6. …but people still expect them to show up the second they ring the call bell.
7. Sometimes they’re working so hard, they can go entire shifts without eating, drinking water, or sitting.
Lunch break? What’s that?
Wed, Jan 21, 2015 @ 11:17 AM
Lunch break? What’s that?
Mon, Jan 05, 2015 @ 11:35 AM
By Catharine Paddock PhD
The rise of drug-resistant bacteria - such as MRSA - is making it increasingly difficult to control even common infections like pneumonia or urinary tract infections with standard antibiotics. After repeated exposure, the bugs mutate into strains that are immune to the drugs that once killed them.
There is clearly a desperate need for new drugs to fight these superbugs. But there is also another option - to extend the useful life of a drug. Now, researchers have developed a computer algorithm that can help in this area.
Imagine the war against a superbug as a chess game, with each move that your opponent makes being a mutation in the superbug that makes it more drug-resistant.
To stand a good chance of winning, it helps to anticipate your opponent's most likely counter-moves.
Now, a team of researchers - including members from Duke University in Durham, NC - has developed a computer algorithm that stands a good chance of beating a superbug at its own game.
The software - called OSPREY - predicts the most likely mutations that a bug develops in response to a new drug before the drug is even given to patients.
Writing in the Proceedings of the National Academy of Sciences, the team describes how they tested OSPREY with the superbug MRSA (methicillin-resistant Staphylococcus aureus).
The researchers programmed the algorithm to identify the genetic changes that MRSA would have to undergo in order to become resistant to a promising new class of experimental drug. And when they exposed MRSA to the new drugs, they found some of the genetic changes the software had predicted actually arose.
"This gives us a window into the future to see what bacteria will do to evade drugs that we design before a drug is deployed," says author Bruce Donald, a professor of computer science and biochemistry at Duke.
The team hopes the approach they are developing will give drug designers a head start in the race against superbugs, as co-author and Duke graduate student Pablo Gainza-Cirauqui explains:
"If we can somehow predict how bacteria might respond to a particular drug ahead of time, we can change the drug, or plan for the next one, or rule out therapies that are unlikely to remain effective for long."
Resistant forms of Staphylococcus aureus now kill 11,000 people in the US every year - more than HIV. In 1975, around 2% of infections caused by the bacterium were resistant to treatment - rising to 29% in 1991 - and now the proportion is 55%.
Depending on the drug, it can take up to 20 years for resistant strains to emerge. Sometimes it only takes 1 year.
The team believes approaches like OSPREY beat the current method where scientists have to look up "libraries" of previously observed resistance mutations - an approach that is not necessarily satisfactory for predicting future mutations. Prof. Donald explains:
"With a new drug, there is always the possibility that the organism will develop different mutations that had never been seen before. This is what really worries physicians."
OSPREY - which stands for Open Source Protein REdesign for You - is based on a protein design algorithm. It identifies changes to DNA sequences in the bacteria that would enable the resulting protein to block the drug while still being able to work normally.
The team tested OSPREY with a new class of drugs called propargyl-linked antifolates that attack a bacterial enzyme called dihydrofolate reductase (DHFR), used for building DNA and other tasks. The drugs - still to be tested in humans - are showing promise as a new treatment for MRSA infections.
Using OSPREY, the team came up with a ranked list of possible mutations. They picked out four - none of which had been seen before.
When they treated MRSA with the new drugs, they found more than half of the bacteria that survived carried the mutation they predicted would give the organism the greatest amount of resistance: a tiny change in the bacterial DNA that reduced the effectiveness of the new drugs by 58%.
"The fact that we actually found the new predicted mutations in bacteria is very exciting," Prof. Donald says, adding that the approach could be expanded to anticipate the bug's responses more than one move ahead:
"We might even be able to coax a pathogen into developing mutations that enable it to evade one drug, but that then make it particularly susceptible to a second drug, like a one-two punch."
The team is now enhancing OSPREY to predict resistance mutations to drugs designed to treat E. coli and Enterococcus infections.
They believe OSPREY will be useful for predicting drug resistance in cancer, HIV, flu and other diseases where culturing resistant strains is harder than it is with bacteria.
Prof. Donald and colleagues are developing OSPREY in open source format so it is freely available for any researcher to use.
In September 2014, Medical News Today learned about a study that showed how an old drug may lead to a potential new class of antibiotics . The study showed that lamotrigine - currently used as an anticonvulsant - can inhibit the assembly of ribosomes in bacteria.
