Lit Bits: January 18, 2006

From the recent medical literature...

1. Percutaneous Coronary Intervention May Be Beneficial After Failed Thrombolytic Therapy

Laurie Barclay, MD. Jan. 3, 2006 — Rescue percutaneous coronary intervention (PCI) may be beneficial after failed thrombolytic therapy, according to the results of a multicenter trial published in the December 29, 2005, issue of The New England Journal of Medicine.

"The appropriate treatment for patients in whom reperfusion fails to occur after thrombolytic therapy for acute myocardial infarction [MI] remains unclear," write Anthony H. Gershlick, MB, BS, from University Hospitals of Leicester, United Kingdom, and colleagues from the Rescue Angioplasty versus Conservative Treatment or Repeat Thrombolysis (REACT) Trial Investigators. "There are few data comparing emergency percutaneous coronary intervention (rescue PCI) with conservative care in such patients, and none comparing rescue PCI with repeated thrombolysis."

In this multicenter trial, 427 patients with ST-segment elevation MI (STEMI) and failed reperfusion, defined as less than 50% ST-segment resolution within 90 minutes after thrombolytic treatment, were randomized to repeated thrombolysis (142 patients), conservative treatment (141 patients), or rescue PCI (144 patients). The main outcome measure was a composite of death, reinfarction, stroke, or severe heart failure within 6 months.

Rates of event-free survival were 84.6% for patients treated with rescue PCI, 70.1% for those receiving conservative therapy, and 68.7% for those undergoing repeated thrombolysis (overall P = .004). For repeated thrombolysis vs conservative therapy, the adjusted hazard ratio (HR) for the occurrence of the primary endpoint was 1.09 (95% confidence interval [CI], 0.71 - 1.67; P = .69) compared with adjusted HR of 0.43 (95% CI, 0.26 - 0.72; P = .001) for rescue PCI vs repeated thrombolysis and 0.47 (95% CI, 0.28 - 0.79; P = .004) for rescue PCI vs conservative therapy.

All-cause mortality was similar in all groups. Nonfatal bleeding, mostly at the sheath-insertion site, was more common in the rescue PCI group. Freedom from revascularization at 6 months was present in 86.2% of the rescue-PCI group, 77.6% of the conservative-therapy group, and 74.4% of the repeated-thrombolysis group (overall P = .05).

Study limitations include lack of data on myoglobin and other markers for detecting failed thrombolytic therapy; early trial termination; and possible selection bias.

"Event-free survival after failed thrombolytic therapy was significantly higher with rescue PCI than with repeated thrombolysis or conservative treatment," the investigators write. "Rescue PCI should be considered for patients in whom reperfusion fails to occur after thrombolytic therapy."

Four of the authors have disclosed various relevant financial relationships with Cordis, Boston Scientific, Medtronic, Guidant, Eli Lilly, and/or Conor Medsystems.

N Engl J Med. 2005;353:2758-2768

2. Two million Americans harbor MRSA, CDC estimates

[So what percentage is 2 million? Just how many Americans are there? According to the latest US Census data, as of July 1, 2005, the population hovered around 296,410,404. 2 million is less than 1%. --DRV]

January 4, 2006. NEW YORK (Reuters Health) - About 2 million people in the United States carry methicillin-resistant Staphylococcus aureus (MRSA) in their nasal passages, the US Centers for Disease Control and Prevention estimates.

Dr. Matthew J. Kuehnert and colleagues assessed S. aureus nasal carriage in 9,622 participants in the 2001-2002 National Health and Nutritional Examination Survey and found that 32.4% were colonized with S. aureus, of whom 0.8% harbored MRSA.

This translates into weighted population estimates of 89.4 and 2.3 million Americans colonized with S. aureus and MRSA, respectively, they report in the January 15th issue of The Journal of Infectious Diseases. S. aureus prevalence was highest among males and children between the ages of 6 and 11 years, whereas MRSA prevalence was highest among females and those older than age 60.

"In light of the increasing frequency of community-acquired MRSA infection," write the authors of a related editorial, "new antimicrobials are needed, particularly given the emergence of glycopeptides-resistant strains."

"Yet, new antimicrobials will remain fingers in the proverbial dike until a more-definitive solution can be found," contend Dr. Clarence Buddy Creech II and colleagues from Vanderbilt University in Nashville.

