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Biomarker Outperforms Gold Standard to Detect Brain Shunt Infections

Biomarker Outperforms Gold Standard to Detect Brain Shunt Infections

In a study of children with brain shunts at Children’s of Alabama, a University of Alabama at Birmingham investigational biomarker outperformed the current “gold standard” test for detecting bacterial infections in the shunts. This is the second potential diagnostic application for the biomarker, say Scott Barnum, Ph.D., professor, and Theresa Ramos, Ph.D., research associate, both of the UAB Department of Microbiology. The biomarker has already shown the ability to distinguish viral meningitis from bacterial meningitis. This is valuable because patients with viral meningitis usually get better in several weeks, while bacterial meningitis can kill within hours. Bacterial shunt infections are also potentially life-threatening and may require surgical removal of the shunt. A quick and accurate test for bacterial infection in brain shunts or meningitis would improve the quality and efficiency of patient care and patient outcomes. Such a test would also lower health care expenses by avoiding needless hospitalization and treatment. The UAB investigational biomarker has a pending international patent related to immunodiagnostics. The shunt study, which was headed by senior author James Johnston Jr., M.D., a UAB assistant professor in the Division of Pediatric Neurosurgery, Department of Neurosurgery who treats patients at Children’s of Alabama, and first author Ramos, was recently published in JCI Insight. Ventricular brain shunts — a drain from cavities in the brain to the abdomen — are the most common procedure to treat hydrocephalus, a condition of excess cerebrospinal fluid in the brain that affects 1 million people in the United States. The national health expenditures for shunts run about $2 billion a year. Studies have shown that one-eighth of shunts fail within 30...
Active Surveillance Trends for Prostate Cancer

Active Surveillance Trends for Prostate Cancer

According to current estimates, prostate cancer is the most frequently diagnosed cancer in men after skin cancer. About 220,800 new cases of prostate cancer are diagnosed each year in the United States, and more than 27,500 of these patients die from the disease. Studies indicate that more and more men diagnosed with low-risk prostate cancer are opting for active surveillance rather than aggressive treatment to avoid the potentially debilitating side effects associated with surgery and radiation, such as erectile and urinary dysfunction. Active surveillance involves routine PSA testing, regular office visits for physical examinations, and at least one additional prostate biopsy within a 2-year period.   An Important Comparison “There has been significant interest in the utilization of active surveillance for men with prostate cancer,” says Karim Chamie, MD. Despite this goal, few studies have examined the quality of surveillance for patients with prostate cancer. To address this research gap, Dr. Chamie and colleagues had a study published in Cancer that explored the intensity of surveillance among patients diagnosed with localized prostate cancer who opted for watchful waiting/active surveillance and compared it with those who received active treatment. The authors examined records of 37,687 men aged 65 and older who were diagnosed with prostate cancer between 2004 and 2007 and followed them through 2009. “Less than 5% of men diagnosed with prostate cancer who did not undergo aggressive treatment were being monitored appropriately,” says Dr. Chamie. When compared with patients who were receiving active treatment, those undergoing watchful waiting/active surveillance were less likely to receive PSA testing and to attend office visits within the 2 years after diagnosis.  ...
Defibrillator Use After Myocardial Infarction in Older Adults

Defibrillator Use After Myocardial Infarction in Older Adults

According to current estimates, more than 350,000 people experience sudden cardiac death in the United States each year. Patients with low ejection fraction (EF) are at risk for sudden cardiac death, and clinical trials have established that implantable cardioverter-defibrillators (ICDs) improve survival for these individuals. Guidelines recommend ICDs as primary prevention for patients with an EF of 35% or lower if they do not improve after being treated with optimal medical therapy for at least 40 days after a myocardial infarction (MI). Studies suggest that ICDs are underutilized in routine clinical practice, especially after a patient suffers an MI. The incidence of MI and the resulting sequelae from these events increase with age. The benefit of ICDs as primary prevention is controversial among older patients because this population is underrepresented in clinical trials. Clinicians may be uncertain about the efficacy of ICDs in an older patient population and must also consider treatment goals and procedural risks. These factors may discourage the use of ICDs among older adults.   A Closer Look In a retrospective study published in JAMA, Sean D. Pokorney, MD, MBA, and colleagues examined data from Medicare beneficiaries with an EF of 35% or less after MI. Participants were treated at 441 U.S. hospitals between 2007 and 2010, but were excluded if they had a prior ICD implant. The investigators evaluated the incidence and hospital variation of 1-year ICD implantation after MI among potentially eligible patients. They also examined factors that were linked to 1-year ICD implantation and compared 2-year mortality between patients with and without ICDs. The study was unique in that it evaluated the use...
Breaking News: FDA advises testing for Zika virus in all donated blood

