CDC – Seasonal Influenza (Flu) – Situation Update: Summary of Weekly FluView

Go get your flu shot, it looks like they hit it on the head (which is remarkable, at least to me). Picking the right antigens is always tricky.

From the CDC:

  • Since October 1, 2012, CDC has antigenically characterized 140 influenza viruses, including two 2009 influenza A (H1N1) viruses, 90 influenza A (H3N2) viruses and 48 influenza B viruses.
  • The 2009 influenza A (H1N1) viruses were characterized as A/California/7/2009-like. This is the influenza A (H1N1) component of the Northern Hemisphere vaccine for the 2012-2013 season.
  • All 90 of the influenza A (H3N2) viruses were characterized as A/Victoria/361/2011-like. This is the influenza A (H3N2) component of the Northern Hemisphere influenza vaccine for the 2012-2013 season.
  • Approximately 71% of the 48 influenza B viruses belonged to the B/Yamagata lineage of viruses, and were characterized as B/Wisconsin/1/2010-like, the influenza B component for the 2012-2013 Northern Hemisphere influenza vaccine.
  • The remaining 29% of the tested influenza B viruses belonged to the B/Victoria lineage of viruses.
  • Since October 1, 2012, CDC has tested two 2009 influenza A (H1N1), 122 influenza A (H3N2), and 81 influenza B virus isolates for resistance to neuraminidase inhibitors this season. Each of the viruses showed susceptibility to the antiviral drugs oseltamivir and zanamivir. High levels of resistance to the adamantanes (amantadine and rimantadine) persist among 2009 influenza A (H1N1) and A (H3N2) viruses. (Adamantanes are not effective against influenza B viruses.)

So, Tamiflu should help (some).

Dr Seuss Does Malaria « Contagions

Terrific!

This Malaria map was illustrated by Theodor Seuss Geisel, better known as Dr. Seuss, during World War II to educate young GIs. According to the Naval Department Library, this map was printed on the back of a Newsmap (two sided poster) that showed the five war fronts in 1943: Russia, Italy, “air offensive”, southwest Pacific and Burma.

via Dr Seuss Does Malaria « Contagions.

Excellent primer on Malaria (and Ann!).

via @doctorgrumpy @docgrumpy on Twitter

ACEP 12 tweeting: Bukata and Hoffman

Those who don’t follow me on Twitter probably have calm, productive lives. Those who do wonder why I twitter at all. Because it keeps me busy and engaged, that’s why.

Here’s an edited compilation of two of the American College of Emergency Physicians Scientific Assembly 2012 lectures in tweets by me from Denver. These encompass about 3.5 hours of lecture by the same two legends, Jerry Hoffman and Rick Bukata reviewing the medical literature as it applies to EM.

I used Storify to put these together (it couldn’t have been easier). I left out a lot of comments from others, not as they weren’t interesting but as I’m trying to tell the story of this lecture.

At the end there’re some pictures of the Twitterers and Bloggers who get together after ACEP. Nice how we’re birds of a feather. For a bonus, at the end are Joe Lex’s 4 Rules of Emergency Medicine, which deserves its own compilation.

ACEP 2012 Tweets by me: Hoffman & Bukata

I went to the American College of Emergency Physicians Scientific Assembly held in Denver in October, 2012. I live tweeted some of the lectures I attended. Here they are.First, I’m going to combine the tweets from Hoffman and Bukata’s 2 lectures, as they’ll make more sense that way. Then pictures!

