FW: QOD 2 12 10

In the United States, approximately what percentage of children between the ages of 6 and 19 years are estimated to be overweight or obese?
		A.	15%.
		B.	25%.
		C.	35%.
		D.	45% It has been estimated that at the turn of the 21st century, approximately 15% of U.S. children between the ages of 6 and 19 years (11 million children) were overweight or obese, a prevalence that is unlikely to decline in the near future and that is triple the prevalence among children of the same age in the 1960s. Obesity in children who do not have diabetes is associated with an increased rate of death from endogenous causes during early adulthood, an association that may be partially mediated by the development of glucose intolerance and hypertension in childhood. In contrast, the cholesterol level in childhood is not a major determinant of premature death in this population. Childhood obesity is becoming increasingly prevalent around the globe. Failure to reverse this trend may have wide-reaching consequences for the quality of life and longevity. Such evidence underscores the importance of preventing obesity starting in the early years of life. Answer: A

FW: QOD 1 19 10

According to a recent study published in the NEJM, what was the approximate mortality rate among pregnant women hospitalized with 2009 H1N1 influenza?
		A.	8%.
		B.	14%.
		C.	22%.
		D.	30%. In this large series of pregnant and postpartum patients who were hospitalized with or died from 2009 H1N1 influenza, 95% of the pregnant patients were infected in the second or third trimester, and almost one fifth required intensive care. One third of the pregnant patients had medical conditions besides pregnancy that are recognized risk factors for complications from influenza. Eight patients who were hospitalized had an onset of symptoms within 2 weeks post partum; half required intensive care and two died, highlighting the continued high risk immediately after pregnancy. The pregnant women were less likely to have underlying medical conditions than the nonpregnant women hospitalized with 2009 H1N1 influenza. Although pregnant women frequently presented with mild or moderate symptoms, many had a rapid clinical progression and deterioration. Over the 4-month study period, the cause-specific maternal mortality ratio for 2009 H1N1 influenza was estimated at 4.3 in California. The maternal mortality ratio for death from any cause was 19.3 in California in 2005 and 13.3 in the United States in 2006. More than two thirds of maternal deaths in the United States each year are directly related to obstetrical factors, and maternal deaths due to influenza have been rare. The high 2009 H1N1 influenza–specific maternal mortality suggests that this pandemic has the potential to notably increase overall maternal mortality in the United States in 2009. The severity of influenza seen in this case series is consistent with the increased risk of severe disease among pregnant women that has been documented for seasonal influenza and previous pandemics. Consistent with the excess number of influenza-associated deaths among pregnant women observed during previous pandemics is the disproportionate number of pregnant women, as compared with their prevalence in the overall population, among all patients who have died and all critically ill patients, as was recently reported in the United States and other countries during the current pandemic. Although an association between severe illness and pregnancy is well documented for seasonal influenza, the rapid clinical deterioration observed in some of our patients appears to be qualitatively different from the course of seasonal influenza observed previously. One quarter of the women requiring mechanical ventilation in the study were severely ill at the time of presentation and required intubation on the day of admission. Six deliveries occurred in an ICU, including four emergency cesarean deliveries, which is a relatively rare obstetrical occurrence and suggests that the condition of the patients was too unstable at the time of delivery for them to be transferred to an appropriate labor and delivery unit. Furthermore, although the data are limited, deaths among pregnant women due to seasonal influenza appear to be uncommon. In a study of more than 4000 women enrolled in the Tennessee Medicaid program between 1974 and 1993 who had a cardiopulmonary event during the influenza season, none of the 104 maternal deaths that occurred were likely to have been due to influenza. The Centers for Disease Control and Prevention (CDC) recommends prompt antiviral treatment of pregnant women with suspected or confirmed 2009 H1N1 influenza, ideally within 48 hours after symptom onset. In this study, pregnant women who received treatment after 48 hours had a risk of admission to the ICU or death (8%) that was about 4 times the risk among those who received earlier treatment. Delay in treatment was often multifactorial in cause; in some cases, pregnant women did not promptly seek medical care after symptom onset, whereas in other cases, there were delays by health care providers in initiating antiviral treatment. The recognition and diagnosis of influenza-like illness may be complicated during pregnancy, when women and their health care providers may attribute certain signs and symptoms (e.g., myalgia or shortness of breath) to pregnancy rather than influenza. Furthermore, pregnant women or their health care providers may want to avoid antiviral treatment during pregnancy because of concerns about the fetus. Although rapid influenza tests are widely available and can be completed within 15 minutes, reliance on rapid test results might have contributed to treatment delays. In this study, 38% of patients who underwent testing had false negative results; less than 30% of the pregnant women with false negative results received antiviral treatment within 48 hours after symptom onset, and five of the patients who died had false negative results. Recently, the CDC issued a health advisory alerting clinicians about the poor sensitivity of rapid test results and stating that clinical decisions about the treatment of influenza should not be guided or delayed by negative results on rapid testing. The fact that eight of the cases of influenza in this study involved a postpartum onset of symptoms, with severe disease and death in some of these cases, highlights the continued high risk immediately after pregnancy. A variety of cardiac, respiratory, hormonal, and immunologic changes that occur during pregnancy may contribute to the increased risk of influenza-related morbidity and mortality among pregnant women. Although it is unknown how long after delivery these changes persist, some of them (i.e., immunologic alterations) might persist longer than others (e.g., decreased lung capacity due to uterine compression). Although some studies of seasonal influenza have not shown an increased period of risk during the postpartum period, the immediate postpartum period probably represents a transitional period during which the risk of severe disease is returning to, but has not yet reached, the baseline level. In light of these emerging data, the CDC recently issued revised guidelines, recommending prompt initiation of antiviral treatment in patients with suspected or confirmed influenza up to 2 weeks after delivery. Answer: A

