Lit Bits: September 18, 2006

From the recent medical literature...

1. Sudden Cardiac Death Is Often Preceded by Symptoms

Muller D, et al. Circulation 2006, doi:10.1161/CIRCULATIONAHA.106.616318

Many patients with sudden cardiac death experience angina and other symptoms in the minutes and hours leading up to their collapse, according to a study published early online by Circulation. The study, conducted in Germany, found that about one-quarter of 274 patients with witnessed arrest experienced angina for a median of 2 hours. In addition, angina was present in about a third of the patients with symptom duration of less than 1 hour. Nearly three-quarters of patients had some symptom, such as dizziness or nausea.

"Our data show that 'sudden cardiac death' is not nearly as sudden in most cases as the term may suggest," and symptoms are present for "a surprisingly long time in many patients," the authors wrote.

They said at-risk patients and their families should be given information about warning symptoms and training in CPR.

ABSTRACT
Background--Out-of-hospital sudden cardiac death (SCD) is a frequent cause of death. Survival rates remain low despite increasing efforts in medical care. Better understanding of the circumstances of SCD could be helpful in developing preventive measures and facilitating proper reactions to such a pending event.

Methods and Results--Information on cases of out-of-hospital SCD was collected in the Berlin, Germany, emergency medical system via a questionnaire. Bystander interviews were performed by the emergency physician on scene immediately after declaration of death or return of circulation. Of 5831 rescue missions, 406 involved patients with presumed cardiac arrest. Sixty-six percent had a known cardiac disease. In 72%, the arrest occurred at home, and in 67%, it occurred in the presence of an eyewitness. Information on symptoms immediately preceding the arrest was available in 80% (n=323) of all 406 patients and in 274 of those with witnessed arrest. Symptoms were identical in the 2 groups. Typical angina was present for a median of 120 minutes in 25% of the 274 patients with witnessed arrest and in 33% with a symptom duration of less than 1 hour.

Conclusions--SCD occurs most often at home in the presence of relatives and after a longer period of typical warning symptoms. Although the much-hailed use of public access defibrillation is supported by several studies, the present results raise the question of whether educational measures and targeted educational programs tailored for patients at risk and their relatives should have a higher priority.

2. Report Finds Americans Have Middling Medical Literacy

Most Americans have an intermediate level of health literacy and may often have difficulty following written health directions, according to a report by the National Center for Educational Statistics.

The findings were based on a health literacy test taken by 19,000 adults. On the test, which has a perfect score of 500, men averaged 242, while women averaged 248.

An example of intermediate literacy is the ability to determine what time a person can take a medication based on label instructions. An example of proficient literacy is the ability to define a medical term by searching through a complex document.

One of the investigators, interviewed by the Associated Press, said insurers, drug makers, and doctors write at a level that is difficult for the general public to understand. For instance, people checking labels for salt content might not understand what "sodium" means.

The results showed that adults age 65 and older had lower health literacy than younger people. Whites and Asians had higher literacy than blacks, Hispanics, and American Indians.

The report itself (all 76 pages!): http://nces.ed.gov/pubs2006/2006483.pdf

3. Incidence and Nature of Adverse Events During Pediatric Sedation/Anesthesia for Procedures Outside the OR: Report From the Pediatric Sedation Research Consortium

Cravero JP, et al. Pediatrics 2006; 118: 1087-1096.

OBJECTIVE. We sought to use a large database of prospectively collected data on pediatric sedation and/or anesthesia for diagnostic and therapeutic procedures to delineate the nature and the frequency of adverse events that are associated with sedation/anesthesia care for procedures that are performed outside the operating room in children.

METHODS. Data were collected by the Pediatric Sedation Research Consortium, a collaborative group of 35 institutions that are dedicated to improving sedation/anesthesia care for children internationally. Members prospectively enrolled consecutive patients who were receiving sedation or anesthesia for procedures. Data on demographics, primary illness, coexisting illness, procedure performed, medications used, outcomes, airway interventions, and adverse events were collected and reported on a Web-based data collection tool.

