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

QOD 11 25 09

Which of the following statements accurately describes the risk of hepatic failure following acetaminophen overdose?

A. If N-acetylcysteine is started more than 2 hours post-ingestion, the risk of hepatic failure begins to increase.
B. If N-acetylcysteine is started more than 4 hours post-ingestion, the risk of hepatic failure begins to increase.
C. If N-acetylcysteine is started more than 6 hours post-ingestion, the risk of hepatic failure begins to increase.
D. If N-acetylcysteine is started more than 8 hours post-ingestion, the risk of hepatic failure begins to increase.
E. The risk of hepatic failure is dependent on the amount of ingestion, not the time before antidotal therapy is started.

Following ingestion, acetaminophen is rapidly absorbed from the gastrointestinal tract. It has a relatively low volume of distribution (0.8-1.0 L/kg) and is 25% protein-bound. The half-life of acetaminophen is approximately 1.5-2.5 hours, although it can be slightly prolonged at supratherapeutic concentrations.

Following ingestion, approximately 4% of the ingested acetaminophen is excreted unchanged in the urine, while the remainder is metabolized in the liver. In adults, 45-55% of acetaminophen is glucuronidated, while 20-30% is sulfonated. In pediatric patients, however, sulfation is the primary pathway, and glucuronidation is a minor component. The remainder of acetaminophen is metabolized via the cytochrome P450 isoenzyme CYP2E1 to form a substance called N-acetyl-para-benzoquinoneimine (NAPQI). Normally, the body's endogenous glutathione supplies are able to bind to and reduce NAPQI, resulting in renal excretion in the form of cysteine or mercaptopuric acid conjugates. In the setting of overdose, however, the NAPQI production exceeds the body's endogenous glutathione supply, and hepatotoxicity can result.

Acetaminophen's toxicity is due to the metabolism to NAPQI by the cytochrome P450 isoenzyme CYP2E1. Thus, any xenobiotic that induces the P450 isoenzyme CYP2E1 can theoretically increase the risk for acetaminophen-induced hepatotoxicity. Perhaps one of the best-studied agents for inducing CYP2E1 is ethanol. Thus, chronic ethanol consumption leads to increased CYP2E1 activity and, in theory, subsequently increases the risk of hepatotoxicity (see Special Populations below). In contrast, the co-ingestion of ethanol with acetaminophen may result in inhibition of the microsomal oxidation of acetaminophen, thereby providing some degree of protection from acetaminophen-induced hepatotoxicity during acute intoxication. The strongest risk factor for developing hepatotoxicity, however, is the time from a toxic ingestion until the antidote, N-acetylcysteine, is administered. The risk of hepatotoxicity if N-acetylcysteine is started within the first eight hours of the overdose is exceedingly low, while the risk increases substantially with delays longer than eight hours.

Answer: D