Breaking News: FDA advises testing for Zika virus in all donated blood

As a further safety measure against the emerging Zika virus outbreak, today the U.S. Food and Drug Administration issued a revised guidance recommending universal testing of donated Whole Blood and blood components for Zika virus in the U.S. and its territories. “There is still much uncertainty regarding the nature and extent of Zika virus transmission,” said Peter Marks, M.D., Ph.D., director of the FDA’s Center for Biologics Evaluation and Research. “At this time, the recommendation for testing the entire blood supply will help ensure that safe blood is available for all individuals who might need transfusion.” The revised guidance of those issued in February recommends that all states and U.S. territories screen individual units of donated Whole Blood and blood components with a blood screening test authorized for use by the FDA under an investigational new drug (IND) application, or a licensed test when available. Alternatively, an FDA-approved pathogen-reduction device may be used for plasma and certain platelet products. Recommendations The following recommendations are intended to reduce the risk of ZIKV transmission by blood and blood components. The recommendations apply to the collection of all Whole Blood and blood components5in the United States and its territories. If, based upon the available scientific evidence, the risk of ZIKV transmission by blood and blood components significantly changes, FDA may update these recommendations as warranted. In making this determination, FDA will consider available epidemiologic and other scientific evidence. A. Testing and Pathogen Reduction We recommend the following: 1) Test all donations collected in the U.S. and its territories with an investigational individual donor nucleic acid test (ID-NAT) for ZIKV under an investigational...
Minorities & Adnominal Pain Care in EDs

Minorities & Adnominal Pain Care in EDs

Acute abdominal pain is one of the most common reasons for patients to visit the ED, but few studies have examined if there are racial and ethnic disparities for how this pain is managed. Prior research focusing on the management of acute abdominal pain in the ED setting has yielded conflicting results. Adil H. Haider, MD, MPH, FACS, and colleagues had a study published in Medical Care that sought to gain a better understanding of the potential racial and ethnic differences in the use of analgesics in the ED to manage this pain. Using data from the CDC’s National Hospital Ambulatory Medical Care Survey, the investigators analyzed patients aged 18 and older who were seen for non-traumatic abdominal pain at 350 EDs over a span of about 5 years across the United States. Of the more than 6,700 ED visits included in the analysis, 61.2% of the patients were white, 20.1% were black, 14.0% were Hispanic, and 4.7% belonged to other racial or ethnic groups. The study group compared rates of analgesic medication use among these racial and ethnic groups, and then accounted for differences in patient and hospital characteristics.   Observed Disparities According to the results, white patients were most likely to receive any analgesic medication (56.8%) when compared with Hispanic patients (52.8%), black patients (50.9%), and people who were classified as other racial or ethnic groups (46.6%). “Black patients were the least likely to receive narcotic analgesics despite having similar rates of severe pain as other racial and ethnic groups,” says Dr. Haider. After adjusting for other factors, blacks, Hispanics, and patients of other races and ethnicities...
A Program to Rapidly Test for Hepatitis C