Storified by GruntDoc · Sat, Oct 13 2012 12:55:37

I’m going to start with my general Twitter disclaimer. I mean it.
Disclaimer: my tweets from #ACEP12 were paraphrasing, errors mine, don’t change practice based on reading tweets, do your homework.GruntDoc
And, off to the lectures:
HofKata: Trauma surgery is dooming their specialty going to the ER over and over for nothing surgical for them. #ACEP12GruntDoc
Referencing a European paper citing very very few went to the OR emergently from the ER to the OR, recommended calling TSS when the ER doc needs them, not a routine event.
(Will not catch on for a long time, Trauma needs their Activation Fee).
This following one had to do with ?whatever to do with those very tiny occult pneumothoraces we’re finding on trauma CT’s of the chest. Long, meandering discussion; sizes of the PTX weren’t defined, no criteria for getting a thoracostomy tube were made, just ‘did they get a chest tube or not’.
HofKata: discussion muddied as there is not a clear definition for want made the doc put in the tube to start with. #ACEP12GruntDoc
Not much was gotten from that article. Perhaps I missed the point.
HofKata: docs caught between doing what’s right for pt and right for doc; for doc getting test is right answer, not always for pt. #ACEP12GruntDoc
This next one tried to determine, in a ‘pan-scan’ for trauma ED, if there were some agreement on what trauma scans the ED attending and the Trauma Surgery attending could prospectively agree they didn’t need.

All the scans trauma wanted were gotten with a prospective form filled out by both about which scans they didn’t want. In the end the ED…

HofKata: wanted 30% fewer, and the TSS and EM in the end couldn’t decide about the value of the discovered incidentalomas. #ACEP12GruntDoc
They found a bunch of incidental things, and in the end couldn’t reconcile whether finding completely incidental things that didn’t affect management was worth the CT.
HofKata: factor VIIa is 10k for a 70kg pt in trauma and it didn’t help ( the non hemophiliac). Stop it. 97% uf use was off label. #ACEP12GruntDoc
HofKata: if you have 1 CT the likelihood is that you’ll have 5 in the next 5 years. Found a pt w 57 CTs. Wow. #ACEP12GruntDoc
The first CT is a gateway study to more, apparently.
HofKata: but when docs look at the same problem for themselves they typically choose less awful treatment, even if means pal care#ACEP12GruntDoc
Doctors will err on the side of survival in recommendations to patients, when they themselves often look at the data and decide they’d rather forgo some or all treatments and skip the unpleasant effects. Interesting.
HofKata: DC instructions. Pts have to understand, and they have to know when to come back. Ethical prob sending self limited prob #ACEP12GruntDoc
HofKata: to a referral, when its more cost for no benefit. #ACEP12GruntDoc
Bukata felt sending things like ankle sprains to PCP’s as a routine thing was ethically bad, as ‘it’s self limiting’ and costs the pt more for no benefit.
I disagree, many needs some Physical Therapy to have a more stable ankle that doesn’t recurrently sprain.

Also not a fan of these 9 page DC instructions we’re printing out.

