NEW YORK PRESBYTERIAN HOSPITAL

EMERGENCY MEDICAL SERVICES

Continuing

Medical

Education

NYP/Weill Cornell

Wednesday January 6th, 2010 4:00-8:00 pm

NYP/Weill Cornell Campus Room M-107

Four Hour CME; Lectures

4:00 pm – 5:00 pm Infection Control

Keeping ourselves safe/ keeping our Patients safe

with Jean-Marie Cannon, R.N.

5:00pm – 6:15 pm Pediatric Call Review with Dr. Marie Lupica

6:30 pm -7:30 pm BIG Training Review and Practice Session with Avram Flamm E.M.T.-P.

Please RSVP

ANY QUESTIONS OR IDEAS PLEASE CONTACT CME COORDINATOR STEVE SAMUELS EMT-P 516-383-7248 SSAMUELS@OPTONLINE.NET

QOD 12 13 09

The "lucid interval" has classically been associated with:

a. subdural hematoma.
b. subarachnoid hemorrhage.
c. diffuse axonal injury.
d. epidural hematoma.
e. None of the above

Epidural hematomas (EDH) typically result from tearing of the middle meningeal artery associated with temporal bone fractures. Blood accumulates between the skull and the dura and gives a biconvex-, lens-, or football-shape collection on CT scan. (See Figure 4.) They are more common in younger people and are rare in the elderly and those younger than 2 years of age. In the elderly, the dura is tightly adhered to the skull; thus, blood does not accumulate in this space.

The classic description of a patient with an EDH is someone who loses consciousness immediately after TBI and then awakens to a normal state of consciousness. As the EDH continues to expand, the patient once again loses consciousness. This "lucid interval"' in reality occurs in only 20%-30% of patients. EDHs are not parenchymal injuries, and thus rapid diagnosis and treatment is imperative to prevent herniation and improve outcome.

Answer: d

Poisoning - fish and shellfish

Overview

• Symptom
• Treatment
• All Information

Alternative Names

Fish poisoning; Dinoflagellate poisoning; Seafood contamination; Paralytic shellfish poisoning; Ciguatera poisoning

Definition of Poisoning - fish and shellfish:

This article describes a group of different conditions caused by eating contaminated fish and seafood. The most common of these are Ciguatera poisoning, Scombroid poisoning, and various shellfish poisonings.

This is for information only and not for use in the treatment or management of an actual poison exposure. If you have an exposure, you should call your local emergency number (such as 911) or the National Poison Control Center at 1-800-222-1222.

Poisonous Ingredient:

In Ciguatera poisoning, the poisonous ingredient is ciguatoxin. This is a poison made in small amounts by certain algae and algae-like organisms called dinoflagellates. Small fish that eat the algae become contaminated. If larger fish eat a lot of the smaller, contaminated fish, the poison can build up to a dangerous level, which can make you sick if you eat the fish. Ciguatoxin is “heat-stable." That means it doesnâ ' t matter how well you cook your fish, if the fish is contaminated, you will become poisoned.

In Scombroid poisoning, the poisonous ingredient is histamine and similar substances. Normal bacteria on these fish create large amounts of this toxin after the fish dies if it is not immediately refrigerated or frozen.

In shellfish poisoning, the poisonous ingredients are toxins made by algae-like organisms called dinoflagellates, which build up in some types of seafood. There are many different types of shellfish poisoning. The most well known types are paralytic shellfish poisoning, neurotoxic shellfish poisoning, and amnestic shellfish poisoning.

Where Found:

Ciguatera poisoning normally occurs in larger fish from warm tropical waters. The most popular types of these fish that are eaten include sea bass, grouper, and red snapper. In the United States, the waters around Florida and Hawaii have the highest potential for contaminated fish. The risk is greatest in the summer months, or any time a large amount of algae are blooming in the ocean, such as during “"red tide." A red tide occurs when there is a rapid increase in the amount of dinoflagellates in the water. However, todayâ ' s transportation means that anyone around the world may be sitting down to a dinner from a fish from contaminated waters.

Scombroid poisoning usually occurs in large dark meat fish such as tuna, mackerel, mahi mahi, and albacore. Since this poison develops after a fish is caught and dies, where the fish is caught doesnâ ' t really matter. The main factor is how long the fish sits out before being refrigerated or frozen.