RESULTS. A total of 26 institutions submitted data on 30037 sedation/anesthesia encounters during the study period from July 1, 2004, to November 15, 2005. Serious adverse events were rare in the institutions involved in this study; there were no deaths. Cardiopulmonary resuscitation was required once. Less serious events were more common with O2 desaturation below 90% for >30 seconds, occurring 157 times per 10000 sedations. Stridor and laryngospasm both occurred in 4.3 per 10000 sedations. Unexpected apnea, excessive secretions, and vomiting had frequencies of 24, 41.6, and 47.2 per 10000 encounters, respectively.

CONCLUSIONS. Our data indicate that pediatric sedation/anesthesia for procedures outside the operating room is unlikely to yield serious adverse outcomes in a collection of institutions with highly motivated and organized sedation services. However, the safety of this practice depends on the systems' ability to manage less serious events.

4. Nonemergency Patients Do Not Affect ED Care for Others

Source: California Healthline (http://www.californiahealthline.org/). Date: August 23, 2006

Diverting nonemergency cases from emergency departments in Canada does not have much impact on the efficiency or timeliness of care given to sicker patients, according to a study published in September on the Annals of Emergency Medicine Web site, the Houston Chronicle reports.

For the study, lead author Michael Schull of the Institute for Clinical Evaluative Sciences in Toronto and his colleagues examined 4.1 million patients at 110 hospitals in Ontario, Canada, between April 2002 and March 2003 to determine whether care for nonemergency patients "cause[d] slower care for sicker patients," the Chronicle reports.

According to the study, for each nonemergency patient who arrives at an ED, each patient seeking emergency care experiences an increased length of stay of 32 seconds. Every 10 patients with nonemergency ailments arriving in any eight-hour period added an average of only 5.4 minutes to emergency patients' length of stay and an average of 2.1 minutes to the time emergency patients' spent waiting to see a physician (Ackerman, Houston Chronicle, 8/23).

Schull cast doubt on the idea that nonemergency cases are the main factor behind ED overcrowding, pointing instead to factors such as a lack of inpatient beds, inefficient use of resources and failure to quickly transfer patients to other departments (Roser, Austin American-Statesman, 8/23).

"The take-away message is that the benefit of diverting patients is so small that it isn't worth it. Caring for patients with minor ailments doesn't lead to clinically important delays and turning them away isn't very patient-focused," Schull said. Thomas Granchi, medical director of Ben Taub General Hospital Emergency Center in Harris County, Texas, said Schull's findings are "counterintuitive" and do not affect physicians' "assumptions or current knowledge." He added that the study compares "apples and oranges" because the U.S. and Canadian health systems differ (Houston Chronicle, 8/23).

5. Ibuprofen May Interfere with Aspirin's Cardioprotective Effect

The FDA advised that ibuprofen taken concomitantly with low-dose aspirin could minimize or negate aspirin's cardioprotective effect.

On the basis of ex vivo human studies -- some unpublished -- but not on the basis of randomized trials, the agency said that ibuprofen should be taken either at least 30 minutes after immediate-release aspirin or at least 8 hours before. (An alternative analgesic, acetaminophen, does not seem to interfere with aspirin.)

The effect seems due to the fact that aspirin and ibuprofen bind to similar sites on cyclooxygenase, inhibiting its ability to promote clot formation by platelets. Aspirin's binding is irreversible, while ibuprofen's is reversible, and the presence of both drugs in the bloodstream changes their pharmacodynamics.
For occasional users of ibuprofen, however, the agency says a negative clinical impact is unlikely.

FDA HealthCare Provider Info Sheet:
http://www.fda.gov/cder/drug/InfoSheets/HCP/ibuprofen_aspirinHCP.htm

FDA Science Paper: http://www.fda.gov/cder/drug/infopage/ibuprofen/science_paper.htm

6. Self-reported Pain Scores in the ED: Lack of Association with Vital Signs

Marco CA, et al. Acad Emerg Med 2006;13: 974-979.

Background: Some practitioners and investigators have presumed relationships between pain scores and heart rate, blood pressure, or respiratory rate. Previous literature has not adequately addressed the association of pain and vital signs.

Objectives: To identify any association between self-reported pain and heart rate, blood pressure, or respiratory rate.

Methods: In this retrospective, observational study, emergency department patients older than 17 years of age presenting between May 2004 and April 2005 with verifiable painful diagnoses (including nephrolithiasis, myocardial infarction, small bowel obstruction, fracture, burn, crush injury, stab wound, amputation, corneal abrasion, and dislocation) were identified. Data were extracted from the hospital's database, including patients' age, gender, emergency department diagnosis, self-reported pain score, heart rate, blood pressure, and respiratory rate.