Stimulated by the development of effective vaccines against Haemophilus influenzae type b (Hib) and pneumococcus, several major pharmaceutical companies are working on staphylococcal vaccines, they also note. "The appropriate components of such a vaccine remain an area of active research, but early successes confirm that the vaccine-based approach is a viable undertaking," Dr. Creech and colleagues charge.

J Infect Dis 2006;193:169-179.

3. L-arginine may increase mortality risk after myocardial infarction
This explains why I’ve never noticed any improvement in the AMI patients to whom I’ve given L-arginine. Another drug bites the dust. But the concept is clever.

The amino acid L-arginine is a substrate for nitric oxide synthase and is increasingly used as a health supplement. Prior studies suggest that L-arginine has the potential to reduce vascular stiffness. Perhaps it might serve as an adjunctive intervention in patients with AMI. Below is a report of a recent RCT published this month in JAMA. [L-Arginine Therapy in Acute Myocardial Infarction: The Vascular Interaction With Age in Myocardial Infarction (VINTAGE MI) Randomized Clinical Trial. Schulman SP, et al. JAMA. 2006;295:58-64.]

NEW YORK (Reuters Health: January 4, 2006) - The amino acid L-arginine provides no benefit to patients who have experienced an ST-segment elevation myocardial infarction, and may even increase mortality in patients over the age of 60, Baltimore-based researchers report.

Based on the hypothesis that L-arginine can reduce vascular stiffness, Dr. Steven P. Schulman, from Johns Hopkins Hospital, and his associates initiated the prospective Vascular Interaction with Age in Myocardial Infarction (VINTAGE MI) clinical trial, in which 153 patients were randomly assigned to L-arginine (up to 3 grams three times daily) or placebo for 6 months after experiencing a first MI.

According to their report in the January 4th issue of The Journal of the American Medical Association, 6-month follow-up data were obtained for 55 subjects in the L-arginine group and 59 in the placebo group. There were no significant changes in either group in measures of ejection fraction, arterial elastance, arterial compliance, pulse pressure, or pulse wave velocity.

However, six deaths occurred in the L-arginine group, including five among patients age 60 years or older, and none in the control group (p = 0.01), which led to early termination of the study.

Dr. Schulman's team proposes several possible mechanisms by which L-arginine could cause post-MI damage, including increased generation of reactive oxygen species, homocysteine production, and increased activity of the inducible isoform of nitric oxide synthase.

"L-arginine therapy should not be given to patients following a myocardial infarction," they advise. Furthermore, they add, "L-arginine therapy in older patients with diffuse atherosclerosis may worsen clinical outcomes.

4. New Data on Treating Bronchiolitis in Kids

In two recent studies, researchers examined aspects of treatment for bronchiolitis, the most common lower respiratory tract infection in young children.

In recent studies, investigators have questioned whether bronchodilators (e.g., albuterol) are helpful for treating bronchiolitis, and whether very young infants might respond differently from older infants. To test this hypothesis, researchers in Austria gave inhaled salbutamol to 41 children (age range, 2 to 18 months) with mild-to-moderate respiratory syncytial virus–positive bronchiolitis. Pulmonary function studies that were conducted 15 minutes after inhalation demonstrated significant improvement in 11 children, worsening in 3 children, and no changes in 27 children. No correlation was observed between age and pulmonary response.

Medications to treat bronchiolitis usually are administered by face masks attached to nebulizers. This mode of delivery often is problematic, because many babies scream and squirm throughout treatment, which makes tight sealing of the masks difficult. In a randomized, controlled trial, Israeli investigators assigned 49 infants hospitalized with bronchiolitis to receive inhaled epinephrine either by conventional nebulizers with masks or passively in a hood. A statistically significant, but not dramatic, clinical improvement was noted in both groups during each of the 3 days of hospitalization, and no difference was observed between the groups. Parents strongly preferred the hood to the mask.

Comment: No medications consistently and effectively treat bronchiolitis in children. Therapeutic efficacy of agents such as bronchodilators and epinephrine should be assessed on an individual basis.

— Robert A. Dershewitz, MD, MSc. Published in Journal Watch January 3, 2006. Source: Modl M et al. Does bronchodilator responsiveness in infants with bronchiolitis depend on age? J Pediatr 2005 Nov; 147:617-21. Amirav I et al. Aerosol delivery in respiratory syncytial virus bronchiolitis: Hood or face mask? J Pediatr 2005 Nov; 147:627-31.