Mon, Jan 05, 2015 @ 11:20 AM
By Sanjay Gupta
After an incredibly busy 2014, during which health stories like Ebola, new food nutrition label rules, and the debate about the right to die sparked by Brittany Maynard dominated the headlines, it's now worth looking at what we may be covering in the next 12 months.
So, in no particular order, here's my take on the nine big health stories to watch for, and the questions they will likely raise, in 2015.
Doctor shortage. There aren't nearly enough of us to care for the U.S. population. By some estimates, the country is already short of tens of thousands of doctors, a problem that will only get worse as the demand for care increases with our aging population. That could mean longer wait times for you when you need to make an appointment. But that also means policy makers will have to consider questions like: Is there a way to increase the number of residency training slots? Are there other health care professionals who can reasonably fill in the gaps? Will the nation's quality of care go down? How can the country avoid a situation where only the wealthy will be able to afford quality care?
Hospital errors and infections. Hospital mistakes and infections are still one of the leading causes of preventable death (indeed, some studies suggest "hospital-acquired conditions" kill more people than car accidents or diabetes).
True, a recent study showed the rate did get better this year, saving tens of thousands of lives. But what else can hospitals do to prevent these mistakes and infections? Can technology like e-prescriptions and electronic health records prevent problems that most often occur: the mistakes caregivers make with a patient's drugs?
Antibiotic resistance. It has been called public health's "ticking time bomb."The World Health Organization calls antibiotic resistant infections one of the biggest threats to global health today. Each year, at least 2 million peoplebecome infected with bacteria that are resistant to antibiotics, and at least 23,000 people die each year. Most of these deaths happen in health care settings and in nursing homes. How can we respond? Well, research teams around the world have already started searching for the next generation of infection-fighting drugs. But it remains to be seen if time will run out, sending us back to the beginning: a time before antibiotics, where even a cut that becomes infected could kill you.
More do-it-yourself health care: apps and technology. Technology has made do-it-yourself patient care much easier. This goes beyond just a patient's ability to look up their symptoms online. There are apps to help with autism, apps that can simulate a check-up, apps that can monitor conditions. Wearables can motivate you to walk more or sleep more or check a diabetic's glucose level. But how does all this helping yourself make your health care better? How much is too much? And what does this mean for your privacy? After all, the health care industry accounted for 43% of all major data breaches in 2013. Meanwhile, although 93% of health care data requires protection by law, some surveys suggest only 57% of it is "somewhat protected." What could this mean for your privacy and personal information if security doesn't get better?
Food deserts. While not everyone agrees with the term food desert, the USDA still estimates 23.5 million people live in these urban neighborhoods and rural towns with limited access to fresh, affordable, healthy food. Without grocery stores in these areas, residents often have to rely on fast food and convenience stores that don't stock fresh produce. It takes a real toll on their health. Families who live in these areas struggle more with obesity and chronic conditions, and they even die sooner than people who live in neighborhoods with easy access to healthy food. More farmers markets are now accepting food stamps and many nonprofits have stepped in to try to bring community gardens and healthy food trucks to these areas, but so far it's not enough. Will cities offer incentives to grocery store chains to relocate to these neighborhoods? How else can this system be helped?
Caregivers for the aging population. We are heading into a kind of caregiver crisis. The number of people 65 years and older is expected to rise 101%between 2000 and 2030, yet the number of family members who can provide care for these older adults is only expected to rise 25%. This raises a series of related questions, not least who is going to step up to fill the gaps? Will cities that don't traditionally have strong public transportation systems add to their routes? Will developers create more mixed-use buildings to make shopping and socializing easier to access? Could the government create a kind of caregiver corps that could check in on the isolated elderly? Who will pay for this expensive kind of safety net?
The cost of Alzheimer's. Currently about 5.2 million Americans have Alzheimer's. That number is expected to double every 20 years. With a cure some way off, what can be done to ease the emotional and financial burden on families and communities affected by the disease? The Alzheimer's Association predicts that by 2050, U.S. costs for care will total $1.2 trillion, making it the most expensive condition in the nation. How will we be able to afford the costs of caring for this population? What can the country do to achieve the goal the White House set for preventing and effectively treating Alzheimer's by 2025?
Marijuana. With the growing acceptance of weed, we can expect that more laws will change to allow medical and recreational use of marijuana. How will the rest of the laws in this country adjust? For instance, Washington state is coming up with a Breathalyzer-type device to check if drivers are high. But it will be interesting to see how readily available these devices are going to be. Will legalization improve the scientific understanding of the long-term consequences of the drug? What other uses could this drug have to help those who may need pain relief most?