Results: Among 1,063 subjects, the most common diagnoses were nephrolithiasis (25%; n = 267) and fracture (23%; n = 249). The mean (+/- SD) triage pain score was 7 (+/- 3). The mean (+/- SD) heart rate was 85 (+/- 16) beats/min, mean (+/- SD) systolic blood pressure was 141 (+/- 23) mm Hg, and mean (+/- SD) respiratory rate was 19 (+/- 3) breaths/min. There were no clinically significant differences in mean vital signs across the individual pain scores, as demonstrated by overlapping confidence intervals across pain scores.
Conclusions: No clinically significant associations were identified between self-reported triage pain scores and heart rate, blood pressure, or respiratory rate.

7. Fruit and Vegetable Juice Consumption Tied to Lower Risk for Alzheimer Disease

Dai Q, et al. American Journal of Medicine 2006;119: 751-759.

The authors followed more than 1500 Japanese Americans (age 65 or older and dementia-free at baseline) for a mean of 6 years. For those who reported at baseline drinking juice at least three times a week, the hazard ratio for probable Alzheimer disease diagnosis was 0.24 compared to those who drank juice less than once a week; for those who drank juice once or twice a week, the hazard ratio was 0.84. These ratios include adjustment for education; gender; physical activity; baseline cognitive scores; dietary intake of vitamin C, vitamin E, and beta-carotene; and other potential confounders.

The authors note that prior research suggests that polyphenols -- antioxidants found in fruits and vegetables -- may be neuroprotective. They couldn't specify which juices might account for their findings or the duration of consumption required to confer protection.

http://www.amjmed.com/article/PIIS0002934306006772/abstract

8. A couple headlines from the September issue of Pediatrics:

A Controlled, Randomized, Double-Blind Trial to Evaluate the Effect of a Supplement of Cocoa Husk That Is Rich in Dietary Fiber on Colonic Transit in Constipated Pediatric Patients

Gemma Castillejo, et al. Pediatrics 2006; 118: e641-e648.

A Staging System for Infantile Krabbe Disease to Predict Outcome After Unrelated Umbilical Cord Blood Transplantation

Maria L. Escolar, Michele D. Poe, Holly R. Martin, and Joanne Kurtzberg. Pediatrics 2006; 118: e879-e889.

[In my years of clinical experience, I have found the response of constipated children to cocoa husks often helps me to more accurately stage their Krabbe Disease. I think you'll agree.]

9. Can Medication Help Prevent Diabetes?

Lifestyle changes and not drugs still seem the most reliable way to prevent diabetes, according to evidence and opinion presented in the Lancet and the New England Journal of Medicine.

The journals early-released results of a manufacturer-sponsored randomized trial assessing two drugs -- the ACE inhibitor ramipril (Altace) and the thiazolidinedione rosiglitazone (Avandia) -- for their use in preventing diabetes in those at risk.

Both drugs were tested against placebo in a 2-by-2 factorial design in a group of over 5000 patients with impaired fasting glucose levels, impaired glucose tolerance, or both. People with previous cardiovascular disease were excluded. Since there was no significant interaction between therapies, the results were presented separately for each drug. Median follow-up was 3 years.

Patients receiving rosiglitazone had a reduction in incident diabetes or death from any cause (the composite primary outcome) of 60% compared with those receiving placebo. In secondary outcomes, significantly more patients in the rosiglitazone group became normoglycemic. The authors said that the reduction in incident diabetes was "of much the same magnitude as the reduction achieved with lifestyle approaches." They noted a small increase in heart failure in those on the drug.

For those on ramipril, rates of diabetes or death did not differ significantly from placebo. In a secondary analysis, ramipril showed a slight advantage in the number of patients with a normal two-hour postprandial glucose level.
Editorialists in both journals expressed doubts that the drugs would find a role in preventing diabetes. The Lancet's commentator concluded: "Given the prolonged benefits and demonstrable cost effectiveness of intensive lifestyle intervention for people at high risk of diabetes, such interventions should remain the mainstay for the prevention of type 2 diabetes."

