the new policy brief, "California
Budget Cuts Fray the Long-Term Safety Net."
The research — based on recent data, published research and
nearly two-dozen interviews with program and services
experts — is the first comprehensive analysis of the likely
impact of state budget cuts on California's disabled
elderly.
"Our research finds that the state cuts to long-term care
services are driven primarily by a quest for saving dollars
that disregards the human impact of the results," said
Steven P. Wallace, associate director of the UCLA Center for
Health Policy Research and a co-author of the study. "These
kinds of cuts hit our most vulnerable citizens: seniors with
disabilities and low incomes who typically have no resources
to fall back on and little in the way of additional family
support."
Among the programs particularly affected by the cuts:
* Alzheimer's day care resource centers to lose all state
funding
Centers that provide day care for more than 3,200 mostly
low-income or socially isolated seniors with Alzheimer's
disease will have to curtail hours of service or shut down
altogether in response to budget cuts that go into effect
Oct. 1.
* Supplemental Security Income (SSI/SSP) cut 8 to 10 percent
SSI is a cash assistance program for more than 500,000 very
low-income people who are elderly, blind or permanently
disabled. California has always supplemented the federally
funded benefit using state funds (SSP). Cuts in the state
portion will bring total cuts this year of the combined
benefit to 8 percent for individuals (from $907 to $830
maximum benefit) and nearly 11 percent for couples (from
$1,579 to $1,407).
* In-Home Supportive Services Program (IHSS) cut 30 percent
This program aids seniors with incomes above what is needed
to qualify for SSI but still not high enough to afford
in-home supportive services. IHSS provides a subsidy to help
defray the costs of in-home personal care and essential
household services that seniors are unable to perform
without monitoring or assistance. As of Nov. 1, 30 percent
of the 445,584 individuals of all ages enrolled in this
program will lose some or all of their benefits; about 60
percent are elderly.
"We need lawmakers to rethink these punishing cuts," said
Bruce Chernof, president of the SCAN Foundation, which
funded the research. "With a rapidly growing older
population, we need to make our publicly funded long-term
care system more efficient and effective, and this report
shows that the cuts do neither."
The state's adult day health care centers, which serve more
than 37,000 seniors, were also scheduled for Oct. 1 cuts
until a federal judge issued an injunction Sept. 11
preventing California from cutting services until its poor,
elderly and disabled clients are provided other Medi-Cal
services to prevent their institutionalization. However,
many of the seniors who patronize these centers will still
endure cuts to their SSI checks.
"It means the meal seniors get at an adult day health care
center may be the only meal of the day," Wallace said. "They
won't have the income they need to pay for all of their
basic necessities."
The cuts to long-term care programs that support the
low-income or disabled elderly are expected to shave about
$500 million from California's budget. However, Wallace said
the cuts may ultimately have the reverse effect, by forcing
seniors further into poverty and, ultimately, forcing some
into Medi-Cal supported nursing homes.
"As a state, we have two choices," Wallace said. "We can
either help seniors live with dignity in their own homes, or
we can reduce them to destitution and force them into
nursing homes. Either way, the state of California is going
to pick up the tab."
1003 Surgical masks vs.
N95 respirators for preventing influenza among health-care
workers [McMaster University]--Surgical masks
appear to be no worse than, and nearly as effective as N95
respirators in preventing influenza in health care workers,
according to a study released early online today by JAMA.
The study was posted online ahead of print because of its
public health implications. It will be published in the
November 4 issue of JAMA.
Influenza is the most important cause of medically attended
acute respiratory illness worldwide and the authors write
there is heightened concern this year because of the
influenza pandemic due to the H1N1 virus. "Data about the
effectiveness of the surgical mask compared with the N95
respirator for protecting health care workers against
influenza are sparse," the authors provide as background
information in the article. "Given the likelihood that N95
respirators will be in short supply during a pandemic and
not available in many countries, knowing the effectiveness
of the surgical mask is of public health importance."
Mark Loeb, M.D., M.Sc., from McMaster University, Hamilton,
Ontario, Canada, and colleagues conducted a randomized
controlled trial of 446 nurses in eight Ontario hospitals to
compare the surgical mask with the N95 respirator in
protecting health care workers against influenza. The nurses
were randomized into two groups: 225 were assigned to
receive surgical masks and 221 were assigned to receive the
fitted N95 respirator which they were to wear when caring
for patients with febrile (fever) respiratory illness. The
primary outcome of the study was laboratory-confirmed
influenza. Effectiveness of the surgical mask was assessed
as non-inferiority of the surgical mask compared with the
N95 respirator.
Between September 23, 2008 and December 8, 2008, "influenza
infection occurred in 50 nurses (23.6 percent) in the
surgical mask group and in 48 (22.9 percent) in the N95
respirator group (absolute risk difference -0.73 percent),"
indicating non-inferiority of the surgical mask the authors
report. Even among those nurses who had an increased level
of the circulating pandemic 2009 H1N1 influenza strain,
non-inferiority was demonstrated between the surgical mask
group and the N95 respirator group for the 2009 influenza
A(H1N1).
"Our data show that the incidence of laboratory-confirmed
influenza was similar in nurses wearing the surgical mask
and those wearing the N95 respirator. Surgical masks had an
estimated efficacy within 1 percent of N95 respirators," the
authors write. "That is, surgical masks appeared to be no
worse, within a prespecified margin, than N95 respirators in
preventing influenza."
In conclusion the authors state: "Our findings apply to
routine care in the health care setting. They should not be
generalized to settings where there is a high risk for
aerosolization, such as intubation or bronchoscopy, where
use of an N95 respirator would be prudent. In routine health
care settings, particularly where the availability of N95
respirators is limited, surgical masks appear to be
non-inferior to N95 respirators for protecting health care
workers against influenza."
Editor's Note: This study was supported by the Public Health
Agency of Canada.
Editorial: Respiratory Protection Against Influenza
In an accompanying editorial, Arjun Srinivasan, M.D., from
the Centers for Disease Control and Prevention (CDC),
Atlanta, and Trish M. Perl, M.D., M.Sc., from the School of
Medicine and Bloomberg School of Public Health, Johns
Hopkins University, Baltimore, write: "The 2009 influenza
A(H1N1) pandemic has revived debate about the role of
respiratory protection in preventing the transmission of
influenza to health care personnel." The "N95 particulate
respirators protect wearers from small particles when
appropriately designed and worn." The World Health
Organization and Society for Healthcare Epidemiology of
America recommend the use of medical masks for most patient
care. The CDC and Institute of Medicine recommend the use of
N95 respirators during care of patients infected with the
H1N1 influenza.
"That this study is, to our knowledge, the first and only
published randomized trial assessing respiratory protection
for preventing influenza transmission is a sad commentary on
the state of research in this area. Uncovering the truth and
identifying the most appropriate way to protect health care
personnel will require that other investigators build on
this study ...," they write. "Ultimately, accumulating a
body of evidence on this topic will provide much-needed
answers."
1003 Parasite bacteria
may help fight spread of mosquito-borne diseases [Wellcome
Trust]--Infecting mosquitoes with a bacterial
parasite could help prevent the spread of lymphatic
filariasis, one of the major neglected tropical diseases of
the developing world, according to research published today
in the journal Science.
Lymphatic filariasis affects more than 120 million people
worldwide – over 40 million of these are seriously
incapacitated and disfigured by the disease. It is caused by
infection with the parasitic filarial nematode, a threadlike
worm that is spread by mosquitoes and occupies the lymphatic
system. In chronic cases, infection leads to a condition
known as elephantiasis, which can cause severe swelling in
the legs, male scrotum and female breasts.
Previous research has shown that infecting a mosquito with a
strain of the bacterial parasite Wolbachia known as wMelPop
– nicknamed 'popcorn' – can halve its lifespan.
Mosquito-borne parasites such as the filarial nematode or
the malaria parasite require an incubation period between
ingestion and transmission, so only older mosquitoes can be
infective. Skewing the mosquito population towards younger
individuals reduces the number of infectious insects.
Now, researchers funded primarily by the Wellcome Trust have
shown that as well as reducing the mosquito's lifespan,
wMelPop directly inhibits transmission of the filarial
nematode by encouraging the mosquito's immune system to
attack the worm. They found that significantly reduced
numbers of filarial nematodes developed in mosquitoes
infected with wMelPop – in some cases, less than 15% of the
number in mosquitoes which were not carrying wMelPop.
"Wolbachia infection appears to significantly increase the
activity of around two hundred mosquito genes, many of which
are involved in the immune response," says Dr Steven Sinkins,
a Wellcome Trust Senior Research Fellow at the University of
Oxford. "This then primes the mosquito's immune system to
fight infection by the filarial nematodes, preventing the
worm from developing to a stage where transmission to humans
is possible."
Wolbachia infections – including wMelPop – have also been
shown to protect against certain viruses. Today's research
suggests that this effect could also be a result of the
boost to the mosquito's immune system.
Dr Sinkins and colleagues are currently looking at whether
infecting other species of mosquito, such as Anopheles
gambiae – the mosquito responsible for the majority of
malaria infections – with wMelPop will have a similar effect
and help inhibit malaria transmission as well as filariasis
transmission. Another potential target is the Aedes
polynesiensis mosquito, which spreads lymphatic filariasis
in the islands of Polynesia, where decades of mass drug
administration have failed to eradicate the filarial
parasites from the human population.
"The Wolbachia 'popcorn' strain is a naturally-occurring
organism found in a particular species of fruit fly which,
if successfully introduced into mosquito populations, could
potentially help us fight a number of the world's most
serious diseases," says Dr Sinkins.
Wolbachia have been shown in previous studies to be capable
of spreading rapidly through insect populations. When a male
carrying Wolbachia mates with a female that does not, the
resulting eggs fail to develop. However, a female that is
infected with Wolbachia can breed successfully with any
male, and thus produces more offspring on average than
Wolbachia-uninfected females.