5. Children Fare Better Than Adults After In-Hospital Cardiac Arrest

Do kids and adults differ in their presenting rhythm? And how might this difference effect outcomes?

First Documented Rhythm and Clinical Outcome From In-Hospital Cardiac Arrest Among Children and Adults. Nadkarni VN, et al, for the National Registry of Cardiopulmonary Resuscitation Investigators. JAMA 2006;295:50-57,96-97.

By Anthony J. Brown, MD. NEW YORK (Reuters Health) Jan 04 - Contrary to what had been hypothesized, survival is better for children who experience in-hospital cardiac arrest than for adults, according to a report in the Journal of the American Medical Association for January 4. The results also suggest that CPR approaches for the two age groups should be more similar than different.

Previous reports have shown that cardiac arrests due to ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) have better outcomes than those due to asystole or pulseless electrical activity. Because the former types were thought to be less common in children than in adults, it was hypothesized that survival would be worse in children.

"Our findings indicate that cardiac arrest due to VF or VT is more common in children than previously thought," lead author Dr. Vinay M. Nadkarni, from the University of Pennsylvania School of Medicine in Philadelphia, told Reuters Health. Still, these types of arrests were less common in children than in adults, he added.

Interestingly, even though these better-prognosis arrests were less common in children, they still had improved survival compared with adults, Dr. Nadkarni said. The reason is because in both age groups, asystole- and pulseless electrical activity-type "arrests are the most common and children fare better after these types than do adults. Why this is the case will require further study."

Dr. Nadkarni's group evaluated nearly 37,000 cardiac arrests that occurred at 253 US and Canadian hospitals between January 1, 2000 and March 30, 2004. About 900 of the arrests logged in this data set, the National Registry of Cardiopulmonary Resuscitation, involved children, the rest involved adults.

Overall, 27% of children survived to hospital discharge compared with 18% of adults, yielding an adjusted odds ratio of 2.29. Of the survivors, the percentage of children and adults with a good neurologic outcome was 65% and 73%, respectively.

VF or pulseless VT constituted 14% of the first documented pulseless rhythms in children and 23% in adults. Asystole was seen in 40% of pediatric arrests and 35% of adult arrests, whereas pulseless electrical activity was the cause of 24% of pediatric arrests and 32% of adult arrests.

As for future studies, Dr. Nadkarni said his group is interested in looking at the impact that the timing of chest compressions has on survival. "If you look at the data, you'll see that children receive chest compressions before they're completely pulseless more frequently than do adults. So, we'd like to look at whether this phenomenon of anticipating the arrest and providing blood flow will have an impact on outcomes. We believe it will."

In a related editorial, Dr. Linda Quan, from the University of Washington School of Medicine in Seattle, comments that these findings question the conventional wisdom that the resuscitation approach for children and adults with cardiac arrest should differ.

"What a great relief it would be to say to those individuals involved in resuscitation care, regardless of the arrest patient's age and setting, there is a universal approach," she adds. "What is good for the goose is also good for the gosling."

6. Statins Signicantly Reduce Recurrence Rate of Paroxysmal Atrial Fibrillation in Pts with Elevated C-reactive Protein Levels

Statins, primarily used for lipid lowering, also reduce systemic inflammation, as measured by a reduction in C-reactive protein. This study suggests that statins can be used to reduce PAF (recurrence at 6 months in controls 65% vs. recurrence in statin group 10%--impressive!).

John Dernellis, MD; Maria Panaretou, MD. Am Heart J. 2005;150(5):1064.e7-1064.e12.

Introduction
C-reactive protein (CRP) may be a risk factor for the development of atrial fibrillation (AF). In addition, trials of aggressive CRP lowering have shown a reduction in the incidence of recurrence of persistent AF. This reduction in AF events is proportional to the degree of CRP lowering, which suggests that regression of inflammation may be the principal mechanism by which CRP lowering alters AF risk. It has been suggested that CRP lowering results in improvement of electrical remodeling affecting recurrent AF. The rise in circulating CRP is associated with activation of the classic pathway of complement and, hence, tissue damage.