Lancet article: http://www.thelancet.com/webfiles/images/clusters/thelancet/dream_article.pdf

NEJM article: http://content.nejm.org/cgi/reprint/NEJMoa065061v1.pdf

10. Watchful Waiting for Acute Otitis Media Works in the ER Too

For children presenting in the emergency department with acute otitis media (AOM), prescribing antibiotics on a wait-and-see basis reduces unnecessary antibiotic use, according to an article in a recent issue of JAMA.

Researchers randomized 283 children with AOM, aged 6 months to 12 years, to receive either a standard antibiotic prescription or a wait-and-see prescription (WASP), which parents were asked not to fill unless the child failed to improve after 48 hours. All patients were given ibuprofen and otic analgesic drops for pain control, in line with current guidelines. Prescriptions were unfilled by 62% of the WASP and 13% of the standard prescription groups. There were no significant differences in the two groups' rates of fever, otalgia, or unscheduled medical visits. The researchers write that theirs is the first trial to support the WASP approach in the emergency department, where patients and practitioners might not have established relationships. An editorialist concludes that the approach "should be acceptable to parents, appears reasonably safe, and provides a significant step in the battle against antibiotic resistance."

JAMA article: http://jama.ama-assn.org/cgi/content/full/296/10/1235

11. Conscious Sedation and ED LOS: A Comparison of Propofol, Ketamine, and Fentanyl/ Versed

Gorchynski J, et al. The California J Emerg Med 2006;7:4-7.

Study Objectives: Three of the most commonly used agents for conscious sedation in the Emergency Department (ED) are ketamine, fentanyl/versed, and propofol. In this study, we measured and compared the total times spent in the ED with each of these agents. Our objective was to determine whether the use of propofol for conscious sedation was associated with a shorter length of ED stay as compared to the other two agents.

Methods: This was a consecutive case series. All patients who required procedural conscious sedation who presented to the ED at University of California, Irvine Medical Center from January 2003 through April 2004 were included in the study. The attending ED physician evaluated the patient and determined which medication(s) would be administered. All patients underwent procedural sedation according to the ED's standardized sedation protocol. The times and dosages of administered medications and the sedation/consciousness level (SCL) scores were recorded by ED nurses at 3-5 minute intervals. Data was abstracted prospectively.

The time to sedation (first dose of agent to SCL score of 2 or less) and time to recovery (last dose of agent to SCL score of 4) of the different regimens were then analyzed and compared. Results: Thirty-eight patients received propofol, 38 received ketamine, and 14 received fentanyl/versed. The mean times to sedation (minutes) were: propofol 4.5 (95% CI: 3.3-5.7), ketamine 10.6 (95% CI: 5.8 15.4), fentanyl/versed 11.5 (95% CI: 3.5-19.4). The mean times to recovery were: propofol 21.6 (95% CI: 16.1-27.1), ketamine 55.4 (95% CI: 46.2-64.5), fentanyl/versed 59.9 (95% CI: 20.3-99.5). Propofol had a statistically significant shorter time to sedation than both ketamine (p<.001) and fentanyl/versed (p=.022). Propofol also produced shorter recovery times than both ketamine (p<.001) and fentanyl/versed (p=.002). Conclusion: In this study, sedation and recovery times were shorter with propofol than with ketamine or fentanyl/versed. The use of propofol for conscious sedation in this non-randomized study was associated with a shorter ED length of stay. 12. Ruling Out the Need for Antibiotics: Are We Sending the Right Message?

Rita Mangione-Smith, MD, MPH, et al. Arch Pediatr Adolesc Med. 2006;160:945-952.

Objectives To examine the relationships among physician-parent communication practices, physicians' perceptions of parental expectations for antibiotic treatment, and inappropriate antibiotic prescribing for viral upper respiratory tract infections.

Design Cross-sectional study of pediatric encounters motivated by cold symptoms between October 1, 2000, and June 30, 2001. Each encounter was videotaped. Physicians completed a postvisit survey that measured whether they perceived the parent as expecting antibiotics. Coded communication variables were merged with survey variables. Multivariate analyses identified key predictors of parent-physician communication practices, physician perceptions of parents' expectations for antibiotics, and inappropriate antibiotic prescribing for viral conditions. Setting Twenty-seven pediatric practices in Los Angeles, Calif.

Participants Thirty-eight pediatricians and 522 consecutively approached parents of children with cold symptoms.