1003 Gun possession of
questionable value in an assault [University of Pennsylvania
School of Medicine]--In a first-of its-kind
study, epidemiologists at the University of Pennsylvania
School of Medicine found that, on average, guns did not
protect those who possessed them from being shot in an
assault. The study estimated that people with a gun were 4.5
times more likely to be shot in an assault than those not
possessing a gun.
The study was released online
this month in the American Journal of Public Health, in
advance of print publication in November 2009.
“This study helps resolve the long-standing debate about
whether guns are protective or perilous,” notes study author
Charles C. Branas, PhD, Associate Professor of Epidemiology.
“Will possessing a firearm always safeguard against harm or
will it promote a false sense of security?”
What Penn researchers found was alarming – almost five
Philadelphians were shot every day over the course of the
study and about 1 of these 5 people died. The research team
concluded that, although successful defensive gun uses are
possible and do occur each year, the chances of success are
low. People should rethink their possession of guns or, at
least, understand that regular possession necessitates
careful safety countermeasures, write the authors.
Suggestions to the contrary, especially for urban residents
who may see gun possession as a defense against a dangerous
environment should be discussed and thoughtfully
reconsidered.
A 2005 National Academy of Science report concluded that we
continue to know very little about the impact of gun
possession on homicide or the utility of guns for
self-defense. Past studies had explored the relationship
between homicides and having a gun in the home, purchasing a
gun, or owning a gun. These studies, unlike the Penn study,
did not address the risk or protection that having a gun
might create for a person at the time of a shooting.
Penn researchers investigated the link between being shot in
an assault and a person’s possession of a gun at the time of
the shooting. As identified by police and medical examiners,
they randomly selected 677 cases of Philadelphia residents
who were shot in an assault from 2003 to 2006. Six percent
of these cases were in possession of a gun (such as in a
holster, pocket, waistband, or vehicle) when they were shot.
These shooting cases were matched to Philadelphia residents
who acted as the study’s controls. To identify the controls,
trained phone canvassers called random Philadelphians soon
after a reported shooting and asked about their possession
of a gun at the time of the shooting. These random
Philadelphians had not been shot and had nothing to do with
the shooting. This is the same approach that epidemiologists
have historically used to establish links between such
things as smoking and lung cancer or drinking and car
crashes.
“The US has at least one gun for every adult,” notes Branas.
“Learning how to live healthy lives alongside guns will
require more studies such as this one. This study should be
the beginning of a better investment in gun injury research
through various government and private agencies such as the
Centers for Disease Control, which in the past have not been
legally permitted to fund research ‘designed to affect the
passage of specific Federal, State, or local legislation
intended to restrict or control the purchase or use of
firearms.’”
This study was funded by the National Institutes of Health.
The authors are also indebted to numerous dedicated
individuals at the Philadelphia Police, Public Health, Fire,
and Revenue Departments as well as DataStat Inc, who
collaborated on the study.
Therese S. Richmond, PhD, CRNP, School of Nursing; Dennis P.
Culhane, PhD, School of Social Policy; Thomas R. Ten Have,
PhD, MPH, and Douglas J. Wiebe, PhD, both from the School of
Medicine, are co-authors.
1003 San Andreas
affected by 2004 Sumatran quake - Largest quakes can weaken
fault zones worldwide [Rice University]--U.S.
seismologists have found evidence that the massive 2004
earthquake that triggered killer tsunamis throughout the
Indian Ocean weakened at least a portion of California's
famed San Andreas Fault. The results, which appear this week
in the journal Nature, suggest that the Earth's largest
earthquakes can weaken fault zones worldwide and may trigger
periods of increased global seismic activity.
"An unusually high number of magnitude 8 earthquakes
occurred worldwide in 2005 and 2006," said study co-author
Fenglin Niu, associate professor of Earth science at Rice
University. "There has been speculation that these were
somehow triggered by the Sumatran-Andaman earthquake that
occurred on Dec. 26, 2004, but this is the first direct
evidence that the quake could change fault strength of a
fault remotely."
Earthquakes are caused when a fault fails, either because of
the buildup of stress or because of the weakening of the
fault. The latter is more difficult to measure.
The magnitude 9 earthquake in 2004 occurred beneath the
ocean west of Sumatra and was the second-largest quake ever
measured by seismograph. The temblor spawned tsunamis as
large as 100 feet that killed an estimated 230,000, mostly
in Indonesia, Sri Lanka, India and Thailand.
In the new study, Niu and co-authors Taka'aki Taira and Paul
Silver, both of the Carnegie Institution of Science in
Washington, D.C., and Robert Nadeau of the University of
California, Berkeley, examined more than 20 years of seismic
records from Parkfield, Calif., which sits astride the San
Andreas Fault.
The team zeroed in on a set of repeating microearthquakes
that occurred near Parkfield over two decades. Each of these
tiny quakes originated in almost exactly the same location.
By closely comparing seismic readings from these quakes, the
team was able to determine the "fault strength" -- the shear
stress level required to cause the fault to slip -- at
Parkfield between 1987 and 2008.
The team found fault strength changed markedly at three
times during the 20-year period. The authors surmised that
the 1992 Landers earthquake, a magnitude 7 quake north of
Palm Springs, Calif. -- about 200 miles from Parkfield --
caused the first of these changes. The study found the
Landers quake destabilized the fault near Parkfield, causing
a series of magnitude 4 quakes and a notable "aseismic"
event -- a movement of the fault that played out over
several months -- in 1993.
The second change in fault strength occurred in conjunction
with a magnitude 6 earthquake at Parkfield in September
2004. The team found another change at Parkfield later that
year that could not be accounted for by the September quake
alone. Eventually, they were able to narrow the onset of
this third shift to a five-day window in late December
during which the Sumatran quake occurred.
"The long-range influence of the 2004 Sumatran-Andaman
earthquake on this patch of the San Andreas suggests that
the quake may have affected other faults, bringing a
significant fraction of them closer to failure," said Taira.
"This hypothesis appears to be borne out by the unusually
high number of large earthquakes that occurred in the three
years after the Sumatran-Andaman quake."
The research was supported by the National Science
Foundation, the Carnegie Institution of Washington, the
University of California, Berkeley, and the U.S. Geological
Survey.
1003 Securing
biological select agents and toxins will require developing
a culture of trust [National Academy of Sciences]--The
most effective way to prevent the deliberate misuse of
biological select agents and toxins (BSATs) -- agents housed
in laboratories across the U.S. considered to potentially
pose a threat to human health -- is to instill a culture of
trust and responsibility in the laboratory, says a new
report from the National Research Council. Focusing on the
laboratory environment will be critical for identifying and
reducing concerns about facilities or personnel.
Mechanisms for fostering a safe and secure laboratory
environment include engaged management, risk-based security
measures, and appropriate monitoring and management of
personnel, as well as training for all researchers in
scientific ethics and understanding "dual-use" research that
could be misused. Other methods of screening and oversight
are incomplete without including the laboratory community in
minimizing potential security risks, the report says.
Policies and procedures that make select agent research more
difficult to conduct, as opposed to more secure, diminish
overall security rather than strengthen it.
Individuals cleared for access to select agents and toxins
are certified for five years. Many changes can occur during
this time, however, including those that impact whether an
individual poses a security risk. Therefore, efforts to
ensure reliable personnel should come from within the
laboratories, the report says, through increased engagement
and monitoring by managers and staff. The goal should be
that individuals watch out for each other and take
responsibility for their own performance and that of others.
In a laboratory context, some security measures can also
improve safety, if there is involvement of researchers in
the process.
BSAT research is presently defined by a list of more than 80
select agents and toxins, developed and jointly regulated by
the Centers for Disease Control and Prevention (CDC) and the
Animal and Plant Health Inspection Service (APHIS).
According to the committee that wrote the report, the list
should be ordered based on the potential of an agent to be
used as a biothreat, and a graded series of security
procedures should be applied so that the greatest resources
and scrutiny go to securing agents that pose maximum risk.
Personnel issues are often the most controversial and
difficult aspects of maintaining security for BSATs.
Security programs can be generally divided into two
categories: screening individuals to determine whether they
are eligible for access, and monitoring the behavior and
performance of employees working with these agents. The
current Security Risk Assessment screening process, which
relies on screening more than 20 criminal, immigration, and
terrorist databases to identify disqualifying behavior or
activities, is appropriate, the report says. However, a
change that should be considered is expanding the appeal
process beyond a simple determination of factual errors to
include the opportunity to consider circumstances
surrounding otherwise disqualifying factors, such as the
length of time since an offense occurred. Currently, any
discovery of disqualifying factors or behaviors
automatically and permanently denies an individual's access.
Improved communication is needed among those funding
research on select agents, those administering the Select
Agent Program, and those conducting the research, the report
says. An advisory committee with members drawn from research
institutions and the private sector should be established to
provide continued engagement of stakeholders.
Representatives from federal agencies would serve in an EX
OFFICIO capacity. Rigorous and continuing evaluation of the
Select Agent Program is needed to ensure that it is running
efficiently and also to consider any intended and unintended
consequences of operation.
The committee concludes that, because biological select
agents can replicate, an undue reliance on accounting
techniques, such as counting vials, to monitor whether a
biological agent has been removed from a laboratory offers a
false sense of security and is counterproductive. Instead,
accountability is best achieved by controlling access to
archived stocks and working materials and recording which
agents are present, where they are stored, who has access to
them, when that access is available, their intended use, and
where they are transported, if moved to another off-site
location.
Physical security is required of all facilities housing
select agents, with broad regulatory guidance provided by
CDC and APHIS. The variation in implementing these
requirements and regulations can lead to inconsistencies and
confusion as facility operators, contractors, and inspectors
attempt to determine whether a facility has met the
necessary security guidelines. The report calls upon the
Select Agent Program to define minimum physical security
requirements to assist facilities in meeting their
regulatory obligations. The report also recommends
laboratory inspectors have scientific and laboratory
knowledge and experience, as well as appropriate training
specific to BSAT research and that the inspections should be
harmonized across agencies. Due to the considerable security
and compliance costs involved in working with select agents,
a separate category of federal funding should be made
available to ensure that facilities always operate with
appropriate security measures in place.