Missing work-life balance. Americans spend more time on the job than most other developed countries. We don't get as much vacation, we don't take what vacation we have, and we are prone to working nights and weekends. This stress has a negative impact on Americans' health. What are companies doing to help? What technology can change this phenomenon? Will millennials who say work-life balance is a bigger priority than other generations rub off on the rest of us? What can we personally do to find a better balance?
We may not be able to answer all these questions in 2015, but we sure will try. And the health team and I look forward to exploring these issues with you in the coming New Year.
Topics: life, work, 2015, marijuana, New Year, doctor shortages, antiobiotic resistance, food deserts, caregivers, apps, technology, health, healthcare, nurse, doctors, population, Alzheimer's, medicine, treatment, hospitals, Americans
Mon, Dec 22, 2014 @ 01:15 PM
Between 1990 and 2013, global life expectancy increased by nearly 5.8 years in men and 6.6 years in women, according to a new analysis of the Global Burden of Disease Study 2013 published in The Lancet.
"The progress we are seeing against a variety of illnesses and injuries is good, even remarkable, but we can and must do even better," says lead author Dr. Christopher Murray, professor of Global Health at the University of Washington.
"The huge increase in collective action and funding given to the major infectious diseases such as diarrhea, measles, tuberculosis, HIV/AIDS and malaria has had a real impact," he says.
"However, this study shows that some major chronic diseases have been largely neglected but are rising in importance, particularly drug disorders, liver cirrhosis, diabetes and chronic kidney disease."
The analysis suggests that life expectancies in high-income regions have been increased due to falling death rates from most cancers - which are down by 15% - and cardiovascular diseases - which are down by 22%.
In low-income countries, rapidly declining death rates for diarrhea, lower respiratory tract infections and neonatal disorders have boosted life expectancy.
Despite the increases in global life expectancy by nearly 5.8 years in men and 6.6 years in women, some causes of death have seen increased rates of death since 1990.
These increased causes of death include:
The report also points to one notable global region where life expectancy is not increasing. Deaths from HIV/AIDS have erased more than 5 years of life expectancy in sub-Saharan Africa, say the authors. HIV/AIDS remains the greatest cause of premature death in 20 of the 48 sub-Saharan countries.
Since 1990, years of life worldwide lost due to HIV/AIDS is reported as having increased by 334%.
In Syria, war is the leading cause of premature death - the conflict caused an estimated 29,947 deaths in 2013, and up to 54,903 and 21,422 deaths in each of the preceding 2 years.
Countries that the authors consider to have made "exceptional gains in life expectancy" over the past 23 years include Nepal, Rwanda, Ethiopia, Niger, Maldives, Timor-Leste and Iran - where, for both sexes, life expectancy has increased by more than 12 years.
Life expectancy at birth in India increased from 57.3 years for men and 58.2 years for women in 1990 to 64.2 years and 68.5 years, respectively, in 2013. The authors say that India has made "remarkable progress" in reducing deaths, with the death rates for children dropping 1.3% per year for adults and 3.7% per year for children.
The report also welcomes dramatic drops in child deaths worldwide over the study period. In 1990, 7.6 million children aged 1-59 months died, but this death rate was down to 3.7 million by 2013.
Igor Rudan and Kit Yee Chan, from the Centre for Population Health Sciences and Global Health Academy at the University of Edinburgh Medical School in the UK, write in a linked comment:
"Estimates of the causes of the global burden of disease, disability, and death are important because they guide investment decisions that, in turn, save lives across the world.
Although WHO's team of experts have been doing fine technical work for many years, its monopoly in this field had removed incentives to invest more time and resources in continuous improvement [...] the competition between WHO and the GBD [Global Burden of Disease Study] has benefited the entire global health community, leading to converging estimates of the global causes of death that everyone can trust."
Wed, Dec 17, 2014 @ 11:50 AM
Chickenpox befell Angelina Jolie this week, preventing the actress-turned-director from attending the premiere of her new film.
Meanwhile, an outbreak of mumps has hit the National Hockey League, sidelining more than a dozen players and two referees.
These are considered kids' diseases. Most adults have vivid, fretful childhood memories of standing in line to get vaccinations that they expected to provide lifetime protection.
Why, then, are these prominent adults -- and scores of others -- coming down with these infections?
Mainly, it comes down to two factors, experts say.
Vaccination rates have declined among children in some parts of the United States, increasing everyone's risk of exposure to virulent diseases like chickenpox, measles, mumps and whooping cough, said Dr. Aaron Glatt, a spokesman for the Infectious Diseases Society of America.