Main Outcome Measures Physicians' perceptions of parental expectations for antibiotics, inappropriate antibiotic prescribing, and parental questioning of nonantibiotic treatments. Results Physicians were 20.2% more likely to perceive parents as expecting antibiotics when they questioned the physician's treatment plan (P = .004; 95% confidence interval, 6.3%-34.0%). When physicians perceived parents as expecting antibiotics, they were 31.7% more likely to inappropriately prescribe them (P<.001; 95% confidence interval, 16.0%-47.3%). Parents were 24.0% more likely to question the treatment plan when the physician ruled out the need for antibiotics (P = .004; 95% confidence interval, 7.7%-40.3%). Conclusions Parental questioning of the treatment plan increases physicians' perceptions that antibiotics are expected and thus increases inappropriate antibiotic prescribing. Treatment plans that focus on what can be done to make a child feel better, rather than on what is not needed, ie, antibiotics, may decrease inappropriate antibiotic prescribing. 13. Sonography of the Hip-joint by the Emergency Physician: Its Role in the Evaluation of Children Presenting With Acute Limp.

Shavit I, et al. Pediatric Emergency Care. 22(8):570-573, August 2006.

Objective: To describe a new imaging bedside test called Sonography of the Hip-joint by the Emergency Physician (SHEP) and to examine if its use as a triage tool for the presence of fluid in the hip joint can guide the emergency physician to the right diagnosis.

Methods: Case series of 5 children presented to the ED with an acute onset of limp. In addition to a careful clinical history and physical examination, each child received SHEP.

Results: Follow-up confirmed that the presumptive diagnosis made in the ED was correct. The SHEP tests were found helpful in diagnosing transient synovitis (3 cases), septic arthritis (1 case), and osteomyelitis of the femur (1 case).

Conclusions: The SHEP tests provided additional information that narrowed the differential diagnosis, and minimized unnecessary blood tests and diagnostic imaging studies.

14. FDA Approves First Totally Implantable Artificial Heart

The FDA this month approved the first totally implantable artificial heart. The device is approved for patients with bilateral heart failure who have a month or less to live without intervention and who are not eligible for a transplant.
The AbioCor heart consists of an internal pumping unit, which replaces the diseased heart, and a controller and battery implanted in the abdomen. The internal battery is recharged via coils on either side of the skin by an external battery pack or an electrical outlet.

Because it was approved under the FDA's Humanitarian Use Device program, the device will be available to no more than 4000 patients a year. According to an FDA official quoted by the Associated Press, the actual number of devices implanted will likely be just 25 to 50 a year.

More info: http://www.nih.gov/news/pr/sep2006/nhlbi-05.htm

15. The Use of Systemic Fluoroquinolones in Kids

Pediatrics 2006;118:1287-1292.

POLICY STATEMENT. AAP Committee on Infectious Diseases

The only indications for which a fluoroquinolone (ie, ciprofloxacin) is licensed by the US Food and Drug Administration for use in patients younger than 18 years are complicated urinary tract infections, pyelonephritis, and postexposure treatment for inhalation anthrax. Nonetheless, approximately 520 000 prescriptions for fluoroquinolones were written in the United States for patients younger than 18 years in 2002; 13 800 were written for infants and children 2 to 6 years of age, and 2750 were written for infants younger than 2 years.

Clinical trials of fluoroquinolones in pediatric patients with various diagnoses have been published and are reviewed. Fluoroquinolones cause arthrotoxicity in juvenile animals and have been associated with reversible musculoskeletal events in both children and adults. Other adverse events associated with fluoroquinolones include central nervous system disorders, photosensitivity, disorders of glucose homeostasis, prolongation of QT interval with rare cases of torsade de pointes (often lethal ventricular arrhythmia in patients with long QT syndrome), hepatic dysfunction, and rashes. The increased use of fluoroquinolones in adults has resulted in increased bacterial resistance to this class of antibacterial agents.

This report provides specific guidelines for the systemic use of fluoroquinolones in children. Fluoroquinolone use should be restricted to situations in which there is no safe and effective alternative to treat an infection caused by multidrug-resistant bacteria or to provide oral therapy when parenteral therapy is not feasible and no other effective oral agent is available.