1003 Peer pressure
builds more latrines than financial assistance [Duke
University]--Government subsidies persuade some
people to change habits, but social shame works even better,
suggests a recent study of efforts to reduce elevated
childhood death and disease rates blamed on the microbial
pathogens that cause diarrhea in rural India.
"All this started with public health workers there just
beating their heads against the reality of how sticky human
behavior is and how hard it is to change it," said Subhrendu
Pattanayak, an associate professor at Duke University's
Sanford School of Public Policy and Nicholas School of the
Environment.
According to a report in the August issue of the Bulletin of
the World Health Organization, of which Pattanayak was lead
author, experts have disagreed "whether improved access to
sanitation and other health technologies is better achieved
through monetary subsidies or shaming techniques."
Shaming, a strategy first tried in Bangladesh, is an appeal
to the emotions during group gatherings of local residents
to access the impacts of unhygienic practices, Pattnayak
said. Neighbors caught in open defecation, for example, may
be taunted.
Pattanayak's evaluation focused on efforts to combine both
shaming and reward tactics in the state of Orissa, which has
a child mortality rate higher than average for India.
Health workers participating in a Total Sanitation Campaign
had previously knocked on doors throughout India, handing
out pamphlets designed to persuade individual households to
install pit latrines. The poorer households were even
offered construction subsidies that would reduce their costs
to the U.S. equivalent of $7.50.
But after those initial efforts, followup studies found less
than a quarter of the nation's population and less than 10
percent of residents of Orissa had "access to safe water and
good sanitation," according to the report.
So Pattanayak worked with frustrated government officials
and his collaborators at RTI International in Research
Triangle Park, N.C., where he then worked. Collectively they
designed a study, funded by the World Bank, to measure the
effectiveness of what his report called "a social
mobilization strategy."
Twenty Orissa villages were selected at random in 2006 for
locally led efforts that included village "walks of shame"
and "defecation mapping" that identified sources of
contamination and their distances from drinking water
supplies. As that study began, about 30 percent of the
interviewed households reported a child younger than 5 years
had experienced diarrhea within the previous two weeks.
Community based groups were empowered "to establish systems
of fines, taunting or social sanctions to punish those who
continued to defecate in the open," the report said.
As Total Sanitation Campaign workers organized these
additional efforts, Pattanayak's study group remained behind
the scenes gathering data through "before and after" health
and sanitation surveys.
The results were striking when surveys from those 20
villages were compared with 20 other randomly selected
communities where no social mobilization efforts were
organized.
Although subsidies for latrine construction were available
to residents below India's poverty line in all 40 villages,
latrine ownership only rose in those undergoing shaming,
according to the surveys.
Within those "shamed" communities, latrine ownership rose
from 5 percent to 36 percent among families below the
poverty line, and from 7 percent to 26 percent among
households above it. Subsequent surveys by Orissa's state
government showed that all households had installed latrines
by 2007 in 10 of the 20 villages subjected to the shaming.
Statistical analysis suggests that subsidies were
responsible for about one third of the improvements in those
communities and shame for about two thirds, the report
concluded.
Pattanayak, himself a native Indian whose general academic
interest is environmental and development economics, thinks
his countrymen generally understand how bad hygiene can
relate to childhood disease. But they also feel a
combination of fatalism and powerlessness.
"Many view the loss of a child every now and then to
diarrhea and other stomach ailments as part of normal life,"
he said. "While some people recognize the connection and do
something about it, and the rest also recognize it but find
it too abstract compared to life's other problems.
"This is a typical story of why people don't do things that
seem beneficial to others," he said. "You feel you are just
a small part of the picture: 'If I do this there's some
chance that things will improve.' But that is conditional on
how many others also do something about it.
"That's the problem with environmental issues, whether they
are health or non-health. It's how we end up with so much
greenhouse gas in the air and pollution in our water."
1003 Physician-assisted
suicide does not increase severity of depression, grief
among family members [Oregon Health & Science University]--Unlike
other forms of suicide, physician assisted death does not
cause substantial regret, or a sense of rejection among
surviving family members. In addition, the prevalence and
severity of depression and grief among family members whose
loved ones received aid in dying is no different than family
members whose loved ones did not pursue physician assisted
suicide.
These findings are the result
of a study conducted by researchers at Oregon Health &
Science University and published online this week in the
Journal of Pain and Symptom Management.
"Grief following the death of a loved one can be persistent,
painful and debilitating," said Linda Ganzini, M.D., a
professor of psychiatry and medicine in the OHSU School of
Medicine and lead author of the research paper.
"Prior studies on suicides
indicate high levels of shame, guilt, stigma and sense of
rejection in surviving family members. However, until now,
little was known about mental health outcomes in the family
members of a patient who receives physician aid in dying.
Based on our research, we know that family members of loved
ones who pursue physician assisted suicide do not have
different prevalence and severity of depression and
prolonged grief compared to the general population."
To conduct the study, researchers surveyed 95 family members
whose loved ones requested aid in dying through Oregon's
Death with Dignity Act. This group included 59 family
members whose loved one received a lethal prescription and
36 whose loved one died by lethal ingestion. The researchers
compared this information with responses received from 63
family members whose loved one had died from cancer or
amyotrophic lateral sclerosis (Lou Gehrig's disease) and had
not requested aid in dying.
In comparing survey results, the researchers found that the
rate of grief and depression between these two groups was
nearly identical. However, family members of loved ones who
requested a lethal prescription indicated they felt more
prepared for and more accepting of the death.
Among family members whose loved one requested but did not
receive a lethal prescription, there was greater likelihood
that the family members had regrets about how their loved
one died. This group also was less likely to confirm that
the patient's preferences for care were honored, and they
gave a lower rating for overall quality of care the last
week of life.
"One of the other interesting findings in this research was
the fact that families often had shared views when it came
to the acceptability of physician aid in dying," added
Ganzini. "When we communicated with the family members of
those who received aid in dying, 98 percent said they would
consider physician assisted suicide for themselves."
This research was funded by the Greenwall Foundation.
1003 Using
computational models to study fear [University of Missouri]--The
brain is a complex system made of billions of neurons and
thousands of connections that relate to every human feeling,
including one of the strongest emotions, fear. Most
neurological fear studies have been rooted in
fear-conditioning experiments.
Now, University of Missouri
researchers have started using computational models of the
brain, making it easier to study the brain’s connections.
Guoshi Li, an electrical and computer engineering doctoral
student, has discovered new evidence on how the brain reacts
to fear, including important findings that could help
victims of post-traumatic stress disorder (PTSD).
“Computational models make it much easier to study the brain
because they can effectively integrate different types of
information related to a problem into a computational
framework and analyze possible neural mechanisms from a
systems perspective. We simulate activity and test a variety
of “what if” scenarios without having to use human subjects
in a rapid and inexpensive way,” Li said.
From previous experiments, scientists have found that fear
can subside when overcome with fear extinction memory, but
it is not permanently lost. Fear extinction is a process in
which a conditioned response to a stimulant that produces
fear gradually diminishes over time as subjects, such as
rats in auditory fear experiments, learn to disassociate a
response from a stimulus. One theory has concluded that fear
extinction memory deletes fear memory, and another concluded
that fear memory is not lost, but is inhibited by extinction
memory as fear can recover with the passage of time after
extinction.
“Fear extinction memory is not well understood, and our
computational model can capture the neuron response well in
rat during auditory fear conditioning with a mixture of
mathematics and biophysical data,” said Li. “Our main
contribution is that our model predicts that fear memory is
only partially erased by extinction, and inhibition is
necessary for a complete extinction, which is a
reconciliation of the erasure and inhibition theories.
Furthermore, our model shows that the inhibitory connection
from interneurons to pyramidal cells serve as an important
site for the storage of extinction memory.”
For PTSD victims, the fear circuit is disrupted and they
cannot retrieve the fear extinction memory. However, the
fear extinction memory exists, so the fear memory dominates
every time victims get a fear cue. Li and his collaborators
are targeting the inhibitory connection in the brain that
makes it possible to retrieve the extinction memory. Li
hopes that his research can contribute to new drugs that can
help PTSD victims.
“Treatment for PTSD patients depends on which connection
stores the fear extinction memory and which circuit
misfires,” Li said. “With our model, we can figure out what
specific connections store fear/extinction memory and how
such connections are disrupted in the pathology of PTSD,
which may lead to the suggestions of new drugs to treat the
disease.”
Li, in collaboration with Satish Nair, professor of
electrical and computer engineering who just received a
three-year National Institute of Health grant for further
research in fear modeling, and Gregory Quirk, a
neuroscientist in the University of Puerto Rico School of
Medicine research, has been published in the Journal of
Neurophysiology and Psychiatric Annals.
1003 Protect children
first with H1N1 flu vax [University of Alabama at
Birmingham]--The optimal way to control swine
flu, the new H1N1 virus that emerged as a global threat in
2009, is to vaccinate children with the planned H1N1 flu
shot, says the co-director of the University of Alabama at
Birmingham (UAB) Division of Pediatric Infectious Diseases.
"Children are the highest-risk group for spreading the virus
among themselves, and as a consequence, spreading it around
their community," says UAB's David Kimberlin, M.D., one of
four U.S. physicians serving on the federal Safety
Monitoring Committee reviewing clinical trials of H1N1
vaccines. The committee is a part of the Division of
Microbiology and Infectious Diseases at the National
Institute of Allergy and Infectious Diseases.
"Like a bull's-eye, the middle of the target is what you
vaccinate so you don't see infections in the concentric
rings around the center," Kimberlin says. "The center of the
protection bull's-eye should be children."