Like Ciguatera poisoning, most shellfish poisonings occur in warmer waters. However, poisonings have occurred as far north as Alaska and frequently in New England. In addition, most shellfish poisonings occur during the summer months. You may have heard the saying “Never eat seafood in months that donâ ' t have the letter R." This includes May through August. The number of poisonings also increases when there is a "red tide." Shellfish poisoning occurs in seafood with two shells such as clams, oysters, mussels, and sometimes scallops.

Symptoms:

The harmful substances that cause Ciguatera, Scombroid, and shellfish poisoning are heat stable, so no amount of cooking will protect you from becoming poisoned if you eat fish that is contaminated. Symptoms depend on the specific type of poisoning.

Ciguatera poisoning symptoms can occur anywhere from 2 to 12 hours after eating the fish. They include:

• Abdominal cramps
• Diarrhea (severe and watery)
• Nausea
• Vomiting

Shortly after these symptoms develop, you will start to have strange sensations, which may include:

• A feeling that your teeth are loose and about to fall out
• Confusing hot and cold temperatures (for instance, you will feel that an ice cube is burning you, while a match is freezing your skin)
• Headache (probably the most common)
• Low heart rate and low blood pressure (in very severe cases)
• Metallic taste in the mouth

Scombroid poisoning symptoms usually occur immediately after eating the fish. They may include:

• Breathing problems (in severe cases)
• Extremely red skin on face and body
• Flushing
• Hives and itching
• Nausea
• Vomiting

There are different types of shellfish poisoning. Below are the most well known types and their symptoms.

Paralytic shellfish poisoning: About 30 minutes after eating contaminated seafood, you may have numbness or tingling in your mouth. This sensation may spread down to your arms and legs. You may become very dizzy, have a headache, and, in some cases, your arms and legs may become temporarily paralyzed. Some people may also have nausea, vomiting, and diarrhea, although these symptoms are much less common.

Neurotoxic shellfish poisoning: The symptoms are very similar to Ciguatera poisoning. After eating contaminated clams or mussels, you will most likely experience nausea, vomiting, and diarrhea. These symptoms will be followed shortly by strange sensations that may include numbness or tingling in your mouth, headache, dizziness, and hot and cold temperature reversal.

Amnestic shellfish poisoning: This is a strange and rare form of poisoning that begins with nausea, vomiting, and diarrhea, which is followed by short-term memory loss, as well as other less frequent neurologic symptoms.

Home Treatment:

Shellfish poisoning may be a medical emergency. With sudden or significant symptoms, the person should be taken immediately to an emergency medical center. You may need to call the local emergency number (such as 911) or poison control for appropriate treatment information

Before Calling Emergency:

Determine the following information:

• Patient's age, weight, and condition
• Type of fish eaten
• Time it was eaten
• Amount swallowed

Poison Control, or a local emergency number:

The National Poison Control Center (1-800-222-1222) can be called from anywhere in the United States. This national hotline number will let you talk to experts in poisoning. They will give you further instructions.

This is a free and confidential service. All local poison control centers in the United States use this national number. You should call if you have any questions about poisoning or poison prevention. It does NOT need to be an emergency. You can call for any reason, 24 hours a day, 7 days a week.

See: Poison control center - emergency number

What to expect at the emergency room:

If you have Ciguatera poisoning, you may receive:

• Medicines to stop vomiting
• Fluids by IV (to replace fluids lost from vomiting and diarrhea)
• A medication called Mannitol to help reduce neurological symptoms

If you have Scombroid poisoning, you may receive:

• An antihistamine medication, such as diphenhydramine (Benadryl)
• Fluids by IV (to replace fluids lost from vomiting and diarrhea)
• Medicines to stop vomiting
• Medicines to treat severe allergic reactions (if needed)
• Breathing tube (in rare cases)

If you have shellfish poisoning, you may receive:

• Medicines to stop vomiting
• Fluids by IV (to replace fluids lost from vomiting and diarrhea)

If shellfish poisoning causes paralysis, you may have to remain in the hospital until your symptoms improve.