"These vaccines are not perfect," said Glatt, who's also executive vice president of Mercy Medical Center in Rockville Centre, N.Y. "If you don't have a perfect vaccine and you couple that with a less-than-ideal number of people getting it, then if one person gets it then it's more likely to spread to others."
On top of that, even adults who got their shots as kids are at risk of contracting these diseases once exposed to them, because the protection provided by childhood vaccinations can fade over time.
"You can be vaccinated for something and have antibodies that wane over time or disappear entirely," said Dr. Len Horovitz, an internist and lung specialist at Lenox Hill Hospital in New York City. "You can have intermittent immunity, or no immunity."
America's public health defense against infectious diseases is built on a concept called "herd immunity," Glatt explained. If enough people are vaccinated against diseases like chickenpox, influenza, mumps and whooping cough, then even those who aren't vaccinated benefit because those who are immune can't spread the disease.
Skepticism over the effectiveness and safety of vaccines has caused vaccine rates to decline in some parts of the country, Horovitz and Glatt said. In those locations, adults with waning or imperfect immunity could fall prey to childhood infectious diseases, particularly if there's an outbreak.
"There is less vaccination going on than there was previously," Glatt said. "These childhood diseases have not gone away, and there is a strong anti-vaccine lobby that plays a role in people's decision to have their children vaccinated."
Since the early 1980s, there has been an overall increasing trend of whooping cough in the United States, said Angela Jiles, a spokeswoman for the federal Centers for Disease Control and Prevention.
Between Jan. 1 and Aug. 16 of this year, the CDC received reports of 17,325 cases of whooping cough, a 30 percent increase from the same time period in 2013 and the most cases seen in six decades, Jiles said.
California is experiencing its worst outbreak of whooping cough in seven decades.
There also have been more reported mumps cases in the United States this year, due to some larger outbreaks, according to the CDC. A reported 1,078 people have contracted mumps in 2014, compared with 438 the year before. In 2006 -- the worst year in recent history -- there were 6,584 cases of mumps, largely due to outbreaks on college campuses, according to the CDC.
No one has said how Jolie might have contracted chickenpox, but many of the NHL players appear to have gotten mumps from each other, despite efforts by the hockey league to get players vaccinated.
A single dose of mumps vaccine is about 80 percent effective, and two doses is about 90 percent effective, Amy Parker Fiebelkorn, an epidemiologist with the CDC's measles, mumps, rubella and polio team, told The New York Times.
"There is no vaccine that's 100 percent effective," Fiebelkorn said. "There is some margin for fully vaccinated individuals to still be infected with mumps if they're exposed to the virus."
Unfortunately, adults who contract these diseases are in for a rougher ride than children. They are more likely to develop serious complications, and are at higher risk of death, Glatt and Horovitz said.
These viruses also can increase a person's risk of future illness. For example, chickenpox patients like Jolie have a lifetime risk of shingles, a disease that can cause terrible rashes and intense nerve pain. The chickenpox virus hides in deep reservoirs inside the human body, and then emerges later in life to cause shingles.
Concerned adults can ask their doctor for a blood test that will check their antibodies and see if they remain immune to these infectious diseases, Horovitz said.
"It's something that could be done in the course of your annual exam. It takes no more than an extra tube or two of blood," the same as regular checks for blood sugar and cholesterol, he said. "It would be particularly important for people with chronic medical conditions or who do a lot of foreign travel where these diseases are running rampant."
People also can talk with their doctor about vaccinations that are recommended for adults. For example, the CDC recommends that adults get a booster shot every 10 years for tetanus, diphtheria and whooping cough, as well as an annual flu shot.
Wed, Dec 17, 2014 @ 11:35 AM
At birth, a newborn baby is still attached to its mother through the umbilical cord, which is either cut very early - within the first 60 seconds - or later, with some women opting to wait until after the cord has stopped pulsating. Though the right timing for cutting the cord - also referred to as clamping - is widely debated, a new study suggests delaying cord clamping by 2 minutes results in better development for the newborn during the first days of life.
The research, carried out by scientists from the University of Granada and the San Cecilio Clinical Hospital in Spain, is published in the journal Pediatrics, the official journal of the American Academy of Pediatrics (AAP).
According to the American Congress of Obstetricians and Gynecologists (ACOG), the reason that cord clamping timing is so controversial is that a previous series of studies into blood volume changes after birth concluded that in healthy term infants, more than 90% of blood volume was attained within the first few breaths he or she took after birth.