The United States' prospects for developing and distributing
a safe and effective vaccine to prevent infection with the
current H1N1 virus are excellent, Kimberlin says.
"The National Institutes of Health are conducting a number
of studies across the country at special vaccine evaluation
sites they've had set up for 40-60 years, and they have
enrolled several thousand patients into those studies," he
says. "I'm on that federal monitoring board and we look at
the vaccine-safety data constantly. These studies are going
very well."
The reasoning behind making children the highest priority
comes from decades of experience with flu transmission,
prevention strategies, infection monitoring and many other
factors. Additionally, children younger than age 5 are at
higher risk of complications from influenza.
Once the vaccine is available, which is expected to be in
October, children 6 months of age and older, teenagers and
young adults through age 24 will be among the first groups
targeted by the Centers for Disease Control Advisory
Committee on Immunization Practices to receive the shots.
Pregnant women, adults who have high-risk medical conditions
and health-care workers who are direct care providers are
among the others who will be given the earliest shots, says
Kimberlin, who is a member of the American Academy of
Pediatrics Committee on Infectious Diseases and associate
editor of the academy's Red Book, a revered pediatric
treatment manual.
Decisions about expanding or establishing priorities for
vaccination should be made in accordance with local
circumstances based on the judgment of state and county
health officials, advises Kimberlin.
1003 New way to monitor
faults may help predict earthquakes [Carnegie Institution's
Department of Terrestrial Magnetism]--Scientists
at the Carnegie Institution have found a way to monitor the
strength of geologic faults deep in the Earth. This finding
could prove to be a boon for earthquake prediction by
pinpointing those faults that are likely to fail and produce
earthquakes. Until now, scientists had no method for
detecting changes in fault strength, which is not
measureable at the Earth's surface.
Paul Silver* and Taka'aki Taira of the Carnegie
Institution's Department of Terrestrial Magnetism, with
Fenglin Niu of Rice University and Robert Nadeau of the
University of California, Berkeley, used highly sensitive
seismometers to detect subtle changes in earthquake waves
that travel through the San Andreas Fault zone near
Parkfield, California, over a period of 20 years. The
changes in the waves indicate weakening of the fault and
correspond to periods of increased rates of small
earthquakes along the fault.
"Fault strength is a fundamental property of seismic zones,"
says Taira, now at the University of California, Berkeley.
"Earthquakes are caused when a fault fails, either because
of the build-up of stress or because of a weakening of the
fault. Changes in fault strength are much harder to measure
than changes in stress, especially for faults deep in the
crust. Our result opens up exciting possibilities for
monitoring seismic risk and understanding the causes of
earthquakes."
The section of the San Andreas Fault near Parkfield,
sometimes called the "Earthquake Capital of the World," has
been intensively studied by seismologists and is home to a
sophisticated array of borehole seismometers called the
High-Resolution Seismic Network and other geophysical
instruments. Because the area experiences numerous repeated
small earthquakes, it is a natural laboratory for studying
the physics of earthquakes.
Seismograms from small earthquakes revealed that within the
fault zone there were areas of fluid-filled fractures. What
caught the researchers' attention was that these areas
shifted slightly from time to time. The repeating
earthquakes also became smaller and more frequent during
these intervals – an indication of a weakened fault.
"Movement of the fluid in these fractures lubricates the
fault zone and thereby weakens the fault," says Niu. "The
total displacement of the fluids is only about 10 meters at
a depth of about three kilometers, so it takes very
sensitive seismometers to detect the changes, such as we
have at Parkfield."
What caused the fluids to shift? Intriguingly, the
researchers noticed that on two occasions the shifts came
after the fault zone was disturbed by seismic waves from
large, distant earthquakes, such as the 2004 Sumatra-Andaman
Earthquake. Pressure from these waves may have been enough
to cause the fluids to flow. "So it is possible that the
strength of faults and earthquake risk is affected by
seismic events on the other side of the world," says Niu.
The paper is published in the October 1 edition of Nature.
*Paul Silver died tragically in an automobile accident in
August.
1003 Celebs spawn
copycat suicides [Queen Mary Research Centre for Psychology]--Dr
Alex Mesoudi, from Queen Mary's newly established Research
Centre for Psychology, has found evidence that the
increasing reach and influence of the media, combined with a
growing number of people assigned celebrity status, could
increase the probability of widespread suicide pandemics.
The study is published today in the peer reviewed journal
PLoS ONE.
Copycat suicides occur when one person's suicide is at least
partly caused by exposure to another person's suicide.
Sociologists have proposed that clusters of suicides around
the same time or geographical area may be caused by this
copycat effect.
By studying the behaviour of 1000 computer 'people',
pre-programmed with the rules that govern how people learn
from one another, Dr Mesoudi has investigated the problem of
copycat suicides to see whether suicidal behaviour in the
population really does fit with sociologists' assumptions.
Two kinds of suicide clusters have been identified by
previous sociological research. Mass clusters are suicides
that occur around the same time but across an entire
geographic region (eg. a country), and are often associated
with media coverage of celebrity suicides, such as that of
the musician Kurt Cobain.
Dr Mesoudi said: "The findings of the computer simulations
strongly support the proposed link between the mass
reporting of a prestigious celebrity's suicide and an
increase in national suicide figures. This highlights the
need for media guidelines that restrict the dissemination
and glorification of suicides, as already introduced in many
countries, such as Austria, Switzerland and Australia."
In recent years, satellite television and the internet have
increased the global range of the mass media; celebrities
such as film actors and pop singers are being assigned
increasing importance relative to politicians and
intellectuals (whose suicides do not elicit copycat suicide
attempts); and reality television programmes are increasing
the number of celebrities within society.
Additionally, point clusters are suicides that occur around
the same time and physical place, for example a number of
suicides occurring in a school or hospital during a few
weeks or months. Point clusters have been attributed to
direct social learning, where people pick up information in
their local social networks or communities. This is the most
common theory behind the spate of tragic suicides among
young people in Bridgend, South Wales.
The results also showed that direct social learning does
generate point clusters, but that this is partially mimicked
by homophily; a situation where people who are independently
predisposed to committing suicide tend to reside close to
one another. These areas therefore have higher suicide risks
despite no actual social influence.
Dr Mesoudi added: "These findings suggest that social
learning and homophily generate distinct types of clusters.
By using this knowledge to distinguish between genuine
copycat point clusters and homophilous point clusters,
efforts to reduce socially influenced suicides might be more
effectively targeted at the former."
1003 Prenatal exposure
to flu pandemic increased chances of heart disease
[University of Southern California]--People
exposed to a H1NI strain of influenza A while in utero were
significantly more likely to have cardiovascular disease
later in life, reveals a new study published in Journal of
Developmental Origins of Health and Disease on Oct. 1.
"Our point is that during pregnancy, even mild sickness from
flu could affect development with longer consequences," said
senior author Caleb Finch, USC professor of gerontology and
biological sciences.
Finch, Eileen Crimmins (USC Davis School of Gerontology),
lead author Bhashkar Mazumder (Federal Reserve Bank of
Chicago), Douglas Almond (University of Chicago) and Kyung
Park (Columbia University) looked at more than 100,000
individuals born during and around the time of the 1918
influenza pandemic in the United States.
After first appearing in the spring and all but disappearing
in the summer, the 1918 flu pandemic "resurged to an
unprecedentedly virulent October-December peak," the
researchers write. The outbreak of influenza A, H1N1 subtype
killed two percent of the total population. Most people
experienced mild "three-day fever" with full recovery.
"[The] 1918 flu was far more lethal than any since.
Nonetheless, there is particular concern for the current
swine flu which seems to target pregnant women," said Finch,
director of the Gerontology Research Institute at USC.
"Prospective moms should reduce risk of influenza by
vaccination."
The researchers found that men born in the first few months
of 1919 — second or third trimester during the height of the
epidemic — had a 23.1 percent greater chance of having heart
disease after the age of 60 than the overall population.
Heart disease is the leading cause of death in the United
States.
For women, those born in the first few months of 1919 were
not significantly more likely to have cardiovascular disease
than their peers, pointing to possible gender differences in
effects of flu exposure. But women born in the second
quarter of 1919 — first trimester during the height of the
epidemic — were 17 percent more likely to have heart disease
than the general population in later life, according to the
study.
In addition, the researchers examined height at World War II
enrollment for 2.7 million men born between 1915 and 1922
and found that average height increased every successive
year except for the period coinciding with in utero exposure
to the flu pandemic.
Men who were exposed to the H1N1 flu in the womb were
slightly shorter on average than those born just a year
later or a year before, according to the study. The
researchers controlled for known season-of-birth effects and
maternal malnutrition.
"Prenatal exposure to even uncomplicated maternal influenza
can have lasting consequences later in life," said Crimmins,
professor of gerontology and sociology at USC. "The
lingering influences from the 1918-1919 influenza pandemic
extend the hypothesized roles of inflammation and infections
in cardiovascular disease from our prior Science and PNAS
articles to prenatal infection by influenza."
Journal of Developmental Origins of Health and Disease is
published and jointly owned by Cambridge University Press in
association with the International Society for Developmental
Origins of Health and Disease. The research was supported by
the National Institute on Aging, the Ellison Medical
Foundation and the Ruth Ziegler Fund.
Finch et al., "Lingering Prenatal Effects of the 1918
Influenza Pandemic on Cardiovascular Disease." Journal of
Developmental Origins of Health and Disease. DOI:
10.1017/S2040174409990031
1003 Treating even mild
gestational diabetes reduces birth complications
[NIH/National Institute of Child Health and Human
Development]--A National Institutes of Health
network study provided the first conclusive evidence that
treating pregnant women who have even the mildest form of
gestational diabetes can reduce the risk of common birth
complications among infants, as well as blood pressure
disorders among mothers.