QOD 1 15 10

What is the most common endogenous cause of Cushing's syndrome?
		A.	An adrenal tumor.
		B.	A liver tumor.
		C.	A lung tumor.
		D.	A pituitary tumor. Cushing's syndrome results from sustained hypercortisolemia. The most common cause is administration of exogenous glucocorticoids. Secretion of corticotropin from the pituitary (Cushing's disease) accounts for approximately 70% of endogenous cases; adrenal tumors and the ectopic production of corticotropin each account for approximately 15% of cases. The clinical and laboratory features of Cushing's syndrome overlap with many other medical conditions, and very few patients fulfill the classic presentation of facial rounding, weight gain, striae, hirsutism, hypertension, and muscle weakness. The majority of patients have abnormal glucose tolerance, but edema and hypokalemic alkalosis, as seen in this patient, occur in only a minority. The diagnosis of Cushing's syndrome requires the confirmation of hypercortisolism, generally with the measurement of 24-hour urinary cortisol excretion, measurement of midnight salivary cortisol levels, or both. Autonomous production of cortisol can be demonstrated with the use of a dexamethasone (1-mg) suppression test. Once hypercortisolism is established, a corticotropin level of more than 20 pg per milliliter (4.4 pmol per liter) suggests corticotropin dependency; a level below 5 pg per milliliter (1 pmol per liter) suggests an adrenal source. When corticotropin dependency is established, magnetic resonance imaging can identify pituitary tumors approximately 60% of the time. Answer: D

QOD 1 3 10

Household contacts in which of the following age groups are most susceptible to H1N1 infection, according to the results of this week's NEJM published study?
		A.	18 years of age or younger.
		B.	19 to 50 years of age.
		C.	51 to 69 years of age. D. 70 years of age or older Results An acute respiratory illness developed in 78 of 600 household contacts (13%). In 156 households (72% of the 216 households), an acute respiratory illness developed in none of the household contacts; in 46 households (21%), illness developed in one contact; and in 14 households (6%), illness developed in more than one contact. The proportion of household contacts in whom acute respiratory illness developed decreased with the size of the household, from 28% in two-member households to 9% in six-member households. Household contacts 18 years of age or younger were twice as susceptible as those 19 to 50 years of age (relative susceptibility, 1.96; Bayesian 95% credible interval, 1.05 to 3.78; P=0.005), and household contacts older than 50 years of age were less susceptible than those who were 19 to 50 years of age (relative susceptibility, 0.17; 95% credible interval, 0.02 to 0.92; P=0.03). Infectivity did not vary with age. The mean time between the onset of symptoms in a case patient and the onset of symptoms in the household contacts infected by that patient was 2.6 days (95% credible interval, 2.2 to 3.5). Conclusions The transmissibility of the 2009 H1N1 influenza virus in households is lower than that seen in past pandemics. Most transmissions occur soon before or after the onset of symptoms in a case patient. Answer: A