As a result of these findings, as well as a lack of other recommendations regarding optimal timing, the amount of time between birth and umbilical cord clamping was widely shortened; in most cases, cord clamping occurs within 15-20 seconds after birth.
However, before these studies, in the mid-1950s, cord clamping within 1 minute of birth was defined as "early clamping," and "late clamping" was defined as more than 5 minutes after birth. And the ACOG have stated that "the ideal timing for umbilical cord clamping has yet to be established."
Meanwhile, the World Health Organization (WHO) advocate for late cord clamping (between 1-3 minutes after birth), as it "allows blood flow between the placenta and neonate to continue, which may improve iron status in the infant for up to 6 months after birth."
To provide further evidence in the debate of early versus late cord clamping, the researchers from this latest study, led by Prof. Julio José Ochoa Herrera of the University of Granada, assessed newborn outcomes for infants born to 64 healthy pregnant women to determine the impact of clamping timing on oxidative stress and the inflammatory signal produced during delivery.
All of these women had a normal pregnancy and spontaneous vaginal delivery. However, half of the women's newborns had their umbilical cord cut 10 seconds after delivery and half had it cut after 2 minutes.
Results revealed beneficial effects of late cord clamping; there was an increase in antioxidant capacity and moderation of inflammatory effects in the newborns.
Commenting further, Prof. Ochoa says:
"Our study demonstrates that late clamping of the umbilical cord has a beneficial effect upon the antioxidant capacity and reduces the inflammatory signal induced during labor, which could improve the development of the newborn during his or her first days of life."
He adds that umbilical cord clamping is one of the most frequent surgical interventions practiced in humans, with proof of the practice dating back centuries.
With evidence of benefits for delayed cord clamping, however, why are most newborns separated from the placenta within 15-20 seconds after birth? According to the ACOG, there are concerns over universally adopting delayed clamping because it could "jeopardize timely resuscitation efforts, if needed, especially in preterm infants."
"However," the organization states, "because the placenta continues to perform gas exchange after delivery, sick and preterm infants are likely to benefit most from additional blood volume derived from a delay in umbilical cord clamping."
There are also other concerns regarding delayed cord clamping, including an increased potential for "excessive placental transfusion, which can lead to neonatal polycythemia" - an abnormally high level of red blood cells. This is especially of concern in the presence of risk factors including maternal diabetes, intrauterine grown restriction and high altitude.
Another concern stated by the ACOG is that delayed umbilical cord clamping "may be technically difficult in some circumstances."
Still, the WHO say late cord clamping is recommended for all births, and the improved iron status associated with it "may be particularly relevant for infants living in low-resource settings with reduced access to iron-rich foods."
The organization clearly states that early cord clamping - less than 1 minute after birth - is not advised unless the newborn is asphyxiated and needs to be moved for resuscitation.
Wed, Dec 17, 2014 @ 11:04 AM
By Meera Senthilingam
Its name means "bending over in pain." It has no treatment or vaccine. Its symptoms resemble Dengue fever. And it has infected more than 1 million people -- 155 of them fatally -- since spreading to the Americas one year ago.
The mosquito-borne Chikungunya virus has long been diagnosed in travelers returning from countries in Asia and Africa, where the disease is widespread. But in December 2013, the first people infected by mosquitoes local to the region were reported on the Caribbean island of Saint Martin.
This was the first outbreak of the debilitating disease in the Western hemisphere, health officials said.
All countries in Central America have now reported local transmission of Chikungunya [pronounced chik-un-GOON-ya], and the United States had 11 confirmed cases of local infection this year as of December 12, all in the state of Florida. There also have been 1,900 imported cases across the U.S. in returning travelers.
"It wasn't until 2013 that unfortunately a traveler resulted in local transmission of Chikungunya," said Erin Staples of the U.S. Centers for Disease Control (CDC), referring to the people infected in Saint Martin.
Those infected carry the virus in their bloodstream; it can then be picked up by mosquitoes as they bite, making them carriers. The virus has since spread rapidly and shows no signs of leaving, as ecological conditions are perfect for the disease to flourish.
"We knew it would spread," said Staples, a medical epidemiologist.
The big question perplexing officials: Why now?
Two mosquito species primed to the temperatures of Central and South America carry Chikungunya. The species -- Aedes aegypti and Aedes albopictus -- also carry the virus behind Dengue fever.
"Given the level of Dengue in the region, we knew there could be the same levels of Chikungunya," Staples said. Both diseases can cause joint pain and inflammation, headaches, rashes and fever, and can lead to death in rare cases.