Expectations (prognosis):

Fish and shellfish poisonings occur on occasion in the United States. You can protect yourself by avoiding fish and seafood caught in and around the areas of a known red tide, and by avoiding clams, mussels, and oysters during the summer months. If you are poisoned, your long-term outcome is usually quite good.

Scombroid poisoning symptoms usually only last for a few hours after medical treatment has begun. Ciguatera poisoning and the various shellfish poisoning symptoms may last from days to weeks depending on the severity of the poisoning. Only very rarely have serious outcomes or death occurred.

Since these poisons are heat stable, there is no way for the person who prepares the food to know that their food is contaminated. Therefore, it is very important that your doctor tell the restaurant that their food is contaminated so that they may throw it away before other people become sick. Your doctor should also contact the Department of Health to make sure that the suppliers providing the contaminated fish are identified, and all possibly contaminated fish from the same lot are destroyed.

• Reviewed last on: 1/30/2009
• John E. Duldner, Jr., MD, MS, Assistant Professor of Emergency Medicine, Department of Emergency Medicine, Samaritan Regional Health System, Ashland, Ohio. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

References

Goldfrank LR, ed. Goldfrank’s Toxicologic Emergencies. 8th ed. New York, NY: McGraw-Hill; 2006.

The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997- A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.

---

Copyright 2007 University of Maryland Medical Center. All rights reserved.
22 South Greene Street, Baltimore, MD 21201 1-800-492-5538 TDD 410-328-9600

FW: Requested DocAlert: Screening for Prostate and Breast Cancers: Have the Benefits Been Overstated?

Screening for Prostate and Breast Cancers: Have the Benefits Been Overstated?

Dear Clinician,

Here is the information you requested (sourced from Journal Watch).

Screening for Prostate and Breast Cancers

Have the benefits been overstated?

Screening for prostate and breast cancers has been promoted heavily in the U.S., and annual screening costs are US$20 billion for just these two cancers. Lifetime diagnoses of prostate cancer were made in 1 of 11 white men in 1980; in 2009, the risk is 1 in 6. For breast cancer, risks were 1 in 12 in 1980 and 1 in 8 in 2009. Authors of a highly publicized review now challenge the value of such intensive screening.

If screening accurately identifies cancer at an early treatable stage, the incidence of localized cancer should increase after screening is implemented, and the incidence of metastatic cancer should decline. Because this pattern has occurred for neither breast nor prostate cancer, screening simply might identify low-risk non–life-threatening cancers that then are treated inappropriately with aggressive therapy. By comparison, screening for colon and cervical cancers has led to significantly fewer cases of advanced disease. The observed decline in prostate cancer–related mortality in the last 20 years probably is not attributable to screening but, rather, to aggressive new adjuvant therapies.

The costs associated with screening are substantial. For breast cancer, avoiding 1 cancer-related death requires annual screening of more than 800 women (age range, 50–70) for 6 years, which generates hundreds of biopsies and overly aggressive treatment for many patients with low-grade cancers.

The authors recommend greater focus on identifying new biomarkers that differentiate low- and high-risk cancers, minimalist approaches that are appropriate for treating patients with low-risk cancers, better tools to guide physicians and patients in informed decision making, and a greater focus on prevention and screening in high-risk patients rather than broad indiscriminate screening.

— Thomas L. Schwenk, MD

Published in Journal Watch General Medicine October 29, 2009

Citation:
Esserman L et al. Rethinking screening for breast cancer and prostate cancer. JAMA 2009 Oct 21; 302:1685. [Medline® Abstract]

Copyright © 2009. Massachusetts Medical Society. All rights reserved.

The above message comes from "Journal Watch", who is solely responsible for its content.

FW: Salmonella Outbreak Associated with Water Frogs

Salmonella Outbreak Associated with Water Frogs

Investigation Update: Outbreak of Human Salmonella Typhimurium Infections Associated with Contact with Water Frogs

CDC is collaborating with public health officials in many states to investigate a multistate outbreak of human Salmonella serotype Typhimurium infections due to contact with water frogs including African Dwarf Frogs. Water frogs commonly live in aquariums or fish tanks. Amphibians such as frogs and reptiles such as turtles, are recognized as a source of human Salmonella infections. In the course of routine assessment, a number of cases with the same strain have been identified over many months. As of 11:59pm EST on December 9, 2009, 50 individuals infected with the outbreak strain of Salmonella Typhimurium have been reported from 25 states.