Previous studies have investigated the effects of lowering CRP by statins or glucocorticoid on the prevention of recurrent hospitalized AF in patients who have been cardioverted into sinus rhythm. These studies analyzed somewhat a secondary prevention of AF. Hence, we sought to determine the effect of CRP lowering on paroxysmal AF (PAF) as measured by ambulatory electrocardiographic (ECG) monitoring in patients with PAF. We aimed to determine the effects of atorvastatin on asymptomatic episodes of PAF in everyday life, representing a kind of primary prevention of AF.

Abstract
Background: C-reactive protein (CRP) lowering is associated with a reduction in recurrent and permanent atrial fibrillation. This study sought to determine whether CRP lowering also results in a reduction of paroxysmal atrial fibrillation (PAF) during daily life.

Methods and Results: We enrolled 80 patients with proven PAF, CRP between 0.8 and 13 mg/L [the normal value of the C-reactive protein is often considered less than 0.8 mg/dl], and at least 1 episode of PAF on ambulatory electrocardiographic monitoring. Forty patients were randomized to placebo (placebo group) and 40 to atorvastatin (treatment group). Plasma CRP levels and ambulatory monitoring were repeated after 4 to 6 months of therapy. The 2 groups were comparable with respect to baseline characteristics, number of episodes of PAF, and baseline plasma CRP levels. The treatment group had lower median CRP levels at study end and experienced a significant reduction in the number of episodes of PAF compared with the placebo group. Paroxysmal atrial fibrillation was completely resolved in 26 (65%) of 40 patients in the treatment group versus 4 (10%) of 40 in the placebo group. The treatment group exhibited a highly significant reduction in PAF (P < .001). By logistic regression, treatment with atorvastatin was an independent predictor of PAF resolution.

Conclusions: C-reactive protein lowering with atorvastatin appears to be effective in eliminating PAF during daily life in a significant proportion of patients.

Full-text (free): http://www.ahjonline.com/article/PIIS0002870305006472/fulltext?browse_volume=150&issue_key=TOC%40%40JOURNALS%40YMHJ%400150%400005&issue_preview=no&select1=no&select1=no&start=&startpage=&vol=

7. Sedation and Analgesia for Pediatric Fracture Reduction in the Emergency Department: A Systematic Review

Russell T. Migita, MD; Eileen J. Klein, MD, MPH; Michelle M. Garrison, MPH. Arch Pediatr Adolesc Med. 2006;160:46-51.

Objective To assess the safety and efficacy of various forms of analgesia and sedation for fracture reduction in pediatric patients in the emergency department, as observed in randomized controlled trials in pediatric populations.

Data Sources Cochrane Controlled Trials Register, CINAHL (Cumulative Index to Nursing & Allied Health Literature), and MEDLINE. The search terms "fractures," "manipulation, orthopedic," "an(a)esthetics," "analgesics," and "hypnotics and sedatives" were used.

Study Selection Studies were included if they were randomized controlled trials studying sedative and/or analgesic regimens for fracture reductions in pediatric patients in the emergency department. The search yielded 915 references. From these, 8 studies inclu ding 1086 patients were selected.

Data Extraction Interventions studied included intravenous regional blocks (Bier blocks), nitrous oxide, and parenteral combinations. Data on measures of effectiveness and safety were extracted.

Data Synthesis Ketamine hydrochloride–midazolam hydrochloride was associated with less distress during reduction than fentanyl citrate–midazolam or propofol-fentanyl. Patients receiving ketamine-midazolam required significantly fewer airway interventions than those in whom either fentanyl-midazolam or propofol-fentanyl were used. Data comparing Bier blocks with systemic forms of sedation or analgesia were limited.

Conclusions Ketamine-midazolam seems to be more effective and have fewer adverse events than fentanyl-midazolam or propofol-fentanyl. Data on other forms of analgesia or sedation are too limited to make comparisons. More research is needed to define the regimen that maximizes safety, efficacy, and efficiency for fracture reduction in pediatric patients.

8. Cough medicines’ effect is mainly placebo

Abergavenny Roger Dobson (BMJ 2006;332:8)

Cough medicines work mostly through their sweet tastes and placebo effect, says a new report. The sweet syrups used in most over the counter medicines may contribute to the cough suppressant and expectorant activity, says a review published online in Respiratory Physiology and Neurobiology on 2 December

Ronald Eccles. Mechanisms of the placebo effect of sweet cough syrups. Respiratory Physiology & Neurobiology, In Press, Corrected Proof, Available online 2 December 2005.