But this tropical disease with an exotic name (which originates from the African Makonde dialect) causes more intense joint pain and inflammation. For some people the pain can last for months or years, resulting in additional psychological strain.
The lack of immunity among people living in the Americas provided a blank canvas for Chikungunya to spread throughout the population this year. As of December 12, more than 1.03 million people have been infected, in addition to the 155 who died, according to the Pan-American Health Organisation (PAHO). Almost all of the fatalities occurred in the Caribbean island countries of Guadaloupe and Martinique.
"Where we saw the biggest jump was after it reached the Spanish-speaking countries in the region," said Staples, referring to the weakened infrastructures and health systems of countries such as the Dominican Republic, which has reported more than 520,000 cases -- more than half of the overall outbreak and 5% of the island country's population.
As South American countries approach their summer, numbers are expected to rise there as the mosquitoes flourish in the heat.
"Brazil, Peru, Paraguay are coming into their summer months and reporting their first local transmission," Staples said. Already, more than 2,000 people have been infected in Brazil.
Is there cause for concern?
Because infection with Chikungunya is rarely fatal, the issue of most concern to officials is the burden on health services and the impact of the debilitating symptoms on the economy.
"The high number of cases can overload health services," says Dr. Pilar Ramon-Pardo, regional adviser for PAHO, the regional office of the World Health Organization. Until recently, monitoring for Chikungunya was not part of routine surveillance in the region.
"Clinicians have to be ready to diagnose," she said
About 20% to 30% of cases are expected to become chronic, with symptoms such as arthritis and other rheumatic manifestations leading to physical disabilities, Ramon-Pardo said. Further long-term effects are psychological as people become more depressed and tired.
All of this can result in missed work and lower school attendance, she said, hurting local economies.
Is it here to stay?
The warm climate of the region offers potential for Chikungunya levels to be maintained for years to come, just like Dengue fever. But areas of most concern are the tropics.
"The areas which have year-round favorable climate for the mosquito are at the greatest risk," says Dr. Laith Yakob of the London School of Hygiene and Tropical Medicine, which is monitoring the spread of the outbreak.
While the climate and mosquitos have long been present, Ramon-Pardo said, "we don't know why this is happening now." She said globalization is likely to blame, with increased population movement from one country to another. This offers more opportunities for local mosquitos to bite infected humans.
The CDC's Staples said she is temporarily at ease regarding numbers in the U.S. "We're moving into fall and winter periods, which should see activity decrease," she said. Cold temperatures reduce mosquito survival rates.
The rapid spread of Chikungunya this year also could help minimize future infections. "Chikungunya will go through a region quite rapidly and create a level of population immunity which helps mitigate large outbreaks of the disease," Staples said. Unlike Dengue, infection with Chikungunya results in lifelong immunity.
Like many other infections, Chikungunya could, however, remain in the background through animals capable of carrying the virus in their bloodstream and acting as so-called reservoirs of the disease.
"In Asia and Africa there is a transmission cycle in small mammals and monkeys," Ramon-Pardo said, meaning these animals keep the virus present within the population. "In the Americas ... we don't know yet."
Those words -- "we don't know" -- resonate throughout the community of scientists and government officials trying to control the outbreak.
The future risk of spread, levels of future immunity, risk from animal reservoirs, why this is only happening now, and the total economic impact are all unknown.
"Mathematical models are under construction by numerous research groups around the world to improve confidence over projections of future spread," said Yakob, whose team is modeling the disease. As they work, control efforts continue.
Getting it under control
When it comes to controlling Chikungunya, there are two main strategies -- reduce the likelihood of bites and remove the ever-biting mosquito. Prevention is the priority.
Unlike the mosquitoes behind malaria, which bite at night, the species behind Chikungunya bite any time, day or night. Those living in affected areas are asked to use repellent, sleep under bed nets and wear long clothing to avoid getting bitten. The air conditioned and indoor environments of people living in the U.S. mean numbers are likely to stay low there.
But mosquito control is at the heart of it all. Mass spraying of insecticides and removal of any sources of shallow water in which mosquitoes can breed are taking place across the continents. According to the CDC's Staples, Florida has been highly aggressive with its approach to control. "We're only at 11 (cases) due to such proactive measures," Staples said. For now, prevention is all they have as officials wait and see how the outbreak pans out.
"There is no vaccine currently and no good antivirals, so we are trying to control the spread of the disease," Staples said. "There are a lot of questions and only time will tell what we'll see for Chikungunya in the future."