HofKata: IO lines are great, and stop doing central lines because you can’t find a vein, use CL if need to measure things #ACEP12GruntDoc
HofKata: no need to give hydrocortisone if you use etomidate for induction. (Silly study). #ACEP12GruntDoc
HofKata: Tylenol w Motrin, and either alone. Point of treating fever comfort, not medical. No support to use both at the same time #ACEP12GruntDoc
HofKata: AAP specifically advises against using Tylenol then Motrin and alternating, confusing. Also, tells mom it’s a big deal. #ACEP12GruntDoc
treating pedi fever is about patient comfort, not treating disease. making a big deal out of fever treatment tells mom it’s very important, when it’s for comfort only.
HofKata: UTIs in small kids: can have asymptotic bacteruria and have a viral illnesses w fever and get dxd w uti. Cults have false+ #ACEP12GruntDoc
HofKata: 2-5% of kids have UTIs before puberty. Not happy about treating a ton. #ACEP12GruntDoc
Many of which were incidental findings, and the treatments can cause their own problems.
HofKata: study of 1,228 acute scrotii showed +creamasteric reflex w dxd torsion! 7% had NL or increased flow on US!? #ACEP12GruntDoc
Several people disliked my plural of scrotums being scrotii. I believe scrotae is the correct plural.
HofKata: test torsion, cont: advocates getting a iron consult for those w real sx’s and a negative w/u. Then cites anecdote. #ACEP12GruntDoc
uro(logy) got autocorrected here to iron, No idea why.
HofKata: study of Canadian hosp quick response teams. No difference. Things that seem reasonable often don’t work. #ACEP12GruntDoc
HofKata: several papers, PCR tests didn’t change abx rxing, CRP in URI resulted in 6 hour ED stays and no change in abx Rx, etc #ACEP12GruntDoc
Things being tried to tailor or eliminate antibiotic prescribing don’t. At least not in these studies.
HofKata: docs are reluctant to abandon disproven practices "ESP when lucrative". Most standards of care have never been studied. #ACEP12GruntDoc
HofKata: BNP for dyspnea in the ED. "Routine testing is of no benefit". Targeted okay. #ACEP12GruntDoc
HofKata: high sens Troponins: markedly higher positives, but 90% were causes other than AMI. (I don’t know want this). #ACEP12GruntDoc
Joe Lex ( @JoeLex5 ) commented on this later, ‘you mean low specificity troponins?”, rather than the as-spun high sensitivity. He’s right.
Touché, I’ll remember that. “@JoeLex5: @gruntdoc You mean "low specificity troponins," of course.” #ACEP12GruntDoc
HofKata: stable angina, med mgmt vs stenting: medical therapy on top for everything x persistent pain. #aGruntDoc
HofKata: the US spends 150mil A DAY on angiosperm and stents, most never had a trial of med therapy. #ACEP12GruntDoc
Okay. for some reason the iPad autocorrect thought Angio meant angiosperm, which is weird. I don’t type well, things are flying by, and so I didn’t proofread that one before I hit send. (there were several comments later which I didn’t get, so didn’t play along)(It was busy in there, with all the tweeting and misspelling).
HofKata: shocker: STEMI pts needing transfer for PCI didn’t get transferred within 30 minutes. Median time was 64 minutes. #ACEP12GruntDoc
Bukata said they fixed this at his joint by having the same EMS crew that brought them in take them out, which was very fast, and with the right conversation EMS was all over it.
HofKata: if you can get to the cath lab in less than 4 hours its better than TPa. The 60 min rule for TPa is based on no evidence. #ACEP12GruntDoc
HofKata: then says he’d rather have TPa than stenting. (Weird). #ACEP12GruntDoc
The weird was mine. I don’t get that.
HofKata: 124k STEMI pts w CABG capability did cath then CABG 3%, without very rare. CABG grps did worse. #ACEP12GruntDoc
Wow, confusing tweet.
Issue was, is it safe to do caths in places that cannot do ‘rescue CABG”? In a study of 124K pt’s in centers with and without ‘rescue CABG’ ability, answer was yes, and in places that could do CABG it was done a whole lot more than places where it wasn’t; occasional pt had to be transferred to CABG place, but not many.
HofKata: ABCD2 score for stroke after TIA isn’t reliable. Another data dredging tool fails in real life. #ACEP12GruntDoc
HofKata: redefinition of Tia w MRI findings of infarct to stroke makes both groups look better: makes studies over time hard #ACEP12GruntDoc
Way more ‘strokes’ are now very minimal (what we used to call TIA’s) so the ‘stroke category looks better, and the TIA category looks smaller. Will confound studies looking both directions.
This next one it a review of IST-3, the never-ceasing desire to give TPa to every stroke no matter the time elapsed.