“The review proposes that the major benefit of cough medicines for treatment of cough associated with common cold is related to the placebo effect rather than the pharmacological effect of an active ingredient,” says the author, Ron Eccles, head of the Common Cold Centre at the University of Cardiff.

All but two of the 60 over the counter cough medicines available in the United Kingdom contain a sweetener, such as sucrose, glucose, honey, treacle, or, in children’s medicines, a sugar-free sweetener. The sweet or bitter taste of a medicine may trigger salivation and the secretion of mucus, the report says: “Cough syrups that contain sapid substances, such as sugar, honey; spicy substances, such as capsicum; and bitter tasting substances, such as lemon and citric acid, will readily cause reflex salivation and may also promote secretion of airway mucus,” it says.

A sweet taste may also have a beneficial effect on a cough by influencing the production of endogenous opioids. And the true placebo effect of a cough medicine may be linked to this generation of opioids, the report says.

Professor Eccles points out other examples of similar beneficial effects: “It is interesting to note that application of crystalline sugar to the tongue has also been reported to inhibit another respiratory reflex—the hiccup. This indicates that the pharmacological activity of most cough medicines is questionable,” he adds, “but it does not mean that cough medicines are ineffective in treating cough. The major benefits of over the counter cough medicines may be related to the different components of the placebo effect.”

9. Implications of Incidentally Discovered Bundle-Branch Block

Bundle-branch block (BBB) is found occasionally on the electrocardiogram of an apparently healthy person. The prognostic significance of this finding has varied in previous studies. In this retrospective observational study, Mayo Clinic researchers used a medical database from Olmsted County, MN, to identify 723 patients (mean age, 63) with isolated BBB (58% with left BBB [LBBB] and 42% with right BBB [RBBB]). None of the patients had known cardiovascular disease when the BBB was discovered, and all had normal left ventricular function as determined by imaging studies.

During long-term follow-up, patients with BBB had significantly lower estimated 20-year survival than expected from general population data (about 50% vs. 60%). In another analysis, 540 patients with BBB were compared with 540 age- and sex-matched controls who did not have cardiovascular disease or ventricular dysfunction. Because BBB patients were more likely than controls to have cardiac risk factors, a multivariate analysis was performed: After adjustment for diabetes, hypertension, and hyperlipidemia, LBBB (but not RBBB) remained independently associated with increased risk for death compared with no BBB (hazard ratio, 1.5). Time to onset of any first cardiovascular event was also significantly shorter for LBBB patients than for controls.

Comment: These data suggest that isolated asymptomatic left bundle-branch block is a cardiovascular risk factor. Although the therapeutic implications are unclear because BBB is not modifiable, an incidentally discovered LBBB should at least prompt close attention to whatever modifiable risk factors are present.

— Allan S. Brett, MD. Published in Journal Watch January 6, 2006. Source: Miller WL et al. Risk factor implications of incidentally discovered uncomplicated bundle branch block. Mayo Clin Proc 2005 Dec; 80:1585-90.

10. Radiculopathy Quiz

Question: What is the most common anatomic cause of cervical radicuopathy and how does it differ from the most common cause of lumbar radiculopathy?

The Answer is: Foramen encroachment due to decreased disc height and DJD causes 70-75% of cervical radiculopathies. In contrast to lumbar radiculopathy, a herniated nucleus pulposus is the cause of only 20-25% of cervical cases (S. Carette and M. G. Fehlings. Cervical Radiculopathy
NEJM. 2005;353:392-399).

11. Attenuated Vaccine Against Severe Rotavirus Gastroenteritis May Be Safe, Effective

[Here’s another stab at making a rotavirus vaccine, hopefully without increasing the rate of intussusception, which aborted the utility of the last attempt. --DRV]

News Author: Laurie Barclay, MD; Medscape Medical News

Jan. 5, 2006 — Attenuated G1P[8] human rotavirus vaccine (HRV) is highly efficacious in protecting infants, with no increase in incidence of intussusception, according to the results of a randomized, double-blind, phase 3 trial reported in the January 5 issue of The New England Journal of Medicine.