Wed, Dec 10, 2014 @ 01:54 PM
By John Gever
Not all children with severe brain injuries need to be monitored for subclinical seizures, researchers said here, which means that resources can be focused on those at the highest risk.
Victims of abuse, those younger than 2, and those with bleeding within the brain rather than only in the epidural compartment are the pediatric ICU patients most likely to show significant seizure activity that should be detected and treated, said Rajsekar Rajaraman, MD, of the University of California Los Angeles (UCLA).
A separate study by many of the same investigators also found that, in a broader range of pediatric brain injury cases, risk of seizures could be predicted with "fair-to-good" accuracy on the basis of clinical characteristics that would be recorded routinely at admission.
Both studies were reported at the American Epilepsy Society's annual meeting here.
A senior author on both studies, Nicholas Abend, MD, of Children's Hospital of Philadelphia, said at an AES press briefing that identifying and treating seizures is important in the pediatric ICU. When seizures are extremely frequent or long-lasting -- and these can easily go without detection in hospitalized children who are unconscious or lethargic -- they significantly increase the likelihood of poor short- and long-term outcomes.
Such seizures can only be detected via continuous EEG monitoring, Abend explained, which also requires interpretation from trained electroneurologists.
Another investigator in the studies, UCLA's Jason Lerner, MD, noted that children may appear to be napping peacefully while actually undergoing continuous seizures.
Although it would be desirable to perform intense monitoring on all pediatric cases involving head trauma, that is not feasible at most centers, Abend said. He said the field could benefit from risk-stratification models that would allow the care team to track only those patients at the highest risk for damaging subclinical seizures.
Such models, he added, could be tailored to meet the needs of individual centers on the basis of their patient mix, staffing, and other factors.
In a platform session at AES, Rajaraman described one approach to developing such a model. He and colleagues collected data on 135 consecutive pediatric patients (ranging in age from infant to late adolescent) with traumatic brain injury who were treated in ICUs at UCLA and at Children's Hospital of Colorado in Denver. These children had continuous EEG monitoring for detecting subclinical seizures.
They found that all such seizures occurred in children younger than 2 and in those with intradural bleeding, and that the vast majority also involved abusive head trauma. Rajaraman and colleagues then sought to validate these associations in a separate cohort of 44 pediatric ICU patients with head injuries treated at Children's Hospital of Philadelphia. The same patterns were seen.
Across both cohorts, 81% of those with subclinical seizures were determined to have been victims of abusive head trauma, whereas the prevalence of such trauma in all the patients was 25%. Abend said it was uncertain why abusive trauma should be such a strong predictor of these seizures, but speculated that "shaken baby syndrome" -- the most common form of abuse of infants and toddlers -- may produce fundamentally different injuries in the brain compared with falls and car accidents.
Also, such abuse is often chronic, such that the episode that brings a child to the hospital is only the latest in a series of abusive incidents.
The other study, led by Abend, was aimed at producing a predictive model yielding a risk index score that pediatric centers could use to identify critically ill children who could benefit the most from continuous EEG monitoring. It was based on clinical information to which the attending neurologist would have ready access: age, seizure etiology, presence of clinical seizures prior to beginning continuous EEG, initial EEG background category, and interictal discharge category.
Data to design the model were drawn from a database of 336 patients from 11 centers, and then tested against a separate validation dataset of 222 patients treated at Children's Hospital of Philadelphia.
Normalized scores in the model could range from 0 to 1.0, and Abend and colleagues examined the sensitivity and specificity of various cutoffs. When set at 0.10 in the validation cohort, sensitivity was 86% but sensitivity was only 58% -- the high sensitivity meant that 43% of patients would be identified as candidates for continuous monitoring. At the other end, a cutoff of 0.45 reversed the sensitivity and specificity percentages to 19% and 97%, respectively, such that only 5% of patients would be assigned to monitoring.
Abend said the beauty of this approach is that an individual center could choose its own optimal cutoff depending on the resources it has available to monitor multiple patients at one time. A well-equipped and staffed ICU could thus opt for high sensitivity whereas one with more limited resources could be more restrictive.
Wed, Dec 03, 2014 @ 12:11 PM
U.S. health officials are poised to endorse circumcision as a means of preventing HIV and other sexually transmitted diseases.
The U.S. Centers for Disease Control and Prevention on Tuesday released its first-ever draft guidelines on circumcision that recommend that doctors counsel parents and uncircumcised males on the health benefits of the procedure.