HofKata: IST-3 showed in a no blinded study using untrained family members as evaluators showed a tiny trend to improvement. #ACEP12GruntDoc
HofKata: IST-3 the first 300 pts evaluated by neurologists showed the tpa out to 6 hrs is much worse. #ACEP12 scathing editorials yesterdayGruntDoc
Family members, who knew whether or not their loved one got the TPa were asked by postal mail to evaluate their loved ones’ recovery, trended better for those who got TPa. Bizarre study bias built it. To say they were unimpressed would be an understatement.
HofKata: shocker: TPa for people with dissection causing their strokes do poorly. #ACEP12GruntDoc
“@gruntdoc: HofKata: shocker: TPa for people with dissection causing their strokes do poorly. #ACEP12” surprise surpriseJennie
HofKata: Geriatric and dizzy with a normal neuro exam will not have ICH. Based on a paper from 1998 w 4 pts found to have cblr bld. #ACEP12GruntDoc
There’s a practice that’ll be hard to change.
HofKata: no decent studies on ischemic stroke leaving BP up or the older lowering. Unless going to give TPa. #ACEP12GruntDoc
HofKata: kids w brain rumors typically represent w recurrent headaches, etc. authors rec scanning in kids w recurrent ha. #ACEP12GruntDoc
Means, don’t scan a kid on first HA or first week of HA.
HofKata:Canadian SAH CT study w 3rd gen scanner didn’t LP 50% of the pts in study. Gold std was pos CT. 30% lost to f/u. LP for SAH #ACEP12GruntDoc
HofKata: says Dr Newman who presented this paper yesterday as not needing LP is incorrect. #ACEP12GruntDoc
This could be ACEP’s first Pay Per View smackdown, Hoffman vs. Newman on this Canadian CT for SAH study.
HofKata: accumulating evidence quinolones can cause neuro sx’s. still safe drug as denominator is vast, but be aware. #ACEP12GruntDoc
HofKata: giving reglan over 15 vs 2 mins decreased the akathasia. 7% vs 26%. #ACEP12GruntDoc
Turkish study, makes sense.
HofKata: CO poisoning. Hyperbaric didn’t help, showed no benefit over high flow o2. Small study. #ACEP12GruntDoc
HofKata: studied on neurosurgeon, 1/2 sit vs stand on first postop visit. Again, pts like the seated visit. #ACEP12GruntDoc
Shocker here was that this was timed, it was these NS pt’s first post-surgical visit, and they lasted about a minute and 10 seconds. Wow.
HofKata: 8% of German studies eligibility criteria weren’t included in the paper,13 published modified info. Can’t extrapolate1/2 .#ACEP12GruntDoc
HofKata: 2/2 those findings to groups that were excluded. Theme is that funded studies seem to play fast and loose w reporting. #ACEP12GruntDoc
Throws a lot of what’s published into doubt, and when they don’t report excluded groups we assume their results are applicable for the general population, which isn’t correct.
What about the deep dive into the study information that’s given to the FDA from drug companies, that’s easily digestible, right?
HofKata: Cochrane authors report that it would take 2 FTEs 14 months to analyze, and found things never addressed in the papers. #ACEP12GruntDoc
The papers mean the studies that get publishe in journals. Not getting the whole story.
HofKata: Cochrane cont: the US FDA wouldn’t give the data, had to get from AUS. puts a lot of the publications in doubt. #ACEP12GruntDoc
Interesting.
This was about the new ‘high sensitivity’ troponins that are about to come out, for what reasons none of us in EM can discern, as it absolutely isn’t helpful…
Touché, I’ll remember that. “@JoeLex5: @gruntdoc You mean "low specificity troponins," of course.” #ACEP12GruntDoc
Thanks, but I just tweet it. The glory goes to the lecturers, some were phenomenal. “@fayazg99: @gruntdoc fantastic stuff!” #ACEP12GruntDoc
Great coverage! RT @gruntdoc: That ends the lectures for me for today. Hope you enjoyed my coverage.Doc Gurley
@docgurley Awww, shucks ma’am. *tips hat*.GruntDoc
Meeting the social media twitter and blog greats at #ACEP12 @emcrit @gruntdoc @drrwinters @movinmeat @EMDocBrett http://pic.twitter.com/D6dLKId3Alexei Wagner
@JoeLex5 s 3 rules of emergency medicine:1) the nurse can hurt you way more than you can hurt themGruntDoc
@JoeLex5 s 3 rules of emergency medicine:2) you will never waken someone with narcan that you will like more awake than asleepGruntDoc
@JoeLex5 s 3 rules of emergency medicine:3) the LP target is always 1cm deeper than you think.GruntDoc
@JoeLex5 s 3 rules of emergency medicine:4) bonus: if you really don’t want someone to elope, hide their shoes.GruntDoc
“@gruntdoc: All the twitterers from #ACEP12 in one place. The rest of you are safe. For now. http://pic.twitter.com/j8i2uwb0” Wish I was there….realEDdoc