Treatment of severe gestational diabetes is known to benefit
mothers and infants. Although treatment is routinely
prescribed for all women with gestational diabetes, before
the current study, there was no evidence to show whether
treating the mild form of the condition benefited, or posed
risks for, mothers or their infants.
The researchers found that, compared to the women's
untreated counterparts, women treated for mild gestational
diabetes had smaller, leaner babies less likely to be
overweight or abnormally large, and less likely to
experience shoulder dystocia, an emergency condition in
which the baby's shoulder becomes lodged inside the mother's
body during birth. Treated mothers were also less likely to
undergo cesarean delivery, to develop high blood pressure
during pregnancy, or to develop preeclampsia, a
life-threatening complication of pregnancy that can lead to
maternal seizures and death.
The study was conducted by researchers in the Maternal Fetal
Medicine Units Network of the NIH's Eunice Kennedy Shriver
National Institute of Child Health and Human (NICHD) and
appears in the Oct. 1 New England Journal of Medicine. The
study's first author was Mark Landon of Ohio State
University.
"Whether to treat mild gestational diabetes has never been
entirely clear," said study coauthor Catherine Y. Spong,
chief of the Pregnancy and Perinatology Branch at the NICHD.
"The study results show conclusively that both mothers and
infants do better when gestational diabetes is controlled."
In addition to funding from the NICHD, the study was also
supported by the NIH's National Center for Research
Resources.
Gestational diabetes occurs when pregnant women who did not
have any signs or symptoms of diabetes before they were
pregnant develop high blood sugar levels. The condition
affects from 1 to 14 percent of all U.S. pregnancies.
Gestational diabetes is not well understood, but is thought
to occur when hormones produced during pregnancy interfere
with the body's ability to use insulin to absorb sugar from
the blood.
In most cases, treatment for gestational diabetes consists
of lowering blood sugar levels through proper diet and
exercise. If diet and exercise alone fail to lower blood
sugar levels, women may be treated with drugs that increase
the body's ability to use insulin, or may be prescribed
insulin itself.
The current study is the first to test whether treatment for
mild gestational diabetes is beneficial. The researchers
defined mild gestational diabetes as having normal blood
sugar levels after fasting but abnormally high levels in at
least two readings over the course of three hours after an
oral glucose tolerance test, in which women consume a sugary
drink. Severe diabetes was defined as high blood sugar
levels even after fasting.
To conduct the study, the researchers enrolled 958 women
with mild gestational diabetes. Roughly half were treated
for their diabetes and half were not, receiving only
standard pregnancy care.
In their statistical analysis of the study results, the
researchers combined several serious potential outcomes into
one figure, to represent a single and primary outcome. The
primary outcome consisted of all cases of newborn death,
stillbirth, newborns with low blood sugar or with high
insulin levels, birth-related injuries, and high bilirubin
levels (an indicator of newborn jaundice). In terms of the
primary outcome, there were no differences between the two
groups of women. But the women who received treatment fared
significantly better than the untreated women on other
measures.
Specifically, compared to women who did not receive
treatment, those who did were:
* half as likely to have an unusually large baby,
* half as likely to experience shoulder dystocia during
childbirth,
* four-fifths as likely to give birth by cesarean section,
and
* three-fifths as likely to develop high blood pressure or
preeclampsia.
"Obstetricians are concerned with the immediate risks of
birth trauma which may accompany delivery of large infants
to women with diabetes," Dr. Landon said.
These risks include fracture of the skull and collar bones,
and injury to the nerves that connect the arm, hand and
shoulder to the spine.
"Our study demonstrates that treating even mild diabetes can
reduce fetal overgrowth and thus could also reduce these
birth related risks."
Previous studies suggest that the higher birthweights and
greater proportion of body fat seen in the newborns of women
with gestational diabetes also pose increased health risks
for these children later in life, Dr. Spong said. The
children are more likely than other children to be
overweight and, as adults, more likely to have impaired
glucose tolerance, a prediabetic condition.
"The children would need to be followed long term to be
certain, but it's possible that treating women with mild
gestational diabetes to reduce birthweight and body fat
among their newborns may benefit these children later in
life," Dr. Spong said.
1003 Air pollutants
from abroad a growing concern [National Research Council]--Plumes
of harmful air pollutants can be transported across oceans
and continents -- from Asia to the United States and from
the United States to Europe -- and have a negative impact on
air quality far from their original sources, says a new
report by the National Research Council. Although degraded
air quality is nearly always dominated by local emissions,
the influence of non-domestic pollution sources may grow as
emissions from developing countries increase and become
relatively more important as a result of tightening
environmental protection standards in industrialized
countries.
"Air pollution does not recognize national borders; the
atmosphere connects distant regions of our planet," said
Charles Kolb, chair of the committee that wrote the report
and president and chief executive officer of Aerodyne
Research Inc. "Emissions within any one country can affect
human and ecosystem health in countries far downwind. While
it is difficult to quantify these influences, in some cases
the impacts are significant from regulatory and public
health perspectives."
The report examines four types of air pollutants: ozone;
particulate matter such as dust, sulfates, or soot; mercury;
and persistent organic pollutants such as DDT. The committee
found evidence, including satellite observations, that these
four types of pollutants can be transported aloft across the
Northern Hemisphere, delivering significant concentrations
to downwind continents. Ultimately, most pollutants' impacts
depend on how they filter down to the surface.
Current limitations in modeling and observational
capabilities make it difficult to determine how global
sources of pollution affect air quality and ecosystems in
downwind locations and distinguish the domestic and foreign
components of observed pollutants. Yet, some pollutant
plumes observed in the U.S. can be attributed unambiguously
to sources in Asia based on meteorological and chemical
analyses, the committee said. For example, one study found
that a polluted airmass detected at Mt. Bachelor Observatory
in central Oregon took approximately eight days to travel
from East Asia.
The health impacts of long-range transport vary by
pollutant. For ozone and particulate matter -- which cause
respiratory problems and other health effects -- the main
concern is direct inhalation. While the amount of ozone and
particulate matter transported on international scales is
generally quite small compared with domestic sources,
neither of these pollutants has a known "threshold," or
concentration below which exposure poses no risk for health
impacts. Therefore, even small incremental increases in
atmospheric concentrations can have negative impacts, the
committee said. For instance, modeling studies have
estimated that about 500 premature cardiopulmonary deaths
could be avoided annually in North America by reducing ozone
precursor emissions by 20 percent in the other major
industrial regions of the Northern Hemisphere.
For mercury and persistent organic pollutants, the main
health concern is that their transport and deposition leads
to gradual accumulation on land and in watersheds, creating
an increase in human exposure via the food chain. For
example, people may consume mercury by eating fish. There is
also concern about eventual re-release of "legacy" emissions
that have been stored in soils, forests, snowpacks, and
other environmental reservoirs.
In addition, the committee said that projected climate
change will lead to a warmer climate and shifts in
atmospheric circulation, likely affecting the patterns of
emission, transport, transformation, and deposition for all
types of pollution. However, predicting the net impacts of
the potential changes is extremely difficult with present
knowledge.
In the coming decades, man-made emissions are expected to
rise in East Asia, the report says. These increases could
potentially be mitigated by increasingly stringent pollution
control efforts and international cooperation in developing
and deploying pollution control technology.
To enhance understanding of long-range transport of
pollution and its impacts, the committee recommended a
variety of research initiatives, such as advancing
"fingerprinting" techniques to better identify
source-specific pollutant characteristics, and examining how
emissions from ships and aircraft affect atmospheric
composition and complicate the detection of pollution from
land-based sources. The committee emphasized developing an
integrated "pollution source-attribution" system that
improves capabilities in emissions measurements and
estimates; atmospheric chemical and meteorological modeling;
long-term, ground-based observations; satellite remote
sensing; and process-focused field studies.
Moreover, the committee stressed that the United States, as
both a source and receptor of long-range pollution, has an
interest in remaining actively engaged in air pollutants
that travel abroad, including support of more extensive
international cooperation in research, assessment, and
emissions control efforts.
The report was sponsored by the U.S. Environmental
Protection Agency, National Oceanic and Atmospheric
Administration, NASA, and National Science Foundation. The
National Academy of Sciences, National Academy of
Engineering, Institute of Medicine, and National Research
Council make up the National Academies.
1003 Most would refuse
emergency use H1N1 vaccine or additive [University of
Pittsburgh Schools of the Health Sciences]--A
majority of Americans would not take an H1N1 flu vaccine or
drug additive authorized for emergency use by the Food and
Drug Administration, according to a University of Pittsburgh
Graduate School of Public Health and University of Georgia
study. The study, available online today in Biosecurity and
Bioterrorism: Biodefense Strategy, Practice, and Science,
found that fewer than 10 percent of those surveyed said they
would be willing to take such a vaccine or drug and nearly
30 percent remained undecided.
The passage of the Project Bioshield Act in 2004 created the
emergency use authorization (EUA) giving the FDA the ability
to use experimental or "off label" drugs in the event of an
actual or potential emergency. To date, four vaccines
against H1N1 virus have been approved under the same process
used by the FDA for the seasonal flu vaccine. Also, several
drug additives, or adjuvants – sometimes added to vaccines
to strengthen the immune response and stretch the quantity
of available vaccines in the event of a pandemic – have been
ordered and stockpiled by the federal government in case
they may be needed. But adding them to H1N1 vaccines would
trigger an EUA, which is one of the reasons the federal
government has chosen not to use them.
"Although the U.S government has held off on including an
adjuvant in H1N1 vaccines for now, American officials may
need to reconsider this decision as the pandemic unfolds,"
said study author Sandra Quinn, Ph.D., associate dean for
Student Affairs and Education and associate professor at the
University of Pittsburgh Graduate School of Public Health.
"There also remains a significant shortage of the vaccines
in many countries around the world. Given this, our finding
that few people would accept a new but not yet fully
approved H1N1 vaccine or drug is very worrisome," she said.