"Every year, rotavirus is associated with 25 million clinic visits, 2 million hospitalizations, and more than 600,000 deaths worldwide among children younger than five years of age," write Guillermo M. Ruiz-Palacios, MD, from the Instituto Nacional de Ciencas Medicas y Nutricion, México Distrito Federal in Mexico, and colleagues from the Human Rotavirus Vaccine Study Group. "Development of a safe and effective rotavirus vaccine is therefore a high priority, particularly but not exclusively in developing countries, where the burden of disease is highest. Since the withdrawal from the market of the tetravalent rhesus–human reassortant vaccine (RotaShield, Wyeth Laboratories) because of an association with intussusception, ruling out such a risk has become critical for the licensure and universal use of any new rotavirus vaccine."

The investigators studied 63,225 healthy infants from 11 Latin American countries and Finland who received 2 oral doses of either the HRV vaccine (31,673 infants) or placebo (31,552 infants) at approximately 2 months and 4 months of age. Active surveillance identified severe gastroenteritis episodes, and the 20-point Vesikari scale was used to grade disease severity.

In a subgroup of 20,169 infants (10,159 vaccinees and 10,010 placebo recipients), the efficacy of the vaccine against severe rotavirus gastroenteritis and against rotavirus-associated hospitalization was 85% (P < .001 vs placebo), and it was 100% effective against more severe rotavirus gastroenteritis.

The vaccine was associated with a 42% reduction in hospitalization for diarrhea of any cause (95% confidence interval [CI], 29% - 53%; P < .001). Definite intussusception occurred in 6 vaccine recipients and in 7 placebo recipients during the 31-day window after each dose (difference in risk, -0.32 per 10,000 infants; 95% CI, -2.91 to 2.18; P = .78).

"Two oral doses of the live attenuated G1P[8] HRV vaccine were highly efficacious in protecting infants against severe rotavirus gastroenteritis, significantly reduced the rate of severe gastroenteritis from any cause, and were not associated with an increased risk of intussusception," the authors write. "Efforts should now be focused on bringing this vaccine to infants as part of routine immunization programs, especially in areas where rotavirus is associated with an important proportion of the burden of illness and childhood death. Wide use of this vaccine will require parallel implementation of post-marketing surveillance, including follow-up investigations of deaths among HRV vaccine recipients, to answer a number of remaining questions."

GlaxoSmithKline Biologicals, the maker of the HRV vaccine, funded and coordinated the study. Some of the authors have disclosed various relevant financial relationships with GlaxoSmithKline Biologicals and/or Merck Sharp & Dohme.

In an accompanying editorial, Roger I. Glass, MD, PhD, and Umesh D. Parashar, MB, BS, MPH, from the Centers for Disease Control and Prevention in Atlanta, Ga, discuss safety and efficacy of the monovalent G1P[8] and a pentavalent vaccine, based on this study and on a second study reported in the same issue.

"These trials leave open the question of whether either vaccine might cause intussusception if administered to older infants or to a larger number of infants," Drs. Glass and Parashar write. "Given the troubling legacy of RotaShield and concern among the public and physicians over intussusception, an effective system of surveillance should be put in place after licensure to monitor this rare outcome. Hundreds of thousands of children will need to be immunized before a clean bill of health can be given to these vaccines."

Drs. Glass and Parashar have disclosed no relevant financial relationships.

N Engl J Med. 2006;354:11-22, 75-77.

12. Physicians' Beliefs May Lead to Racial Disparities in Cardiac Treatment

NEW YORK (Reuters Health) Jan 05 - Physicians' perceptions of patients' characteristics can lead to racial disparities in the treatment of coronary artery disease, according to a report to be published in the February issue of American Journal of Public Health.

"Under certain conditions, it seems that we are capable of becoming aware of how unconscious beliefs influence our expectations of others," Dr. Michele van Ryn from University of Minnesota Medical School, Minneapolis, told Reuters Health. "These conditions include having the motivation and cognitive resources to self-monitor (put effort into becoming aware of unconscious processes), to actually self-monitor and identify automatic beliefs, and to examine whether these automatic beliefs are accurate in the individual case."

Dr. van Ryn and colleagues evaluated the factors associated with provider recommendations for coronary artery bypass graft surgery (CABG) in a subset of 532 patients who were appropriate candidates for this procedure but not for other aggressive treatments. Thirty-four percent were white, 30% were black and 36% were Hispanic.

Only 21% of black men received a recommendation for CABG, the authors report, compared with 40% of white and Hispanic men. There were no differences in treatment based on race or ethnicity among women.

Black patients were significantly younger than whites, the results indicate, and they had only about half the rate of left main coronary artery disease.