16. Accuracy of Physician Self-assessment Compared With Observed Measures of Competence: A Systematic Review

David A. Davis, MD; et al. JAMA. 2006;296:1094-1102.

Context: Core physician activities of lifelong learning, continuing medical education credit, relicensure, specialty recertification, and clinical competence are linked to the abilities of physicians to assess their own learning needs and choose educational activities that meet these needs.

Objective: To determine how accurately physicians self-assess compared with external observations of their competence.

Data Sources: The electronic databases MEDLINE (1966-July 2006), EMBASE (1980-July 2006), CINAHL (1982-July 2006), PsycINFO (1967-July 2006), the Research and Development Resource Base in CME (1978-July 2006), and proprietary search engines were searched using terms related to self-directed learning, self-assessment, and self-reflection.

Study Selection: Studies were included if they compared physicians' self-rated assessments with external observations, used quantifiable and replicable measures, included a study population of at least 50% practicing physicians, residents, or similar health professionals, and were conducted in the United Kingdom, Canada, United States, Australia, or New Zealand. Studies were excluded if they were comparisons of self-reports, studies of medical students, assessed physician beliefs about patient status, described the development of self-assessment measures, or were self-assessment programs of specialty societies. Studies conducted in the context of an educational or quality improvement intervention were included only if comparative data were obtained before the intervention.

Data Extraction: Study population, content area and self-assessment domain of the study, methods used to measure the self-assessment of study participants and those used to measure their competence or performance, existence and use of statistical tests, study outcomes, and explanatory comparative data were extracted.

Data Synthesis: The search yielded 725 articles, of which 17 met all inclusion criteria. The studies included a wide range of domains, comparisons, measures, and methodological rigor. Of the 20 comparisons between self- and external assessment, 13 demonstrated little, no, or an inverse relationship and 7 demonstrated positive associations. A number of studies found the worst accuracy in self-assessment among physicians who were the least skilled and those who were the most confident. These results are consistent with those found in other professions.

Conclusions: While suboptimal in quality, the preponderance of evidence suggests that physicians have a limited ability to accurately self-assess. The processes currently used to undertake professional development and evaluate competence may need to focus more on external assessment.

17. Oral Betamethasone Versus Intramuscular Dexamethasone for the Treatment of Mild to Moderate Viral Croup: A Prospective, Randomized Trial.

Amir, Lisa MD, MPH; et al. Pediatric Emergency Care. 22(8):541-544, August 2006.

Objective: Intramuscular dexamethasone is an effective, but painful, treatment for croup. The effectiveness of betamethasone, an oral, palatable, and equally potent glucocorticoid has not been studied. The purpose of this study was to compare the effectiveness of a single oral dose of betamethasone with intramuscular dexamethasone in the outpatient treatment of mild to moderate croup.

Methods: Children aged 6 months to 6 years presenting to a tertiary care pediatric emergency department (ED) with a modified Westley croup score of 0 to 11 were randomized to receive either 0.6 mg/kg IM dexamethasone or 0.4 mg/kg PO betamethasone. Croup score, heart rate, respiratory rate, pulse oximetry, and need for supplemental treatments were recorded at study entry and at 1, 2, and 4 hours after treatment. Follow-up data were collected by daily telephone follow-up on persistence of symptoms and the need for additional treatment or physician visits up to 7 days after the ED visit.

Results: Each study group contained 26 patients. Despite randomization, the mean baseline croup score was higher in the dexamethasone group (3.6 +/- 2.6 vs. 2.0 +/- 2.4, P = 0.03). Patients in both groups showed a significant reduction in the croup score after treatment, and there were no significant differences between croup scores at 4 hours (P = 0.18). Similarly, there were no differences between groups in the hospital admission rate, time to resolution of symptoms, need for additional treatments, or number of return ED visits.