QOD 1 4 10

Which of the following statements is true regarding thrombolysis in cases of frostbite?
		A.	Doppler signals should be detectable in the extremity before thrombolysis.
		B.	Infusion of vasodilators should be avoided.
		C.	Intraarterial infusion of the thrombolytic agent is preferred.
		D.	Priority should be given to the feet rather than the hands. After rewarming, if the patient's feet or hands remain without evidence of perfusion, the presence of vascular thrombosis should be suspected. In this situation, emergency lytic therapy would seem to address the primary pathophysiology, if ischemia time has been brief. Intravenous or intraarterial thrombolytic therapy has been reported in two retrospective studies to reduce the rate of major amputation. Because it is primarily the smaller arteries that are occluded in frostbite, thrombolytic agents may be more effective when selectively infused intraarterially, with the catheter tip positioned near the target areas of malperfusion. Catheter-directed administration of tissue plasminogen activator (t-PA) may be more effective, since a higher concentration of the agent locally permeates and binds to thrombus at the target. The use of an ultrasound-accelerated thrombolysis catheter to deliver the thrombolytic agent has been performed; ultrasonography has been shown to reversibly loosen fibrin strands and reduce their diameter, exposing more individual strands, increasing thrombus permeability, and exposing more plasminogen-receptor sites for binding. More rapid and complete thrombolysis has been reported with the use of this technique than with standard catheter-directed thrombolysis. The treatment end points for thrombolytic therapy include angiographic or clinical demonstration that perfusion has been reestablished, failure to show any improvement in perfusion on angiograms obtained after 24 hours and after 48 hours of therapy, and the development of bleeding complications such as hematoma, stroke, or hemorrhage involving solid organs or the gastrointestinal tract. Answer: C

Suprisises in the Kitchen

Surprises…and Cautions…in the Kitchen
Is it true that….
Enough vanilla extract can make you drunk?Poppy seeds contain opium?A lot of nutmeg is like a little PCP?Oil of wintergreen can cause an aspirin overdose?
All of these statements are true, though none of these foods and flavorings is dangerous to use as recommended. With holiday baking season upon us, it’s time to review some kitchen poison safety tips.
Vanilla extract contains ethanol, the same type of alcohol found in beer, wine, and hard liquor (and other types of flavoring extract, perfume, cologne, aftershave, and mouthwash, too). The amount of extract called for in recipes would not be dangerous. But a child who swallowed the contents of a bottle might be at risk of alcohol poisoning. Keep flavoring extracts out of reach, along with other alcohol-containing liquids.
The poppy seeds we bake with or eat on bagels could, in fact, cause a positive drug screen for opiates. When people eat poppy seeds, a drug test could be positive for morphine or codeine, which are metabolites (break-down products) of heroin. BUT – this generally happens only if people eat a lot of poppy seeds – more than one poppy seed bagel, for example, a short time before the test. Drinking poppy seed tea has actually caused poisoning and is NOT recommended!
vanilla
poppy
Nutmeg tastes great in cookies and eggnog, but too much can cause hallucinations. Children who get into the container, and people who deliberately swallow a lot of nutmeg trying to get high, can become miserably sick. Nausea, vomiting, agitation, prolonged drowsiness, and coma are all possible. Keep the nutmeg, and its relative, mace, out of the reach of children.
Oil of wintergreen is another name for methyl salicylate, a relative of aspirin (acetylsalicylic acid). Small amounts are safe to use as flavoring agents, but the bottle MUST be locked up, where children can’t get to it. Small amounts of oil of wintergreen, like small amounts of aspirin, can poison children. Because oil of wintergreen is rapidly absorbed, children can become dangerously ill very quickly.
It’s important to keep safety in mind even when using ordinary kitchen ingredients. Use only recommended amounts in recipes. Lock up ingredients that might be harmful if children swallow too much. And, as always, call the Poison Center right away if you suspect that someone has swallowed too much of anything. Even though you’re baking or partying, the experts at the Poison Center are there to answer your phone call and help you through any poison emergency. Call 1-800-222-1222 – 24 hours a day, every day of the year.
To return to The Poison Post, close this window.The Poison Post, National Capital Poison Center eNewsletter - www.poison.orgCopyright 2009, National Capital Poison Center. All Rights Reserved.

QOD 12 31 09

A 6-month-old child with a two-day history of vomiting and diarrhea presents with lethargy, pallor, weak pulses, and delayed capillary refill. Which of the following should be administered?

A. Normal saline 20 mL/kg
B. Packed red blood cells 10 mL/kg
C. Fresh frozen plasma 20 mL/kg
D. Whole blood 20 mL/kg

You are unable to obtain IV access for the patient in question above. Which of the following is the next appropriate step?

A. Transfer the patient to another facility.
B. Place an intraosseous access device.
C. Discharge the patient with instructions for a clear liquid diet.
D. Attempt to place a central venous line.