White patients were significantly less likely than black patients to have Medicaid or no insurance coverage, at 3% and 21%, respectively.

Overall, physicians were significantly less likely to rate blacks as likely to comply with medical advice, have significant career demands, have social support and have a physically active lifestyle, and to rate them as significantly more likely to abuse drugs.

Physicians' perception that the patient desired a physically active lifestyle and was educated was significantly associated with a recommendation for CABG, the researchers note.

When these variables were added to the model, the effect of patient race and ethnicity on physician recommendations for CABG disappeared.

"I think it might be worthwhile for providers to try to self-monitor and then treat these unconscious beliefs as hypotheses to be tested in the clinical encounter," Dr. van Ryn said. "For example, if a cardiologist monitored herself and became aware that she had concerns about whether a patient would engage in high-risk behaviors or wouldn't participate in cardiac rehab...that could be...a cue to explore these matters with the patient."

"Although we know that patient race can influence physician decision-making, we know little about the individual characteristics that make the physician more or less susceptible to unconscious bias," Dr. van Ryn added. "To develop effective interventions, we need to know a lot more about the factors that mediate and moderate this effect."

Am J Public Health, 2006;96.

13. Use of a pacifier is associated with reduced risk of SIDS

[And for your parents of newborns…Here’s a study performed in CA, and published in the BMJ. --DRV]

The reduction in the incidence of sudden infant death syndrome (SIDS) after the Back to Sleep campaign in the United States and other countries showed that sleep environment strongly influences the risk of SIDS, although the underlying mechanisms remain poorly understood. Despite the considerable reduction in the incidence of SIDS after this public health intervention, it remains one of the leading causes of infant mortality. Identification of new preventative measures to further reduce the incidence continues to be a priority. Some studies have reported that use of a dummy (pacifier) is associated with a reduced risk of SIDS, though few have examined the association in detail and in the context of other risk factors.

Dummies usually have a bulky external handle, which could alter the infant's sleep environment by changing the configuration of the airway passage surrounding the nose and mouth. For example, pacifiers may prevent accidental hypoxia as a result of the face being buried into soft bedding or overlaying by objects (such as blankets, cosleepers, etc) by providing an air passage created by the bulky handle. Sucking on a dummy may enhance the development of neural pathways that control the potency of the upper airway.

We examined data collected in a population based case-control study of risk factors for SIDS in California to determine whether use of a dummy during sleep is associated with a reduced risk of SIDS, what factors may modify the association between use and SIDS, and whether use influences other risk factors related to sleep environment.

Infants who died of sudden infant death syndrome (SIDS) were less likely to sleep with dummies (pacifiers) in their mouths than controls. Li and colleagues carried out a population based case-control study with mothers or caretakers of 185 babies whose deaths were attributed to the syndrome and 312 randomly selected controls matched for race, ethnicity, and age. After known confounders were adjusted for, the odds ratio for SIDS in infants who used a dummy during their last sleep was 0.08 (95% CI 0.03 to 0.21) compared with infants not given dummies. Use of a dummy may reduce the influence of known risk factors in the sleep environment, say the authors.

BMJ 2006;332:18-22. Abstract: http://bmj.bmjjournals.com/cgi/content/abstract/332/7532/18

14. Childhood and Adolescent Immunization Schedule updated for 2006

January 6, 2006. NEW YORK (Reuters Health) - The 2006 Childhood and Adolescent Immunization Schedule includes new recommendations for immunizing against meningococcal disease, pertussis, influenza, hepatitis A and hepatitis B, the US Centers for Disease Control and Prevention reported today.

Some key changes are as follows:

-- Meningococcal conjugate vaccine (MCV4) should be administered to all children between 11 and 12 years old as well as to unvaccinated adolescents at high school entry (age 15 years), and college freshmen living in dormitories should also be vaccinated with MCV4 or meningococcal polysaccharide vaccine (MPSV4). Vaccination with MPSV4 for children 2 to 10 years old and with MCV4 for older children in certain high-risk groups is also recommended.

-- To protect adolescents against whooping cough, a new tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap adolescent preparation) is recommended for adolescents 11 to 12 years, and for those aged 13 to 18 years who missed their earlier Tdap booster dose. Subsequent Td boosters are recommended every 10 years.

-- Annual influenza vaccine is now recommended for children younger than 6 months who have certain risk factors, including conditions that can cause breathing or swallowing difficulties, such as spinal cord injuries, seizure disorders, or other neuromuscular disorders.