A Program to Rapidly Test for Hepatitis C

An ED screening and diagnostic testing program found a high prevalence of hepatitis C. Results suggest that continued efforts are needed to develop and evaluate policies for ED-based hepatitis C screening.   Hepatitis C virus affects about 3 million Americans and is a leading cause of end-stage liver disease, hepatocellular carcinoma, and liver transplants. National recommendations endorse using risk-based hepatitis C screening, which includes screening patients with a history of injection drug use as well as one-time screenings of “baby boomers,” or patients born between 1945 and 1965. Current data suggest that the baby boomer generation accounts for 75% of people infected with hepatitis C, but 1.25 to 1.75 million of them are unaware that they are infected. “Hepatitis C screening has long been considered impractical for EDs, but advances in rapid testing technology, the development of new therapies, and improvements in reimbursement for selective screening has created new opportunities to implement these screenings in the ED setting,” says Douglas A.E. White, MD. Despite these advances, clinical experience with hepatitis C virus screening in EDs is limited.   Testing a New Program Recently, Dr. White and colleagues at Alameda Health System implemented an ED-based screening program for both HIV and hepatitis C into the triage process according to recommendations from the CDC and United States Preventive Services Task Force. As an adjunct to screening, physicians could order HIV and hepatitis C testing when clinically indicated. For a study published in Annals of Emergency Medicine, the research team reported results of the hepatitis C portion of this screening program. The primary objective was to determine the prevalence of hepatitis C...
Physical Activity & HF Prevention

Physical Activity & HF Prevention

Current guidelines from the American Heart Association (AHA) and other groups for adults recommend a minimum of at least 150 minutes of moderate-intensity aerobic physical activity (PA) per week. Despite this recommendation, some studies have suggested that even more PA can better protect patients from adverse cardiac events. Prior studies have shown that there appears to be an inverse association between PA and risk of heart failure (HF). “The role of PA in coronary heart disease has been studied comprehensively, but few analyses have focused exclusively on the quantitative relationship between the amount—or specific dose—of regular PA and the risk of HF,” says Ambarish Pandey, MD. In a study published in Circulation, Dr. Pandey and colleagues pooled data from 12 studies from United States and Europe. The analysis collectively included 370,460 patients with varying levels of PA at baseline and 20,203 HF events over an average of follow-up about of 15 years. PA was measured by self-reported levels of activity using standard questionnaires. According to the research team, this approach provided an opportunity to assess the dose-response relationship between PA and HF risk in the general population.   More Is Better “Our findings suggest a dose-dependent inverse association between PA levels and risk for HF such that  patients who had the highest levels of PA had a significantly lower risk of developing HF than those with the lowest levels of PA,” says Dr. Pandey. This relationship was consistent across all age, sex, race, and geographic location based subgroups studied. Participants who engaged in guideline recommended minimum levels of PA—150 minutes of moderate intensity PA per week—had modest reductions in...
CME: Needle Exchange Cuts HIV Transmission

CME: Needle Exchange Cuts HIV Transmission

Research has shown that needle exchange programs can effectively lower the risk of HIV transmission among injection drug users. In 1988, Congress passed legislation prohibiting the use of federal funding for any activities associated with needle exchange. While states and localities were able to use their own revenue to fund such programs, in 1998, the United States Congress passed legislation prohibiting the District of Columbia from using its municipal revenue to fund these programs. Until Congress lifted the ban in 2007, these policies limited access to needle exchange in the city.   A Big Impact “Following the policy change in Washington, DC, it was important to determine whether or not it was going to make a difference,” says Monica S. Ruiz, PhD, MPH. “Clinicians need to know the impact of this policy change on people’s ability to access services.” For a study published in AIDS and Behavior, Dr. Ruiz and colleagues used existing surveillance data from the Department of Health in Washington, DC from September 1996 through December 2011 to project the impact of needle exchange access on the number of new HIV cases associated with injection drug use (IDU). “We used mathematical modeling to estimate the number of infections there would have been without the policy change in order to see if there was a significant difference between that and the number of cases that actually occurred,” Dr. Ruiz explains. “Interrupted time series analyses were used to control for other factors, such as HIV-focused educational campaigns.” The investigators estimated that about 120 infections were averted as a result of the policy change. In the 2 years following the...
Why can’t more doctors apologize for mistakes?