The guidelines do not outright call for circumcision of all male newborns, since that is a personal decision that may involve religious or cultural preferences, Dr. Jonathan Mermin, director of the CDC's National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, told the Associated Press.
But "the scientific evidence is clear that the benefits outweigh the risks," Mermin said.
Circumcision involves the surgical removal of the foreskin covering the tip of the penis. Germs can collect and multiply under the foreskin, creating issues of hygiene.
Clinical trials, many done in sub-Saharan Africa, have demonstrated that circumcision reduces HIV infection risk by 50 percent to 60 percent, the CDC guidelines note. The procedure also reduces by 30 percent the risk of contracting herpes and human papilloma virus (HPV), two pathogens believed to cause cancer of the penis.
The guidelines do point out that circumcision has only been proven to prevent HIV and sexually transmitted diseases in men during vaginal sex. The procedure has not been proven to reduce the risk of infection through oral or anal sex, or to reduce the risk of HIV transmission to female partners.
The scientific evidence is mixed regarding homosexual sex, the guidelines say, with some studies having shown that circumcision provides partial protection while other studies have not.
Circumcision does reduce the risk of urinary tract infections in infants, according to the CDC guidelines.
The most common risks associated with the procedure include bleeding and infection.
Male circumcision rates in the United States declined between 1979 and 2010, dropping from almost 65 percent to slightly more than 58 percent, according to a CDC report issued last year.
The new draft guidelines mirror an updated policy on circumcision released by the American Academy of Pediatrics in 2012.
"The American public should take confidence that these are pretty much converging guidelines. There is no doubt that it [circumcision] does confer health benefits and there is no doubt it can be performed safely, with a less than 1 percent risk of complications," Dr. Susan Blank, chair of the task force that authored the AAP policy statement, said Tuesday. "This is one thing a parent can do to protect the future health of their children."
In its policy statement, the AAP declared that the health benefits are great enough that infant male circumcision should be covered by insurance, which would increase access to the procedure for families who choose it, said Blank, who is also assistant commissioner of STD Control and Prevention at the New York City Department of Health and Mental Hygiene.
"The push from the academy's point of view is to really have providers lay out for parents what are the risks, what are the benefits, and give the parents the information they need to make a decision," Blank said. "And the academy feels strongly that since there are proven health benefits, the procedure should be covered by insurance."
The guidelines are expected to spur a response from anti-circumcision groups.
"There are certainly groups that are troubled by circumcision of an individual who is not in a position to provide their own consent," Blank said.
The public can comment on the draft guidelines through Jan. 16, according to the CDC.
Wed, Nov 26, 2014 @ 11:49 AM
The number of emergency department visits in the United States rose from about 130 million in 2010 to a record 136 million in 2011, according to the U.S. Centers for Disease Control and Prevention.
The findings also showed that fewer people were going to ERs with non-urgent medical needs: 96 percent of patients were identified as needing medical care within two hours of arriving at the ER. In 2010, that number was 92 percent, according to the research.
Sixty percent of patients arrived at the ER after normal business hours (after 5 p.m. on weekdays). One-third of visits were for patients on either end of the age spectrum -- younger than 15 or older than 65, the researchers found.
Almost 30 percent of visits were for injuries. The highest injury rates were among patients 75 and older, the study noted.
"The report also finds that there are large numbers of admitted patients who wait long times for inpatient beds," Dr. Michael Gerardi, president of the American College of Emergency Physicians (ACEP), said in an ACEP news release.
"Nearly two-thirds of patients waited two or more hours for beds in 2011, and nearly three-quarters of hospitals continued to board patients, even when the emergency department was critically overloaded. Hospitals must move admitted patients out of the emergency department faster to make room for the increasing number of people coming," he said.
It's believed that there will be about 140 million ER visits in 2014, according to the ACEP.
"The growth in patient demand aligns with what emergency physicians have been seeing and predicting: demand is going to increase," Gerardi said.
"Given that our nation's population is aging, and emergency departments have a critical role as the front line of responding to disasters and infectious disease outbreaks in America, such as what we saw with Ebola, we need to prepare for increased numbers of patients," he added.
Despite increasing use of ERs, most hospitals had not expanded their ERs as of 2011 and had no plans to expand them in the following two years, according to Gerardi.
"Emergency departments are essential to every community and must have adequate resources," he said. "They continue to be under severe stress and face soaring demands, despite the efficiency of caring for more than 136 million of the sickest patients each year using only 4 percent of the nation's health care dollar. This report is more evidence that we are going to need more resources, not less, in the future."