An Elegantly Icky Solution

Entertaining and medical!

I’d love to shield the identify of the patient in this story. But I can’t, and you’ll understand why in a minute. It’s not that I’m worried about a HIPAA violation or a law suit. After all, the patient was my mother-in-law. She and my father-in-law – Pop Pop – have moved in with us . . . so they aren’t going to sue anybody. And while I hesitate to embarrass my soft-spoken “Mom Mom” with the details of this tale, I have to tell this story straight. Here goes.

via An Elegantly Icky Solution.

Sounds like something we need to try earlier.

Clostridium difficile colitis and you, a video tutorial

Learning can be fun!

Just say no to antibiotics you don’t need.

The ultra-awesome ZDoggmd.com

How large is a British watermelon?

You’ll probably regret asking.

A Las Vegas man who suffers from a rare condition that made his scrotum swell to 100 pounds is basking in the fame that his giant organ has brought him.

The watermelon-size scrotum Mr Warren carries between his legs has landed him on the Howard Stern Show and the Comedy Central program Tosh.0 and made him a local celebrity in his hometown.

via Wesley Warren Jr: Man with 100-pound scrotum REJECTS free $1m corrective surgery | Mail Online.

Emphasis added.

Here’s a family safe pic:

how large are British watermelons, again?

Okay, how large are British watermelons, anyway?

Our unrealistic views of death, through a doctor’s eyes – The Washington Post

I know where this phone call is going. I’m on the hospital wards, and a physician in the emergency room downstairs is talking to me about an elderly patient who needs to be admitted to the hospital. The patient is new to me, but the story is familiar:

via Our unrealistic views of death, through a doctor’s eyes – The Washington Post.

Very Well Done. #fb

HCC Blog calls it quits

Dear Readers,

It has been my pleasure over the last 4 years to blog on HCC-related topics and exchange ideas with many of you. I have learned a ton from everyone.

This is my last post and I anticipate retiring the blog by the end of the month.

via HCC Blog » hccblog.

Another good blogger taps out. Too bad.

The Worst Quackery of 2011: Battlefield Acupuncture – Forbes

So: the 2011 winner of the worst quackery award is: battlefield acupuncture. This bizarre practice, invented just 10 years ago, offers a trifecta of ills:

It offers no medical benefit and carries a real risk of harm for some patients.

The U.S. government is wasting tens of millions of dollars per year on it, and plans to increase its spending next year.

The patients are wounded combat veterans who have no choice about where to get treatment.

In battlefield acupuncture, the “doctor” (no competent doctor would do this) sticks needles into the patient’s ear to relieve pain.

via The Worst Quackery of 2011: Battlefield Acupuncture – Forbes.

Incredible. And infuriating.

(Found on Twitter, but I cannot recall who tweeted it).

Just Say No: FDA permits marketing of the first hand-held device to aid in the detection of bleeding in the skull

I read that headline and said, “Wow!, finally I won’t need to CT all those patients’ heads!”

FDA permits marketing of the first hand-held device to aid in the detection of bleeding in the skull

Helps to determine if immediate CT scan is needed

The U.S. Food and Drug Administration today allowed marketing of the first hand-held device intended to aid in the detection of life-threatening bleeding in the skull called intracranial hematomas, using near-infrared spectroscopy.

via Press Announcements > FDA permits marketing of the first hand-held device to aid in the detection of bleeding in the skull.

But then, wait, said I, is it any good? Apparently Not:

The FDA granted the de novo petition for the Infrascanner Model 1000 based on a review of data comparing results from 383 CT scans of adult subjects with Infrascanner scan results. The Infrascanner was able to detect nearly 75 percent of the hematomas detected by CT scan. When CT scans detected no hematoma, the Infrascanner detected no hematoma 82 percent of the time. The Infrascanner Model 1000, however, is not a substitute for a CT scan.

Anyone considering purchasing one of these based on those numbers? If so, I’ll sell you a random number generator for 1/2 of what they’re asking.

Stated another way, this device will miss more than 25% of intracranial hematomas that are present, and will tell you it’s there when it’s not 18% of the time.

Not ready for prime time. I feel bad for the detailers who are sent out to see this thing, and worse for the patients it’s used on.