The study was based on a survey that focused on attitudes
toward H1N1 and willingness to accept flu vaccines and drugs
not officially approved by the FDA, but authorized for
emergency use. Of the 1,543 adults questioned in June 2009,
46 percent of people surveyed said they were concerned about
getting swine flu. However, nearly 86 percent said they
thought it was unlikely or very unlikely that they
themselves would become ill.
Researchers also report that 63 percent of people surveyed
said they would not be willing to take "a new, but not yet
approved vaccine", and 50 percent said they would be very or
extremely worried about taking it. Of those who reported
they would be moderately to extremely worried, 70 percent
said they would refuse the vaccine outright. Only 4 percent
of the most worried said they would take the vaccine,
compared to 23 percent of those who were not at all or
slightly worried.
In addition, 65 percent of those who said they would refuse
the vaccine reported being confident about their decision,
compared to only 46 percent of those who said they would
take the vaccine.
Race also was associated with refusal to take the vaccine –
66 percent of whites and 60 percent of blacks reported they
would refuse the vaccine, compared to 47 percent of
Hispanics. Blacks reported they were the most worried (62
percent), followed by Hispanics (52 percent) and whites (46
percent).
According to Dr. Quinn, these results differ from some
current opinion polls on public acceptance of an H1N1
vaccine because the researchers explicitly asked about
vaccines approved under the EUA designation.
"Communication about the H1N1 vaccine is enormously
challenging," said Dr. Quinn. "The additional issue of
emergency use designation would further complicate
challenges to clear communication. In the event an
emergency-use adjuvant is required to stem the H1N1
pandemic, public health professionals will need to
articulate a strong case for the vaccine and aggressively
address myths and misinformation to increase understanding
and acceptance."
The potential challenge in communicating with the public
about emergency use authorization is relevant beyond the
question of the H1N1 vaccine, added Dr. Quinn. "EUAs are an
important tool for the protection of the public's health in
an emergency. It would behoove public health agencies to
begin now to think about communication and education of the
public on this issue."
Co-authors of the study are Supriya Kumar, Ph.D., Kelley
Kidwell, B.S., and Donald Musa, Dr.P.H., University of
Pittsburgh; and Vicki S. Freimuth, Ph.D., University of
Georgia. The study was funded in part by the Centers for
Disease Control and Prevention. Drs. Quinn, Kumar and Musa
also were supported by the Research Center of Excellence in
Minority Health and Health Disparities at the National
Institutes of Health.
1003 Uninterrupted
chest-compressions key to survival in cardiac arrest outside
hospital setting [UT Southwestern Medical Center]--Maximizing
the proportion of time spent performing chest compressions
during cardiopulmonary resuscitation (CPR) substantially
improves survival in patients who suffer cardiac arrest
outside a hospital setting, according to a multicenter
clinical study that included UT Southwestern Medical Center.
The findings, available in today’s issue of Circulation,
come from the largest clinical investigation to evaluate the
association between chest compressions by emergency medical
service (EMS) providers before the first attempted
defibrillation and survival to hospital discharge.
Out-of-hospital cardiac arrest is a leading cause of
premature death worldwide, and survival is often less than 5
percent.
One of the most important
aspects of quality CPR is the proportion of time spent
performing chest compressions, but EMS providers typically
perform chest compressions only 50 percent of the total time
spent on resuscitative efforts.
“It’s a common problem, because rescuers are involved in so
many other tasks — checking for a pulse, starting
intravenous therapy and giving ventilation, among other
things,” said Dr. Ahamed Idris, professor of emergency
medicine at UT Southwestern and a pioneer in resuscitation
research and CPR. Dr. Idris also is the principal
investigator for the Dallas portion of the new study,
conducted at seven clinical centers across North America.
“Compressions are being interrupted half of the time or
more, and that has a detrimental effect on the survival of
patients,” Dr. Idris said. “This study reinforces that
interrupting chest compressions has a bad effect on
survival. It also provides a rationale for relatively simple
changes to CPR training and practice, that if implemented
are likely to improve survival.”
Dallas-area paramedics and firefighters are being trained to
begin CPR immediately and to administer uninterrupted chest
compressions for two minutes before re-checking the heart
rhythm or using a defibrillator to shock the heart. UT
Southwestern’s emergency medicine program provides medical
oversight for EMS providers in more than a dozen Dallas-area
cities.
In this study, researchers
studied data from patients in the Resuscitation Outcomes
Consortium (ROC) who had suffered from cardiac arrest with a
heart rhythm indicating ventricular fibrillation or
ventricular tachychardia. The researchers focused on the
effect of the number of chest compressions paramedics
administered per minute before they shocked the heart.
“People who received chest compressions 60 to 80 percent of
the time during CPR did better than those who received fewer
chest compressions,” Dr. Idris said.
Previous animal studies have demonstrated that interruptions
in chest compressions decrease coronary and cerebral blood
flow. Based on further clinical and laboratory observations,
the American Heart Association and the European
Resuscitation Council Guidelines for Cardiopulmonary
Resuscitation in 2005 recommended increasing the proportion
of time spent delivering chest compressions.
In 2008 the American Heart Association updated its CPR
guidelines and now advocates that bystanders only perform
continuous chest compressions for cardiac arrest instead of
combining chest compressions with mouth-to-mouth
ventilation.
The data for this study was collected from the ROC, which is
comprised of 11 regional clinical centers funded by the
National Institutes of Health and several U.S. and Canadian
agencies to test lifesaving interventions for critical
trauma and sudden cardiac arrest.
In addition to UT Southwestern in Dallas, the other U.S.
resuscitation centers are in Birmingham, Ala.; Iowa City,
Iowa; Milwaukee; Portland, Ore.; Seattle and King County,
Wash.; Pittsburgh; and San Diego. Toronto and Ottawa also
have resuscitation centers.
1003 Electronic medical
records could be used as a predictor of domestic abuse
[Children's Hospital Boston Informatics Program and Harvard
Medical School]--Doctors could predict a
patient's risk of receiving a domestic abuse diagnosis years
in advance by using electronic medical records as an early
warning system, according to research published on bmj.com
today.
Lead author Dr Ben Reis from the Children's Hospital Boston
Informatics Program and Harvard Medical School investigated
whether the wealth of historical electronic data could be
used to flag up high risk patients.
Reis says: "Doctors typically do not have the time to
thoroughly review a patient's historical records during the
brief clinical encounter. As a result, certain conditions
that could otherwise be detected are often missed. One such
condition is domestic abuse, which may go unrecognised for
years as it is masked by acute complaints that form the
basis of clinical encounters."
Domestic abuse is the most common cause of nonfatal injury
to women in the United States, accounting for more than half
the murders of women every year. It affects both men and
women and can result in serious injury and death. Given
this, say the researchers, "it is critical that at–risk
patients be identified as early as possible".
While evidence demonstrates that screening is a useful tool
in detecting domestic abuse, the authors believe that
doctors "may not be taking full advantage of the growing
amounts of longitudinal data stored in electronic health
information systems".
The authors analysed medical records from over 500,000
non-identifiable patients over 18 years of age for whom they
had at least four years' data on admissions to hospital and
visits to emergency departments. The patients had over 16
million diagnoses among them and cases of abuse were
identified according to established record-keeping codes.
The researchers developed a scoring system to predict which
patients were likely to receive a domestic abuse diagnosis.
The system was successfully able to predict future diagnoses
of abuse an average of 10-30 months in advance.
Certain risk factors were strongly associated with a future
diagnosis of abuse. For women the risk was highest after
being seen in hospital or the emergency department for
injuries, poisoning, and alcoholism. For men being seen for
mental health conditions such as depression and psychosis
conferred the greatest risk of a subsequent diagnosis of
domestic abuse.
They also developed a prototype risk-visualisation
environment which provides clinicians with instant overviews
of longitudinal medical histories and related risk profiles
at the point of care. According to the authors: "In
conjunction with alerts for high-risk patients, this could
enable clinicians to rapidly review and act on all available
historical information by identifying important risk factors
and long-term trends."
Reis maintains that these risk profiles could help doctors
diagnose domestic abuse much earlier, perhaps many years in
advance. He points out that: "With increasing amounts of
data becoming available, this work has the potential to
bring closer the vision of predictive medicine, where vast
quantities of information are used to predict individuals'
future medical risks in order to improve medical care and
diagnosis."
1003 Cold water
cyclones may have strong impact on hurricane intensity and
activity [LSU]--Complex interactions between the
ocean and overlying atmosphere cause hurricanes to form, and
also have a tremendous amount of influence on the path,
intensity and duration of a hurricane or tropical weather
event.
As researchers develop new
ways to better understand and predict the nature of
individual storms, a largely unstudied phenomenon has caught
the attention of scientists at LSU’s Earth Scan Laboratory,
or ESL. Cool water upwellings occurring within ocean
cyclones following alongside and behind hurricanes are
sometimes strong enough to reduce the strength of hurricanes
as they cross paths.
“Ocean cyclones are areas of upwelling, meaning that cold
water is not far from the surface as compared to the water
surrounding it,” said Nan Walker, ESL director. “The Gulf of
Mexico is full of ocean cyclones, or cold water eddies, many
of which move rapidly around the margin of Gulf’s Loop
Current, which is the main source of water for the Gulf
Stream.”
While the upwelling is important to Gulf fisheries because
it delivers nutrients into the surface waters, causing algal
blooms and attracting marine life to the areas,
oceanographers have recently begun to realize that these
cyclones intensify currents near the surface and along the
bottom of the ocean in areas of gas and oil exploration.
“Now,” Walker added, “our research has shown that ocean
cyclones also provide temperatures cold enough to reduce the
intensity of large Gulf of Mexico hurricanes.”
Walker’s research team has been looking into the upwelling
phenomena since 2004, when they were able to use satellite
data received at the ESL to view ocean temperatures soon
after Hurricane Ivan’s Gulf crossing.
