New York Presbyterian Hospital

Continuing
Medical
Education
NYP/Weill Cornell
Room M-107

Thursday, February 3, 2011 4:30-7:30 pm
4:30pm-6:30pm
Understanding Dive Emergencies;
With Master Scuba Diver Trainer
James Bayreuther, EMT-P

6:30pm-7:30pm
CO Poisoning, Drager CO Monitor, Rad 57 CO Detector
Steven Samuels EMT-P

Weill Cornell Campus ROOM M-107
Approval by NYC REMAC for Three Hours Lecture CME; Applied For
Please RSVP if you plan on attending, by E-Mail
ANY QUESTIONS OR IDEAS
PLEASE CONTACT CME COORDINATOR
STEVE SAMUELS EMT-P 516-383-7248
SSAMUELS@NYP.ORG

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

No virus found in this incoming message.
Checked by AVG - www.avg.com
Version: 8.5.431 / Virus Database: 270.14.122/2590 - Release Date: 01/03/10 09:41:00

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

No virus found in this incoming message.
Checked by AVG - http://www.avg.com/
Version: 8.5.426 / Virus Database: 270.14.95/2546 - Release Date: 12/06/09
07:30:00