Why can’t more doctors apologize for mistakes?

“The unintended consequences of these seemingly well-intentioned laws are doctors who can’t apologize for harming their patients even if they want to…” A recent JAMA article about disclosing medical error described a hypothetical situation involving a dermatologist who, after completing skin biopsies on two patients, discovered that the instruments had not been sterilized. He wondered if he should tell the patients and what he should say. The authors of the piece said patients should be told what happened, and the doctor should apologize. All concerned parties should review the error, and quality assurance, risk management, and the malpractice insurance carriers should be informed. The advice is sound and should be followed by anyone who identifies a medical error that could potentially harm a patient. The authors chose a rather simple scenario. It is very easy for a physician to apologize for an error committed by someone else. It’s a bit different if the doctor is the one who made the mistake. “37 states and the District of Columbia have laws excluding apologies from admissibility in court”   I support disclosing fully, expressing sympathy, and apologizing and did so myself when I felt I was responsible for what happened. But a couple of issues are unresolved. The JAMA article states “healthcare systems must develop a safety culture. An essential element of this is a culture that fosters open reporting of errors, assists clinicians in disclosing errors, and provides emotional support to stressed personnel involved with the error.” Four years ago I wrote that most hospitals had not established the so-called “just culture,” and I don’t believe much has changed since...
CDC August Update: Zika Case Counts in the U.S.

CDC August Update: Zika Case Counts in the U.S.

Laboratory-confirmed Zika virus disease cases reported to ArboNET by state or territory (as of August 24, 2016) Zika virus disease and Zika virus congenital infection are nationally notifiable conditions. This update from the CDC Arboviral Disease Branch includes provisional data reported to ArboNET for January 01, 2015 – August 24, 2016. US States Locally acquired mosquito-borne cases reported: 29 Travel-associated cases reported: 2,487 Laboratory acquired cases reported:  1 Total: 2,517 Sexually transmitted: 22 Guillain-Barré syndrome: 7 US Territories Locally acquired cases reported: 8,968 Travel-associated cases reported: 43 Total: 9,011* Guillain-Barré syndrome: 26 *Sexually transmitted cases are not reported for US territories because with local transmission of Zika virus it is not possible to determine whether infection occurred due to mosquito-borne or sexual transmission. In the U.S. territories, there have been 8,968 locally acquired Zika cases and 43 travel-associated cases, for a total of 9,011. Zika & Pregnancy 584 pregnant women in the U.S. have lab evidence of Zika virus infection 812 pregnant women in the U.S. territories have lab evidence of Zika virus infection 6 babies in the U.S. have been born with Zika-related birth defects 5 pregnancy losses with birth defects linked to Zika in the U.S.  ...
Post-Operative Clostridium difficile Infection Among Veterans Health Administration Patients

Post-Operative Clostridium difficile Infection Among Veterans Health Administration Patients

Recent research has shown that Clostridium difficile infection (CDI) is a growing cause of morbidity and mortality in the United States and is associated with longer hospital lengths of stay (LOS) and higher hospital costs. “CDI has also been shown to be a significant complication for surgical patients,” says William Gunnar, MD, JD. Data show that the healthcare–associated burden of CDI is increasing among surgical patients and varies among types of surgery. Among surgical patients, CDI has been linked to longer mechanical ventilation, longer ICU and hospital LOS, and higher mortality. The 134 Veterans Health Administration (VHA) Surgery Programs throughout the U.S. perform an estimated 400,000 surgical procedures each year. In 2007, the VHA modified the established VA Surgical Quality Improvement Program (VASQIP) to begin  collecting 30-day postoperative CDI data from eligible non-cardiac surgical procedures. For a retrospective observational study published in JAMA Surgery, Dr. Gunnar and colleagues documented CDI incidence in the VHA from fiscal year 2010 through 2013 across different surgical procedures. They also identified risk factors associated with CDI and determined the impact of CDI on postoperative mortality, morbidity, and hospital LOS.   Examining New Data Results of the study showed that the postoperative CDI rate was 0.4% per year, unchanged throughout the study period, and varied by the VHA Surgery Program and surgical specialty. The 30-day CDI rates were higher in emergency procedures, operations with greater complexity and higher relative value units, and those with a contaminated or infected wound classification. Patients with postoperative CDI were significantly older, were more frequently hospitalized after surgery (59.9% vs 15.4%), and had longer preoperative hospital LOS (9.1 days vs 1.9...
ACIP  Immunization Practices: 2016–17 Influenza Season