“Clear skies gave us a rare opportunity to really analyze
the oceanic conditions surrounding the wake of Ivan,” said
Walker. “We saw abnormally low temperatures in two large
areas along the storm’s track, where minimum temperatures
were well below those required to support a hurricane, about
80 degrees Fahrenheit.” This suggested to Walker that areas
of extreme cooling could be providing immediate negative
feedback to Gulf hurricanes, decreasing their intensity.
“In Ivan’s case, we found that its wind field increased the
counter-clockwise spinning of the ocean cyclones in its
path, catapulting cold water to the surface, which in turn
reduced the oceanic ‘fuel’ needed for the hurricane to
maintain its strength,” said Walker. She observed that
Ivan’s intensity decreased as it moved toward the
Mississippi/Alabama coast, despite the presence of a large
warm eddy, a feature generally known for its potential to
increase hurricane strength. Thus, the impact of the cold
eddies overwhelmed that of the warm eddy.
“Cool wakes are most beneficial when the storm occurs later
in the season because the Gulf doesn’t warm as rapidly in
fall and may not have time to warm back up,” said Walker.
The research being conducted at ESL could eventually lead to
novel new weather study techniques.
“Our research, in collaboration with Robert Leben at the
University of Colorado, is providing an advanced monitoring
system so that likely ocean impacts can be assessed in
advance of the Gulf crossing,” said Walker. “However, it is
important to remember that we don’t predict; we provide
valuable information that serves as tools for those in the
business of predicting, such as the National Hurricane
Center.”
Of course, this is only one facet of the work done at LSU’s
ESL. The lab has played a major role in mapping
hurricane-related flooding, tracking oil spills and
determining causes for the size and location of dead zones
in the Gulf of Mexico, along with many other tasks employing
satellite imagery.
1003 Universal
screening lowers risk of severe jaundice in infants [UCSF]--Screening
all newborns for excessive bilirubin in the blood can
significantly decrease the incidence of severe jaundice
which, in extreme cases, can lead to seizures and brain
damage, according to researchers at UCSF Children's Hospital
and Kaiser Permanente's Division of Research in Oakland, CA.
The study, one of the first to examine the effectiveness of
universal screening for hyperbilirubinemia, appears in the
current issue of "Pediatrics," the official journal of the
American Academy of Pediatrics. The study is one of six in
this issue to explore the topic of bilirubin and
hyperbilirubinemia.
Hyperbilirubinemia is caused by an elevation of a bile
pigment, called bilirubin, in the blood. Bilirubin is made
when the body breaks down old red blood cells, and high
levels can cause jaundice, a condition that makes the
newborn's skin and the white part of the eyes look yellow.
The researchers explain that most newborns have a rise in
bilirubin in the days following birth. However, very high
blood levels can be toxic to the nervous system. Monitoring
these levels in babies with jaundice is important so that
treatment can be started before levels become excessive,
explain the researchers. They add that high bilirubin levels
can be treated with light therapy, which converts the
bilirubin into a form that the body can remove.
"While we know that early identification of bilirubin levels
before reaching toxic levels is important, bilirubin
screening has not been universal, as physicians have decided
which infants to screen based upon their degree of jaundice
and clinical risk factors," said Michael Kuzniewicz, MD,
MPH, the lead author of the study and a neonatologist at
UCSF Children's Hospital.
"This study provides evidence
that universal screening during the birth hospitalization is
a more effective method for monitoring bilirubin levels in
order to prevent them from rising to a point that can damage
an infant's brain."
The study evaluated the impact of implementation of the 2004
American Academy of Pediatrics (AAP) guideline on the
management of jaundice in the Northern California facilities
operated by Kaiser Permanente. The guideline recommends that
every newborn be assessed for the risk of developing severe
jaundice with a bilirubin level before discharge home and/or
an assessment of clinical risk factors.
With universal screening, researchers noted a 62 percent
decrease in the number of newborns with very high bilirubin
levels. The study also describes an increase in the use of
phototherapy to treat infants with elevated bilirubin
levels, sometimes even when the AAP guidelines did not call
for it.
Researchers in this study evaluated both blood tests and
devices that estimate the bilirubin level from the color of
the baby's skin as methods of screening. "The method didn't
seem to matter as much as changing the standard operating
procedure, such that all babies are screened," said study
co-author Gabriel Escobar, MD, regional director for
hospital operations research and a research scientist with
the Kaiser Permanente Division of Research's Perinatal
Research Unit in Oakland, CA.
"With additional education to
help avoid excessive use of phototherapy, we think universal
screening is a very good tool to reduce cases of serious
hyperbilirubinemia."
"This research highlights the power of laboratory databases
in supporting research and quality improvement," according
to senior author Thomas B. Newman, MD, MPH, with the UCSF
Department of Epidemiology and Biostatistics and the UCSF
Division of General Pediatrics.
The study was funded by a grant from the National Institute
of Child Health and Human Development.
1003 Women with
diabetes at increased risk for irregular heart rhythm
[Kaiser Permanente]--Diabetes increases by 26
percent the likelihood that women will develop atrial
fibrillation (AF), a potentially dangerous irregular heart
rhythm that can lead to stroke, heart failure, and chronic
fatigue.
These are the findings of a
new Kaiser Permanente study, published in the October issue
of Diabetes Care, a journal of the American Diabetes
Association.
While other studies have found that patients with diabetes
are more likely to have AF, this is the first large
study—involving nearly 35,000 Kaiser Permanente patients
over the course of seven years—to isolate the effect of
diabetes and determine that it is an independent risk factor
for women.
“The most important finding from our study is that women
with diabetes have an increased risk of developing this
abnormal heart rhythm,” said the study’s lead author, Greg
Nichols, PhD, investigator at the Kaiser Permanente Center
for Health Research in Portland, Ore.
“Men with diabetes are also at
higher risk, but the association between the two conditions
is not as strong. For men, obesity and high blood pressure
are bigger risk factors from diabetes.”
“AF is the most common arrhythmia in the world, and diabetes
is one of the most common and costly health conditions. Our
study points out that there is a connection between these
two growing epidemics—one we should pay closer attention to,
especially among women,” says Sumeet Chugh, MD, co-author
and associate director of the Cedars-Sinai Heart Institute
in Los Angeles.
“The gender differences need
to be looked at more closely because they could have
significant implications for how we treat diabetes in men
and women.”
Atrial fibrillation occurs when the two upper chambers of
the heart beat irregularly and too fast, causing blood to
pool and clot. If the clot travels out of the heart and
becomes lodged in an artery or in the brain, it can cause a
stroke.
About 2.2 million Americans
are diagnosed with AF; however, many more people have the
condition but don’t know it. Diabetes affects more than 23
million Americans—and, according to the study, nearly 4
percent, or 1 million, have atrial fibrillation.
The study involved 17,372 patients in Kaiser Permanente’s
diabetes registry in Oregon and Washington and an equal
number of non-diabetic patients, matched for age and sex.
Researchers used Kaiser Permanente HealthConnect®, the
world’s largest civilian electronic health records system,
to identify the non-diabetic patients.
The two groups were followed
for an average of 7.2 years until Dec., 31, 2008, or until
they died or left the health plan. At the start of the study
3.6 percent of the patients with diabetes had AF, vs. only
2.5 percent of the non-diabetic patients—a difference of 44
percent.
During the study period,
diabetics were more likely than non-diabetics to develop AF.
But after controlling for other factors like obesity, high
blood pressure and age, the increased risk was only
significant among women. Women with diabetes were 26 percent
more likely than their non-diabetic counterparts to develop
AF.
Authors include Gregory A. Nichols, PhD, Kaiser Permanente
Center for Health Research; Kyndaron Reinier, PhD, and
Sumeet Chugh, MD, co-author and associate director of the
Cedars-Sinai Heart Institute in Los Angeles.
1003 Risk of bone
fractures associated with use of diabetes drug [London
School of Hygiene and Tropical Medicine]--Research
published this week in the open access journal, PLoS
Medicine, suggests that there is an association between
thiazolidinediones – a type of drug introduced in the 1990s
to treat type 2 diabetes – and bone fracture.
Ian Douglas of the London School of Hygiene and Tropical
Medicine and colleagues searched the UK General Practice
Research Database, a computerised record of clinical records
from over 6 million patients registered at 400 general
practice surgeries in the United Kingdom.
They identified 1,819
individuals aged 40 years or older who had a recorded bone
fracture and who had been prescribed a thiazolidinedione at
least once and conducted a self-controlled case-series
study.
This is a study that compares
how often an event (in this case bone fracture) occurs in a
population of people during the period when they are taking
a particular medication (in this case a thiazolidinedione
drug) against the period when they are not taking that
medication.
Adjusting for age (as older
people are at a higher risk of bone fracture), the
researchers found that in the group of people identified
nearly one and half times as many fractures occurred when
people were taking thiazolidinediones than when they were
not taking these drugs.
The increased risk of fracture
was observed in both men and women and applied to a wide
range of fracture sites on the body. The study also found
that the risk of fracture increased as the duration of
treatment with the drug increased.
The main advantage of the study design is that it eliminates
the possibility that differences between people who do and
do not get prescribed a drug contribute to the results. The
researchers acknowledge that as with any study there could
be other sources of bias because it is observational and not
a randomised trial.
Nevertheless, the findings are
in keeping with findings from recent trials that suggested a
link between thiazolidinediones and bone fracture. The
researchers conclude that the results "should be taken into
consideration in the wider debate surrounding the possible
risks and benefits of treatment with thiazolidinediones.
Funding: This work was funded by a grant from the Wellcome
Trust obtained by Professor Smeeth. The Wellcome Trust
played no part in the design and conduct of the study;
collection, management, analysis and interpretation of the
data; and preparation, review or approval of the manuscript.
Competing Interests: IJD consults for and holds stock in
GlaxoSmithKline. SJE is a co-opted member of the
Pharmacovigilance Working Party at the European Medicines
Agency (EMEA) and therefore advises on issues of drug safety
relevant to Europe. SP consults for GlaxoSmithKline and is
on the steering committee of the RECORD rosiglitazone study.