ADVICE TO CONSUMERS

• Always wash hands thoroughly with soap and water after touching any amphibian (e.g., frog) or reptile (e.g, turtle), their housing, or anything (for example, food) that comes in contact with them or their housing. Adults should assist young children with hand washing.


• Watch for symptoms of Salmonella infection, such as diarrhea, fever, and abdominal cramps. Call your health care provider if you or a family member have any of these symptoms.

Persons who should avoid contact with amphibians and reptiles and their habitats (e.g., aquarium, fish tank, or terrarium)

• Persons at increased risk for serious infection from salmonellosis are children < 5 years old, elderly persons, and persons with weakened immune systems.


• These persons should avoid contact with amphibians (e.g., frogs) and reptiles (e.g., turtles) and anything that comes in contact with them (e.g., aquarium, habitat, and water).


• Keep amphibians and reptiles out of homes with children < 5 years old or people with weakened immune systems.

Placement and maintenance of habitats

• Amphibians (e.g., frogs) and reptiles (e.g., turtles) should not be kept in child-care centers.


• Habitats containing amphibians or reptiles should not be kept in a child’s bedroom, especially children aged < 5 years.


• Do not allow amphibians or reptiles to roam freely through the house, especially in food preparation areas.


• Keep amphibians and reptiles out of kitchens and other areas where food and drink is prepared or served to prevent contamination.


• Habitats and their contents should be carefully cleaned outside of the home. Use disposable gloves when cleaning and do not dispose of water in sinks used for food preparation or for obtaining drinking water.


• Do not bathe animals or their habitats in your kitchen sink. If bathtubs are used for these purposes, they should be thoroughly cleaned afterward. Use bleach to disinfect a tub or other place where reptile or amphibian habitats are cleaned.


• Children aged <5 years should not clean habitats.


• Always wash hands thoroughly with soap and water after cleaning habitats.

QOD 12 7 09

In a study published in NEJM regarding mild traumatic brain injury in US
Soldiers returning from Iraq, which one of the following was most
strongly associated with the development of PTSD?

A.

Exposure to multiple blasts.

B.

High combat intensity.

C.

Hospitalization.

D.

Witnessing death

More than 1.5 million U.S. military personnel have deployed to Iraq or
Afghanistan since the start of military operations in 2001. Because of
improved protective equipment, a higher percentage of soldiers are
surviving injuries that would have been fatal in previous wars. Head and
neck injuries, including severe brain trauma, have been reported in one
quarter of service members who have been evacuated from Iraq and
Afghanistan. Concern has been emerging about the possible long-term
effect of mild traumatic brain injury, or concussion, characterized by
brief loss of consciousness or altered mental status, as a result of
deployment-related head injuries, particularly those resulting from
proximity to blast explosions. Traumatic brain injury has been labeled a
signature injury of the wars in Iraq and Afghanistan

The study questionnaire asked soldiers whether they had been injured
during their deployment by a blast or explosion, a bullet, a fragment or
shrapnel, a fall, a vehicle accident, or other means and whether the
injury involved the head. A soldier was considered to have had a mild
traumatic brain injury if any of three questions - regarding "losing
consciousness (knocked out)," "being dazed, confused, or `seeing
stars,'" or "not remembering the injury" - elicited a positive response.
These questions were based on definitions from the Centers for Disease
Control and Prevention and the World Health Organization that were
adapted by the Defense and Veterans Brain Injury Center working group
for military-wide use. The question regarding loss of consciousness was
analyzed separately to determine whether it was a stronger predictor
than the two other questions pertaining to altered mental status, the
results of which were combined. Soldiers who reported any injury that
did not involve altered mental status or losing consciousness served as
the reference group for all analyses.