ACIP Immunization Practices: 2016–17 Influenza Season

There are 4 primary changes and updates in the recommendations for this influenza season. Find out what they are. This report updates the 2015–16 recommendations of the Advisory Committee on Immunization Practices (ACIP) regarding the use of seasonal influenza vaccines. Routine annual influenza vaccination is recommended for all persons aged ≥6 months who do not have contraindications. Influenza viruses typically circulate widely in the United States annually, from the late fall through early spring. Although most persons who become infected with influenza viruses will recover without sequelae, influenza can cause serious illness and death, particularly among older adults, very young children, pregnant women, and those with chronic medical conditions (1–3). During 31 seasons from the 1976–77 through the 2006–07 season, estimated influenza-associated deaths ranged from approximately 3,300 to 49,000 annually. ACIP provides annual recommendations for the prevention and control of influenza. The ACIP Influenza Work Group meets by teleconference once to twice per month throughout the year. Work Group membership includes several voting members of ACIP and representatives of ACIP Liaison Organizations.* Discussions include topics such as influenza surveillance, vaccine effectiveness and safety, vaccine coverage, program feasibility, cost-effectiveness, and vaccine supply. Presentations are requested from invited experts, and published and unpublished data are discussed. Updates to the recommendations described in in this document are of three types: 1) the vaccine viruses included in the 2016–17 seasonal influenza vaccines, 2) new vaccine licensures and approvals, and 3) an interim recommendation that live attenuated influenza vaccine (LAIV4) not be used during the 2016–17 season. Primary Changes and Updates in the Recommendations Routine annual influenza vaccination of all persons aged ≥6 months...
Outpatient bloodstream infections costly for pediatric transplant and cancer patients

Outpatient bloodstream infections costly for pediatric transplant and cancer patients

Pediatric stem cell transplant and cancer patients often are discharged from the hospital with an external central venous line for medications that parents or other caregivers must clean and flush daily to avoid potentially life-threatening infections. If an outpatient develops a bloodstream infection associated with the central line, research from Dana-Farber/Boston Children’s Cancer and Blood Disorders Center finds, the median charges to treat it total $37,000 for a hospital stay of six days for young patients whose disease treatments have weakened their immune systems and infection-fighting abilities. The results, published online by Pediatric Blood & Cancer, are part of the second phase of a collaborative effort among children’s hospitals to reduce central-line-associated bloodstream infections or CLABSIs. In the first phase, members of the Children’s Hospital Association Childhood Cancer and Blood Disorders Network reduced inpatient CLABSIs by 28 percent in less than three years, according to results published in 2014 in Pediatrics. Because a large portion of pediatric oncology and stem cell transplant patients’ care occurs in ambulatory settings, the consortium is now focusing on understanding and reducing CLABSIs that originate in the home, between outpatient clinic visits. “This issue has resonance beyond the pediatric stem cell transplant and oncology patient population,” says Amy Billett, MD, senior author of the paper and director of safety and quality at Dana-Farber/Boston Children’s. “At a time when many aspects of care are being shifted to the home and of heightened attention to safety and cost, this is the new frontier. What we learn about preventing outpatient bloodstream infections in these patients could have broad relevance.” To determine the economic and hospitalization impact of...
Updated IDSA Guideline on Valley Fever Published in CID