-- Hepatitis A vaccine is now universally recommended for all children at age 1 year. Children not vaccinated at 1 to 2 years of age should be vaccinated during the preschool years.

-- The importance of the hepatitis B vaccine (HepB) birth dose is emphasized in the new schedule, which recommends screening of all pregnant women for hepatitis B surface antigen (HbsAg). The birth dose should be delayed only under rare circumstances and then only if a physician's order to withhold the vaccine and a copy of the mother's original HBsAg-negative laboratory report are documented in the infant's medical record.

The full 2006 immunization schedule is in the CDC's Morbidity and Mortality Weekly Report that is located at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5451-Immunizationa1.htm

MMWR 2006;54:Q1-Q4.

15. CDC Health Advisory

Distributed via Health Alert Network. January 14, 2006, 15:25 EST (03:25 PM EST); CDCHAN-00240-06-01-14-ADV-N

CDC Recommends against the Use of Amantadine and Rimandatine for the
Treatment or Prophylaxis of Influenza in the United States during the
2005-06 Influenza Season

Recent evidence indicates that a high proportion of currently circulating Influenza A viruses in this country are resistant to these medications

While the primary strategy for preventing complications of influenza infections is annual vaccination, antiviral medications with activity against influenza viruses can be effective for the prophylaxis and treatment of influenza. Two classes of antivirals are currently available-the M2 ion channel inhibitors (i.e., the two adamantanes amantadine and rimantadine) and the neuraminidase inhibitors (i.e., oseltamivir and zanamivir). The neuraminidase inhibitors are effective for the treatment and prophylaxis of influenza A and B, while the adamantanes are only active against influenza A viruses. This alert provides new information about the resistance of influenza viruses currently circulating in the United States to the adamantanes, and it makes an interim recommendation that these drugs not be used during the 2005-06 influenza season. Amantadine is also used to treat the symptoms of Parkinson's disease, and should continue to be used for this indication.

Viral resistance to adamantanes can emerge rapidly during treatment because a single point mutation at amino acid positions 26, 27, 30, 31, or 34 of the M2 protein can confer cross-resistance to both amantadine and rimantadine. The transmissibility of adamantane-resistant viruses is not impaired by any of these amino acid changes. A recent report on the global prevalence of adamantane-resistant influenza viruses showed a significant increase (from 1.9% to 12.3%) in drug resistance over the past 3 years. In the United States, the frequency of drug resistance increased from 1.9% in 2004 to 14.5% during the first 6 months of the
2004-05 influenza season.

For the 2005-06 season, 120 influenza A (H3N2) viruses isolated from patients in 23 states have been tested at CDC through January 12, 2006; 109 of the isolates (91%) contain an amino acid change at position 31 of the M2 protein, which confers resistance to amantadine and rimantadine. Three influenza A(H1N1) viruses have been tested and demonstrated susceptibility to these drugs. All influenza viruses from the United States that have been screened for antiviral resistance at CDC have demonstrated susceptibility to the neuraminidase inhibitors.

On the basis of available antiviral testing results, CDC is providing an interim recommendation that neither amantadine nor rimandatine be used for the treatment or prophylaxis of influenza A in the United States for the remainder of the 2005-06 influenza season. During this period, oseltamivir or zanamivir should be selected if an antiviral medication is used for the treatment and prophylaxis of influenza. Testing of influenza isolates for resistance to antivirals will continue throughout the 2005-06 influenza season, and recommendations will be updated as needed. Annual influenza vaccination remains the primary means of preventing morbidity and mortality associated with influenza.

Additional information about the prevention and control of influenza is available at http://www.cdc.gov/flu/ Specific information regarding the use of the neuraminidase inhibitors is available at http://www.cdc.gov/flu/protect/antiviral/index.htm
These websites will be updated as new information becomes available.

Categories of Health Alert messages: Health Alert conveys the highest level of importance; warrants immediate action or attention. Health Advisory provides important information for a specific incident or situation; may not require immediate action. Health Update provides updated information regarding an incident or situation; unlikely to require immediate action.

##This Message was distributed to State and Local Health Officers, Public Information Officers, Epidemiologists, State Laboratory Directors, Weapons of Mass Destruction Coordinators and HAN Coordinators, as well as Public Health Associations and Clinician organizations##