PTSD was strongly associated with mild traumatic brain injury. Overall,
43.9% of soldiers who reported loss of consciousness met the criteria
for PTSD, as compared with 27.3% of those with altered mental status,
16.2% of those with other injuries, and 9.1% of those with no injuries.
In a logistic-regression model that included age, military rank, sex,
hospitalization or no hospitalization, mechanism of injury (blast or
other mechanisms), level of combat intensity, exposure or nonexposure to
multiple blasts from improvised explosive devices, and type of injury
(loss of consciousness vs. other injuries), only loss of consciousness
and combat intensity remained significantly associated with PTSD (odds
ratio for loss of consciousness, 2.98; 95% confidence interval [CI],
1.70 to 5.24; odds ratio for top quartile of combat intensity vs. lowest
quartile, 11.58; 95% CI, 2.99 to 44.83). Injury with loss of
consciousness was also independently associated with major depression
(odds ratio, 3.67; 95% CI, 1.65 to 8.16). Similarly, injuries associated
with altered mental status (as compared with other injuries) and combat
intensity were significantly associated with PTSD (but not with
depression) (odds ratio for injuries with altered mental status, 1.78;
95% CI, 1.13 to 2.81; odds ratio for combat intensity, 6.63; 95% CI,
2.23 to 19.76).

Answer: B

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FW: QOD 12 8 09

QOD 12 8 09

The Centers for Disease Control and Prevention estimates that all of the following are true except:

a. Only 60% of Americans have an fire escape plan.
b. Only 25% of those who have a fire escape plan have practiced it.
c. Smoke alarms cut occupants' chances of dying in a fire in half.
d. Malfunctioning or non-present smoke alarms are found in 30% of home fire deaths.

Fires and related burn injuries are a major issue in health care. The U.S. Fire Administration data shows that in 2006, 3,245 civilians lost their lives as the result of fire. There were 16,400 civilian injuries that occurred as the result of fire; 81% of all civilian fire deaths occurred in residences, and 106 firefighters were killed while on duty. Direct property loss due to fires was estimated at $11.3 billion. In 524,000 structural fires, there were 2,705 deaths and 14,350 injuries, resulting in $9.6 million dollars of direct loss. The U.S. Fire Administration/National Fire Data Center report on fatal fires estimated that there were 3,300 fatal fires that claimed 3,380 civilian lives (86% involved single fatalities, 14% involved multiple fatalities). Seventy-four percent of fatal fires occurred in structures; 94% of these were on residential properties. The leading cause of fires that resulted in fatalities was arson (27%), followed by smoking (18%). Smoke alarms were either not present or not functional in 63% of residential fires.

The Agency for Healthcare Research and Quality (AHRQ) of the Department of Health and Human Services outcomes data for 2005 for burn injuries in the United States shows 40,687 hospital discharges. The mean length of stay was 7.1 days, mean charges were $41,000, and the in-hospital mortality rate was 2.4%. This represents $1.67 billion in health care cost annually for the management of patients with burns. Of this care, 28.7% was provided under private insurance; however, Medicare and Medicaid paid for 42% of care, and this government expenditure represents $709 million. Additionally, uninsured patients, whose costs are passed on to other insurers, represented 15% for $245 million; however, this figure does not represent the entire uninsured group, as many burn patients in most states qualify for Medicaid because of the magnitude of their burn injuries.

Thermal burns may result from contact with flames, hot liquids, hot surfaces, and other sources of intense heat; chemical burns and electrical burns may also occur. In addition, mass casualties and disasters, explosions, and fires can cause a variety of serious injuries, including burns. Prevention and planning are vital; the public must understand how to behave safely in mass casualty and fire situations and to comprehend basic principles of first aid for burn victims, as immediate care can be lifesaving. The Centers for Disease Control and Prevention (CDC) indicates that only 60% of Americans have an escape plan, and of those, only 25% have practiced it. The CDC estimates that smoke alarms cut the chances of dying in a fire in half.

Answer: d

QOD 12 6 09

QOD 12 6 09

Only African Americans can have sickle cell disease.

a. True
b. False

Sickle cell disease is one of the most common genetic disorders worldwide. It comprises several hemoglobin (Hb) variants, typically involving the beta globin chain, that lead to chronic hemolytic anemia and several other acute and chronic complications. The most common form in North America is Hb SS; other mutations include Hb SC, Hb S-beta thalassemia, Hb SO Arab, Hb SD, and Hb SE. Although affected individuals are usually people of African, Mediterranean, Arab, and Indian ancestry, individuals of other ethnicities may also be affected. The degree of anemia, painful episodes, and organ damage vary widely amongst individuals. The introduction of newborn screening and institution of preventative and new therapeutic measures such as penicillin prophylaxis, chronic transfusions, hydroxyurea, and hematopoietic stem cell transplantation have led to significant improvements in the life span and quality of life of children with sickle cell disease.