 

Brought to my attention by @EMNews on twitter. (In case you missed it, I’m getting a lot of my bloggable stuff from Twitter. I don’t blog most of what I comment on. Imagine what you’re missing! Get to twitter, and follow me @gruntdoc).

How Doctors Die « Zócalo Public Square

Worth your time.

It’s Not Like the Rest of Us, But It Should Be

via How Doctors Die « Zócalo Public Square.

We Are All Criminals Now : PANDA BEAR, MD

Panda has resurfaced.

This is not a Panda that eats bamboo, but from all appearances feasts on spleens. Angry ones.

In fact, I was once texting while standing at the nursing station and some supervisor of something-or-another told me that cell-phones were not allowed and then looked on in helpless fury as I laughed and took his pictures to text to my friend. This is a good way to make enemies and I’m sure I’m going to be the first one up against the wall when “Papa Doc” Press Gainey is installed as out Great Leader and Ruler for Life but I did not come through the irritating hell of medical school and residency to be scolded by a bureaucrat like some wayward candy striper.

via We Are All Criminals Now : PANDA BEAR, MD.

I wish I wrote that well.

[AP] Doctor in nurse retaliation surrenders license | arafiles, retaliation, roberts – Odessa American Online

Update: 2 months in jail, then probation.

TO recap: Sheriff Roberts and County Attorney Tidwell got jail time for their role in this sordid misuse of power, and the doctor at the center of this mess now cannot practice medicine.

We’ll have to wait to see if he gets jail time from this.

[AP] Doctor in nurse retaliation surrenders license

November 04, 2011 4:19 PM

THE ASSOCIATED PRESS

AUSTIN A doctor accused of retaliating against two whistle-blowing West Texas nurses has agreed to surrender his medical license.

Dr. Rolando G. Arafiles signed an agreed order with the Texas Medical Board Friday stating he will stop practicing medicine.

via [AP] Doctor in nurse retaliation surrenders license | arafiles, retaliation, roberts – Odessa American Online.

Unfortunately, it’s still not over. Arafiles is still under indictment for aggravated perjury in Andrews County for his statements in the Nurse trial.

None of this restores the careers of the two nurses who were the victims of this.

World’s first malaria vaccine works in major trial | Reuters

Okay, like all of us I want an effective and safe malaria vaccine, and the tone of the article is hopeful. But…

The trial is still going on, but researchers who analyzed data from the first 6,000 children found that after 12 months of follow-up, three doses of RTS,S reduced the risk of children experiencing clinical malaria and severe malaria by 56 percent and 47 percent, respectively.

Loucq said widespread use of insecticide-treated bednets in the trial — by 75 percent of people taking part — showed that RTS,S can provide significant protection on top of other existing malaria control methods.

via World’s first malaria vaccine works in major trial | Reuters.

We’ll have to read the study, but if you’re mixing a change in bednet use AND a new vaccine, well, let’s hope they were measuring what they thought they were.

Obama Administration to Ban Asthma Inhalers Over Environmental Concerns

This underestimates the increased cost by a huge factor…

Remember how Obama recently waived new ozone regulations at the EPA because they were too costly? Well, it seems that the Obama administration is would rather make people with Asthma cough up money than let them make a surely inconsequential contribution to depleting the ozone layer:

Asthma patients who rely on over-the-counter inhalers will need to switch to prescription-only alternatives as part of the federal government’s latest attempt to protect the Earth’s atmosphere.

…But the switch to a greener inhaler will cost consumers more. Epinephrine inhalers are available via online retailers for around $20, whereas the alternatives, which contain the drug albuterol, range from $30 to $60.via Obama Administration to Ban Asthma Inhalers Over Environmental Concerns.

I added the bold in the quote to show where the increased cost is coming from: these people (who were buying these old inhalers without a prescription) are now going to have to see someone with a prescription pad, pay for that visit, and then go buy the more expensive inhalers.

The FDA made the prescription inhaler manufacturers take out the CFC’s a few years ago, and the prices of those inhalers went up substantially.

For the record, I think all these inhalers should be OTC: they’re safe and affective. Off the top of my head, 90% of the meds on the WalMart $4 list should be OTC as well.