Conclusion: There is no difference between oral betamethasone and intramuscular dexamethasonein the management of mild to moderate viral croup. It is palatable and does not require a nurse for administration, making it a good alternative for ambulatory management.
18. Is EBV-Associated Infectious Mononucleosis an STD? Does this PG-rated disease deserve an X rating? A Cohort Study among University Students: Identification of Risk Factors for Epstein-Barr Virus Seroconversion and Infectious Mononucleosis
Crawford DH et al. Clin Infect Dis 2006 Aug 1; 43:276-82
Background. A vaccine against Epstein-Barr virus (EBV) infection is in clinical trials. Up-to-date information on risk factors for EBV infection and infectious mononucleosis (IM) among young adults is required to inform a vaccination strategy.
Methods. We carried out a prospective study on a cohort of university students. All EBV-seronegative students were asked to report symptoms of IM and were followed up 3 years later to undergo repeat EBV testing and to complete a lifestyle questionnaire. EBV typing was performed for these subjects, as well as for students who were EBV seropositive at enrollment and for additional students with IM.
Results. A total of 510 students (25%) who took part in the study were EBV seronegative when they entered the university; 110 (46%) of these experienced seroconversion while at the university, 27 (25%) of whom developed IM. Penetrative sexual intercourse was a risk factor for EBV seroconversion (P = .004), but neither condom use nor oral sex significantly altered the rate of seroconversion. EBV type 1 was significantly overrepresented in IM, compared with silent seroconversion (P = .001).
Conclusions. Our findings suggest that acquisition of EBV is enhanced by penetrative sexual intercourse, although transmission could occur through related sexual behaviors, such as "deep kissing." We also found that EBV type 1 infection is significantly more likely to result in IM. Overall, the results suggest that a large EBV type 1 load acquired during sexual intercourse can rapidly colonize the B cell population and induce the exaggerated T cell response that causes IM. Thus, IM could, perhaps, be prevented with a vaccine that reduces the viral load without necessarily inducing sterile immunity.
19. Myth: Blood transfusion is effective for sickle cell anemia-associated priapism
Merritt AL, et al. Can J Emerg Med 2006;8(2):119-22.
Objective: Priapism is a recognized complication of sickle cell anemia (SCA). When initial conventional treatments fail, simple or exchange blood transfusion has been advocated as a secondary intervention. However, recent literature suggests this may not be an effective therapy and may have significant neurologic sequelae. This paper reviews and summarizes the effectiveness and risks of blood transfusion compared with conventional priapism therapy.
Methods: All relevant papers identified from a MEDLINE search were systematically examined for data related to the use of blood transfusion in the setting of priapism due to SCA. The effectiveness of conventional therapy was compared with transfusion therapy using the outcome of "time to detumescence" (TTD). In addition, papers documenting adverse neurologic sequela were reviewed and summarized.
Results: Forty-two case reports were identified containing complete information with regard to patient age and TTD. The mean TTD was 8.0 days with conventional therapy (n = 16) and 10.8 days with blood transfusion therapy (n = 26). Adverse neurologic sequelae from blood transfusion therapy was described in 9 cases, with long term outcomes ranging from complete resolution to severe residual deficits.
Conclusion: The current literature does not support the contention that blood transfusion is an effective therapy in the treatment of priapism due to SCA, as defined by an acceleration of TTD. In fact, numerous reports suggest that serious neurologic sequelae may result from this treatment. We feel the routine use of this therapy cannot be recommended.
20. Spinach Sickens 109 in 19 States
The outbreak of E. coli O157:H7 associated with bagged spinach now numbers 109 cases, including 16 cases of hemolytic uremic syndrome and one death, the FDA announced last night. The agency advised against eating fresh spinach "until further notice."
The outbreak now includes cases in 19 states: California, Connecticut, Idaho, Indiana, Kentucky, Maine, Michigan, Minnesota, Nevada, New Mexico, New York, Ohio, Oregon, Pennsylvania, Utah, Virginia, Washington, Wisconsin, and Wyoming.
FDA statement (Sunday, Sept 17): http://www.fda.gov/bbs/topics/NEWS/2006/NEW01453.html
21. Record 46.6M U.S. Residents Lacked Coverage in 2005
Source: California Healthline (http://www.californiahealthline.org/)
Date: September 5, 2006. The number of U.S. residents without health insurance increased by 1.3 million in 2005 to a record 46.6 million individuals, or 15.9% of the U.S. population, compared with 45.3 million individuals, or 15.6% of the population, in 2004, according to figures from the U.S. Census Current Population Survey released on Tuesday, the San Francisco Chronicle reports. The data show that almost one in six U.S. residents was uninsured in 2005. In California, the percentage of residents without health insurance increased by about 0.5% to 19% in 2004-2005 from 2003-2004 (Colliver, San Francisco Chronicle, 8/30).