Answer: b

Symposium invitation

Dear Colleagues:

I am pleased to extend an invitation to attend a CME conference:

"New Technologies and Techniques in Pediatric Cardiology"

Please click on the following link for online registration and
additional conference information:
https://register.columbiacme.org/conference.cgi?rm=view&conference_id=374600

Course Objectives:

Exciting discoveries in the understanding and treatment of critically
ill pediatric cardiac patients occur so frequently that pediatric
nurses, pediatricians, pediatric cardiologists and intensivists have a
hard time keeping up. This conference will focus on new advances in the
management of the critically ill child with heart disease. This
conference is designed for the entire Pediatric Cardiac Team:
pediatricians who care for cardiac patients, pediatric cardiologists,
surgeons, nurses, intensivists, anesthesiologists, neonatologists,
perfusionists and all those involved in the care of the pediatric
cardiac patient.

Recent discoveries in genetics have revealed new concepts in
understanding cardiomyopathies and dysrhythmias. Conference attendees
will gain insight into the appropriate work-up of children with these
diseases, the available treatments and when to involve the geneticist.
The medical treatment of heart failure patients may postpone or prevent
the need for a heart transplant. Conference attendees will hear about
the latest innovative treatments of children with heart failure and
learn when to call a heart failure group. When medical treatment fails
and transplant is not an option, we can now support some patients with
mechanical cardiac support devices.

Attendees will learn about the latest devices and understand when to
refer their patients. Interventional cardiologists have started
performing procedures previously done by surgeons. In addition, they
will hear about the innovations, understand which patients they may help
and comprehend the importance of collaboration between cardiologists and
surgeons.

Workshops attendees will see and handle cardiac specimens, understand
what is new in electrophysiology and learn about innovative devices and
monitors. They will know how to improve communication in the ICU and
learn about advances in CPR.

The morning sessions will highlight recent advances in Cardiac Critical
Care and the title of the lectures will be in the format of, "What's new
in ... ." The afternoon sessions will focus on perioperative issues and
ICU solutions.

Course Director: Arthur J. Smerling, M.D., Associate Clinical Professor
of Pediatrics and Anesthesiology,
Columbia University College of Physicians & Surgeons, New York, New York

Program Director: Carolyn Kyne, R.N.

Date:
Sunday, Dec. 13, 2009

Time:
7:15 a.m. - 4:30 p.m.

Location:
Morgan Stanley Children's Hospital of NewYork-Presbyterian, Lobby Level
3959 Broadway
New York, New York 10032

Complimentary parking will be available in the Russ Berrie Pavilion
parking lot located at 1150 St. Nicholas Avenue and West 168th Street,
at the rear of the building.

Accreditation/ Designation of Credit:
The College of Physicians and Surgeons of Columbia University is
accredited by the Accreditation Council for Continuing Medical Education
(ACCME) to provide continuing medical education for physicians. The
College of Physicians and Surgeons designates this educational activity
for a maximum of 7.0 AMA PRA Category 1 Credit(s). Physicians should
only claim credit commensurate with the extent of their participation in
the activity.

The American College of Nurse Practitioners (ACNP) and the American
Academy of Physician Assistants (AAPA) accept AMA/PRA category 1 credit
from organizations
accredited by the ACCME.

The American Nurses Credentialing Center (ANCC) accepts AMA/PRA category
1credit toward recertification requirements.

Pre-registration is required.

You can register online or obtain additional information at:

https://register.columbiacme.org/conference.cgi?rm=view&conference_id=374600

-or-

http://ColumbiaCME.org

Telephone: (212) 305-3334
FAX: (212) 781-6047

We hope that you will be able to attend and encourage your colleagues to
do the same.

FW: Requested DocAlert: Simple Surgical Masks or N95 Respirator Masks to Protect Healthcare Workers From Influenza?