LS reports no conflicts of interest.
Citation: Douglas IJ, Evans SJ, Pocock S, Smeeth L (2009)
The Risk of Fractures Associated with Thiazolidinediones: A
Self-controlled Case-Series Study. PLoSMed 6(9): e1000154.
doi:10.1371/journal.pmed.1000154
1003 What proportion of
psychotic illness is due to cannabis? [University of New
South Wales Sydney]--In this week's PLoS
Medicine, a team of researchers from Australia and the US,
led by Louisa Degenhardt at the University of New South
Wales, Sydney, makes the case for estimating the role that
cannabis has worldwide as a risk factor for psychosis.
This estimation, says the team, will give an idea of how
much impact cannabis has upon public health globally. The
information in turn could be valuable for guiding health
policymakers in deciding about health policies, services,
and research.
The global impact of different diseases and risk factors
upon population health is estimated by a high profile
international research initiative called the Global Burden
of Disease Project
http://www.globalburden.org/.
Some of the risk factors that the project assesses are
smoking, high blood pressure, obesity, and alcohol use. But
in the past the project has not examined cannabis as a risk
factor, say Degenhardt and colleagues, because of concerns
that the evidence linking cannabis use to psychosis is too
weak.
Degenhardt and colleagues examine the studies that have
shown a link between using cannabis and developing psychotic
illnesses such as schizophrenia. Based on the strength of
this evidence, and on the fact that cannabis use is a
potentially preventable exposure, they argue that the Global
Burden of Disease Project should include cannabis as a risk
factor. The authors review lines of evidence which suggest
that cannabis may be a particular risk for those vulnerable
to developing the illness. They propose to model multiple
possible relationships between cannabis and psychosis,
including models of poorer outcomes for those who have
developed the disorder.
Researchers in Australia, for example, included cannabis in
their national study of the impact of risk factors and
diseases upon population health. In estimating the impact of
cannabis, the researchers assumed that the evidence was good
enough to show a link between cannabis use and psychosis,
suicide, and car crashes. "Even after assuming that these
relationships were causal," say Degenhardt and colleagues,
"cannabis was not a major contributor to disease burden in
Australia, accounting for 0.2% of all disease burden, which
amounted to 10% of the total burden attributable to all
illicit drugs."
"These estimates are important for public policy purposes,"
they say, "because failure to make them allows untested
estimates to be offered in public policy debate."
The authors argue that if the international community does
not estimate the global impact of cannabis use, there will
be important consequences. "There will be a reduced public
health, policy, or research imperative, since there will be
no estimated burden."
On the other hand, they say that "if we do attempt to
estimate burden, future work will examine the accuracy of
our estimates and refine them as evidence accumulates.
Debates may emerge and (hopefully) improvements made as new
evidence supports or challenges the assumptions made.''
Funding: This work was given
funding support from the Australian Government Department of
Health and Ageing. LD is the recipient of an Australian
National Health and Medical Research Council (NHMRC) Senior
Research Fellowship. The funders had no role in study
design, data collection and analysis, decision to publish,
or preparation of the manuscript.
Citation: Degenhardt L, Hall WD, Lynskey M,
McGrath J, McLaren J, et al. (2009) Should Burden of Disease Estimates
Include Cannabis Use as a Risk Factor for Psychosis? PLoS Med 6(9):
e1000133. doi:10.1371/journal.pmed.1000133
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1021
New mathematical model more accurately diagnoses acute heart failure in
emergency rooms [Toronto ON]
1021
Magnetic leaves reveal most polluted byways [Boulder CO]
1021
New laryngoscope could make difficult intubations easier [Augusta GA]
1021
Outfoxing pox: Developing a new class of vaccine candidates [Arizona
State University]
1021
News in red and blue: Messages about social factors and health can
backfire [Ann Arbor MI]
1021
Scientists find 'molecular trigger' for sudden death in epilepsy
[Houston TX]
1021
Is the person next to you washing their hands with soap? [London School
of Hygiene and Tropical Medicine]
1021
Popular antidepressant associated with a dramatic increase in suicidal
thoughts amongst men [Kings College, London UK]
1021
Dying from dementia - far greater access to palliative care required
[Indianapolis IN]
1021
Fighting flu: Stricter hand hygiene in schools only a short-term measure
[London School of Hygiene and Tropical Medicine]
1021
CT scans show patients with severe cases of H1N1 are at risk for
developing acute pulmonary emboli [University of Michigan]
1017
Infectious disease experts express concern over N95 recommendations
[Society for Healthcare Epidemiology of America]
1014
Earlier flu viruses provided some immunity to current H1N1 influenza [UC
Davis]
1014
Flu surveillance boosts control, treatment options [University of
Alabama at Birmingham]
1014
H1N1 critical illness can occur rapidly; predominantly affects young
patients [JAMA]
1014
Critical illness from 2009 H1N1 in Mexico associated with high fatality
rate [JAMA]
1014
ECMO saves lives: Swine flu study [Monash University]
1014
Should noninvasive ventilation be considered a high-risk procedure
during an epidemic? [CMAJ]
1014
Over half of cot deaths occur while co-sleeping [BMJ]
1014
Canadian blood supply future uncertain as population ages: Study
[McMaster University]
1014
H1N1 simulation modeling shows rapid vaccine rollout effective in
reducing infection rates [Canadian Medical Association Journal]
1010
NIH prepares to launch 2009 H1N1 influenza vaccine trial in people with
asthma [NIH]
1010
NIH launches 2009 H1N1 influenza vaccine trials in HIV-infected pregnant
women [NIH]
1010
Lessons learned from H1N1 virus pandemic - High impact on ICU beds
[Monash University]
1010
US must focus on protecting critical computer networks from cyber attack
[RAND]
1010
Major healthcare challenges persist for DC children despite high rates
of health insurance coverage [Children's National Medical Center/ RAND
Health]
1010
Injury and hazards in home health care nursing are a growing concern
[Columbia University's Mailman School of Public Health]
1010
Insured African-Americans more likely to use emergency room than other
insured groups [UCLA]
1010
New study finds high rates of childhood exposure to violence and abuse
in US [University of New Hampshire]
1010
Draft NIST report on Cowboys facility collapse released for comment
[National Institute of Standards and Technology]
1010
For safer emergencies, give your power generator some space [National
Institute of Standards and Technology]
1010
The high cost of treating alcohol-impaired drivers [Injury Prevention
Center at Rhode Island Hospital]
1010
Intensive care units poorly equipped to care for the dying [Sahlgrenska
Academy]
1010
Research gives new meaning to 'green' cross code [University of Leeds]
1010
New technology detects chemical weapons in seconds [Queen's University
Belfast]
1010
Tracing ultra-fine dust [Fraunhofer Institute for Laser Technology ILT
in Aachen]
1010
Air pollution may trigger appendicitis [University of Toronto/ Health
Canada]
1010
Keeping children safe: Rethinking design [University of Toronto/ The
Hospital for Sick Children]
1010
Costs of expanding health care coverage partly offset by future Medicare
savings [Harvard Medical School]
1010
Analyses of flu pandemics project savings from earlier vaccinations
[Stanford University Medical Center]
1010
Child burn injuries down significantly yet alarming number of children
still being injured [Nationwide Children's Hospital]
1010
Battery ingestion not uncommon in children; caregivers and physicians
need education [American Academy of Otolaryngology]
1010
Global death toll: 1 million premature babies every year [March of Dimes
Foundation]
1003
Survey finds just 40 percent of adults 'absolutely certain' they will
get H1N1 vaccine [Harvard School of Public Health]
1003
How to limit risk of climate catastrophe [MIT]
1003
Half-million low-income elderly affected by sweeping cuts to state
safety net [UCLA]
1003
Surgical masks vs. N95 respirators for preventing influenza among
health-care workers [McMaster University]
1003
Parasite bacteria may help fight spread of mosquito-borne diseases
[Wellcome Trust]
1003
Gun possession of questionable value in an assault [University of
Pennsylvania School of Medicine]
1003
San Andreas affected by 2004 Sumatran quake - Largest quakes can weaken
fault zones worldwide [Rice University]
1003
Securing biological select agents and toxins will require developing a
culture of trust [National Academy of Sciences]
1003
Peer pressure builds more latrines than financial assistance [Duke
University]
1003
Physician-assisted suicide does not increase severity of depression,
grief among family members [Oregon Health & Science University]
1003
Using computational models to study fear [University of Missouri]
1003
Protect children first with H1N1 flu vax [University of Alabama at
Birmingham]
1003
New way to monitor faults may help predict earthquakes [Carnegie
Institution's Department of Terrestrial Magnetism]
1003
Celebs spawn copycat suicides [Queen Mary Research Centre for
Psychology]
1003
Prenatal exposure to flu pandemic increased chances of heart disease
[University of Southern California]
1003
Treating even mild gestational diabetes reduces birth complications
[NIH/National Institute of Child Health and Human Development]
1003
Air pollutants from abroad a growing concern [National Research Council]
1003
Most would refuse emergency use H1N1 vaccine or additive [University of
Pittsburgh Schools of the Health Sciences]
1003
Uninterrupted chest-compressions key to survival in cardiac arrest
outside hospital setting [UT Southwestern Medical Center]
1003
Electronic medical records could be used as a predictor of domestic
abuse [Children's Hospital Boston Informatics Program and Harvard
Medical School]
1003
Cold water cyclones may have strong impact on hurricane intensity and
activity [LSU]
1003
Universal screening lowers risk of severe jaundice in infants [UCSF]
1003
Women with diabetes at increased risk for irregular heart rhythm [Kaiser
Permanente]
1003
Risk of bone fractures associated with use of diabetes drug [London
School of Hygiene and Tropical Medicine]
1003
What proportion of psychotic illness is due to cannabis? [University of
New South Wales Sydney]
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