Updated IDSA Guideline on Valley Fever Published in CID

Every year, an estimated 150,000 people are infected with coccidioidomycosis, originally nicknamed San Joaquin Valley fever, and about 160 die, note updated guidelines by IDSA on Valley fever, published in Clinical Infectious Diseases. Valley fever is endemic in desert regions ranging from western Texas, Arizona and northern Mexico to the central San Joaquin Valley in California, as well as an area in south central Washington State. Some areas in Central and South America harbor the fungi as well. The fungi that cause the infection – Coccidioides immitis and Coccidioides posadasii – live in desert soil. The fungal spores become airborne when wind blows the dust around, are easily inhaled and settle deep in the lungs, causing pneumonia. The updated guidelines are now much more geared towards primary care clinicians who typically are the first to see and treat patients with pneumonia, but who may overlook valley fever as a potential cause of the illness and prescribe unnecessary tests and therapy. While 60 percent of people with valley fever have a mild infection with few or no symptoms, others may have fever, fatigue, cough, headache, chest pain, skin rash and joint aches. In extreme cases it can cause severe pneumonia, holes in the lungs (cavities), lung nodules, skin sores and meningitis. Pregnant women and people who are immunosuppressed (those with HIV, who had an organ transplant or are taking medication for rheumatologic disease) or have diabetes have a very high risk of complications. Guideline Highlights 1) Fifty to 80 percent of people infected don’t require medication. Their immune systems eventually will rid their bodies of the infection and they will...
Yale Team discovers how Zika virus causes fetal brain damage

Yale Team discovers how Zika virus causes fetal brain damage

The findings suggest that Zika virus might be susceptible to existing antiviral drugs that may prevent disruption to the developing nervous system, said the researchers. Infection by the Zika virus diverts a key protein necessary for neural cell division in the developing human fetus, thereby causing the birth defect microcephaly, a team of Yale scientists reported Aug. 24 in the journal Cell Reports. The findings suggest that Zika virus might be susceptible to existing antiviral drugs that may prevent disruption to the developing nervous system, said the researchers. One of the frightening side-effects of Zika virus infection in pregnant women is the risk of fetal microcephaly, in which babies are born with abnormally small brains. The multidisciplinary collaboration of Yale scientists revealed that Zika virus kills stem cells in the brain and disrupts the process of creating brain cells. An analysis shows that the virus diverts a form of the protein TBK1 from its primary job of organizing cell division to the mitochondria, the cell’s power pack, where it helps initiate an immune response. Lacking the protein at the site of cell division, cells die instead of forming new brain cells, resulting in microcephaly. The data suggest this mechanism may also contribute to microcephaly associated with other common congenital viral infections. Researchers note that an existing FDA-approved drug, Sofosbuvir, showed promise in preventing Zika virus infection of neural stem cells in laboratory culture and also seems to keep phospho-TBK1 involved in cell division. More study needs to be conducted to prove the efficacy of the drug as a medical therapy for Zika virus, the authors said. “There is an...
Serological Response to Treatment of Syphilis with Doxycycline Compared with Penicillin in HIV-infected Individuals.

Serological Response to Treatment of Syphilis with Doxycycline Compared with Penicillin in HIV-infected Individuals.

Acta dermato-venereologica 96(6) 807-11 doi 10.2340/00015555-2289 Abstract Serological response to treatment of syphilis with orally administered doxycycline or intramuscularly administered penicillin was assessed in patients with concurrent HIV. All HIV-infected individuals diagnosed with syphilis attending 3 hospitals in Copenhagen, Denmark were included. Odds ratios (ORs) with 95% confidence intervals (CI) associated with serological outcome were modelled using propensity-score-adjusted logistic regression analysis. In total, 202 cases were treated with doxycycline or intramuscular penicillin. At 12 months, serological failure was observed in 12 cases (15%) treated with doxycycline and in 8 cases (17%) treated with penicillin (OR 0.78 (95% CI 0.16-3.88), p = 0.76). The serological cure rate at 12 months was highest in patients with primary syphilis (100%), followed by patients with secondary (89%), early latent (71%) and late latent (67%) syphilis (p = 0.006). In conclusion, this study provides evidence for the use of doxycycline as a treatment option when treating a HIV-infected population for...
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