N95 Respirators or Surgical Mask for Protection from Influenza?By current knowledge, a surgical mask is sufficient. Save N95 respirators for TB and other aerosol-transmitted diseases.World Health Organization guidelines for protection of healthcare workers from influenza recommend standard droplet precautions — including surgical masks — except during aerosolizing procedures, when N95 respirators should be used. Researchers performed a literature review to determine whether this recommendation is evidence based and identified 21 studies of respiratory protection in healthcare settings and 25 laboratory studies of the devices' filtering efficiency. Clinical studies evaluated transmission of respiratory syncytial virus, Bordetella pertussis, and severe acute respiratory syndrome (SARS). Reviewers rated only one clinical study as high quality.Three studies that evaluated surgical masks reported protection when masks were used in conjunction with hand hygiene, gloves, and gowns; two reported no protection; and one was equivocal. Three studies that evaluated N95 respirators reported protection, and six studies were inconclusive. Four studies that evaluated N95 respirators and surgical masks showed decreased SARS transmission when either device was used consistently, and one study reported no protective effect. One study of combined use of the two devices was inconclusive.Filtering efficiencies ranged from 0% to 99% for surgical masks, as compared with 95.0% to 99.5% for N95 respirators. Although a recent trial comparing surgical masks and N95 respirators (JW Infect Dis Oct 21 2009) showed equal protection with the two devices, the authors of the literature review suggest that based on findings of the laboratory studies, "aerosol transmission of influenza is plausible," and the currently recommended 1-meter respiratory zone should be enlarged.Comment: Despite the article's title, none of the clinical studies examined influenza transmission, and only three directly compared use of N95 respirators and surgical masks. In addition, many confounders compromised the studies' ability to discriminate between the effects of respiratory protection and other factors. Influenza is considered to spread via droplet rather than aerosol. Absent clear evidence of additional benefit over standard surgical masks, N95 respirators should be reserved for protection from diseases that are clearly aerosol transmitted (e.g., varicella, measles, tuberculosis).— Kristi L. Koenig, MD, FACEPPublished in Journal Watch Emergency Medicine November 6, 2009Citation:Gralton J and McLaws M-L. Protecting healthcare workers from pandemic influenza: N95 or surgical masks? Crit Care Med 2009 Sep 1; [e-pub ahead of print]. (http://tinyurl.com/yztbnke) [Medline® Abstract]

Copyright © 2009. Massachusetts Medical Society. All rights reserved.The above message comes from "Journal Watch", who is solely responsible for its content.

FW: QOD 12 1 09

Which of the following statements is false with regard to pain management in patients with sickle cell disease?

a. Opioid and non-opioid analgesics may be used.
b. Patients with sickle cell disease may develop opioid tolerance.
c. Opioid tolerance is the same as addiction.
d. Patient-controlled analgesia is an effective way to treat moderate to severe pain.

Vaso-occlusive pain can be acute or chronic. A thorough history and physical examination should be performed to make sure pain is secondary to vaso-occlusion and not another etiology such as appendicitis or infection. Pain management should be initiated promptly, as delays unnecessarily prolong discomfort and may complicate the diagnostic evaluation. Fluids and analgesics, including non-opioids and opioids, should be started. Most patients with sickle cell disease are opioid-tolerant, and this should be taken into consideration when initiating pain management with opioids. In many cases, patients may be able to communicate what their usual effective dose is. In general, oral opioids such as oxycodone or morphine can be given together with an oral non-opioid analgesic, such as ibuprofen, at a dose of 10 mg/kg. If adequate pain control is attained, patients may be discharged on scheduled oral analgesics for 24 to 48 hours, then as needed. If there is inadequate pain control, the pain should be treated as moderate to severe pain with parenteral opioids and parenteral or oral non-opioid analgesics. Table 2 shows the management strategies for mild to moderate pain. Hydration can be started orally prior to the establishment of IV access. If IV fluids are started, a normal saline bolus should be given, followed by IV fluids at a rate of one to one-and-one-half times maintenance. If acute chest syndrome is suspected, IV fluids should be limited to no more than maintenance, as this may cause pulmonary edema and worsen acute chest syndrome. A temperature should be checked to ascertain that there is no fever. Most patients with sickle cell disease have analgesics at home, and pain management may have been attempted prior to presentation to the ED. If the patient has failed management with oral analgesics and is in the ED or being admitted, patient-controlled analgesia (PCA) should be considered. Answer: c