Appropriate management of patients presenting in shock necessitates rapid recognition of the shock state and determination of the most plausible etiology for the shock. Certain treatment principles apply regardless of the etiology and should be instituted immediately for all patients presenting with signs of shock. Attention should first be directed toward airway and breathing. Even patients with a patent airway and spontaneous respirations may benefit from early intubation to reduce metabolic demand and assure adequate oxygenation and ventilation, especially in cases of severe or decompensated shock. All patients should be placed on supplemental oxygen, preferable by a high-flow mask.

The next management priority should be establishing vascular access. This is best accomplished through the placement of a peripheral intravenous catheter of as large a caliber as is possible for the patient's size. Every effort should be made to have at least two functioning IVs in severely ill or injured patients. The rate of flow through a catheter is proportional to the diameter and inversely proportional to the length of the catheter; therefore short, large-caliber catheters are preferred over long, central venous lines for initial resuscitation. When IV access cannot be quickly established, consideration should be given to placement of an intraosseous (IO) access device. Historically, IO access was recommended only for infants and young children. Newer devices, however, allow the IO route to be used for older children and adults. Fluid therapy should be initiated immediately after access is established. The majority of patients presenting in shock have some degree of absolute or relative intravascular volume depletion and may benefit from intravenous fluids. Early, aggressive fluid resuscitation has been shown in multiple studies to improve survival and outcomes in adult and pediatric septic shock patients. Even patients presenting with suspected cardiogenic shock may benefit from fluid resuscitation, but fluids should be given in smaller amounts and patients should be carefully monitored for signs of worsening congestive heart failure. The following sections will review the general management principles for different types of shock. Medical personnel caring for patients in shock must remember that any given patient may have a mixture of etiologies causing the shock state, and treatment must be tailored to the individual patient's presentation.

While some patients in early shock state may be successfully resuscitated in the emergency department to the point of stability for hospitalization on a regular hospital ward, most patients presenting in shock will need ongoing care in an intensive care setting. During initial resuscitation, plans should be made for transfer to an appropriate level of care.

Hypovolemic shock is the most common shock state affecting pediatric patients. Leading causes of hypovolemic shock in these patients are hemorrhage from trauma and dehydration from gastrointestinal losses (vomiting and diarrhea). All patients presenting in hypovolemic shock require rapid vascular access (IV or IO) and volume resuscitation. Initial fluid therapy should consist of a 20 mL/kg bolus of isotonic crystalloid fluid such as normal saline or Ringer's lactate. This bolus should be given as quickly as possible. If the patient's heart rate, level of consciousness, and capillary do not improve, a second bolus of 20 mL/kg should be rapidly administered. Blood should be drawn for determination of electrolyte and hemoglobin levels and for type and crossmatch of red blood cells in trauma patients. Hypoglycemia should be corrected if present. Patients presenting with severe hypovolemic shock may need 40–60 mL/kg of crystalloid for initial resuscitation. In cases of trauma, if systemic perfusion does not respond to administration of 40–60 mL/kg of crystalloid, packed red blood cells should be transfused in 10–15 mL/kg aliquots. Blood transfusion may be repeated as needed. Type-specific crossmatched blood is preferred; however, Type O blood may be used in urgent circumstances until crossmatched blood is available. Emergent surgical consultation should be arranged for patients exhibiting signs of shock after trauma, as they may require surgical exploration to identify and correct ongoing hemorrhage.

^{Answer: A (first question)}

^{Answer: B (second question)}

QOD 1 3 10

Household contacts in which of the following age groups are most susceptible to H1N1 infection, according to the results of this week's NEJM published study?
		A.	18 years of age or younger.
		B.	19 to 50 years of age.
		C.	51 to 69 years of age. D. 70 years of age or older Results An acute respiratory illness developed in 78 of 600 household contacts (13%). In 156 households (72% of the 216 households), an acute respiratory illness developed in none of the household contacts; in 46 households (21%), illness developed in one contact; and in 14 households (6%), illness developed in more than one contact. The proportion of household contacts in whom acute respiratory illness developed decreased with the size of the household, from 28% in two-member households to 9% in six-member households. Household contacts 18 years of age or younger were twice as susceptible as those 19 to 50 years of age (relative susceptibility, 1.96; Bayesian 95% credible interval, 1.05 to 3.78; P=0.005), and household contacts older than 50 years of age were less susceptible than those who were 19 to 50 years of age (relative susceptibility, 0.17; 95% credible interval, 0.02 to 0.92; P=0.03). Infectivity did not vary with age. The mean time between the onset of symptoms in a case patient and the onset of symptoms in the household contacts infected by that patient was 2.6 days (95% credible interval, 2.2 to 3.5). Conclusions The transmissibility of the 2009 H1N1 influenza virus in households is lower than that seen in past pandemics. Most transmissions occur soon before or after the onset of symptoms in a case patient. Answer: A

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