Emergency Medicine in the Developing World

Posted on December 12, 2011 by Amit Chandra

Global Health Blog – December 2011

I just got back to Botswana after attending the Emergency Medicine in the Developing World conference in beautiful Cape Town, South Africa!  It was exciting to meet so many emergency physicians, residents, paramedics, and nurses from across Africa.  Emergency Medicine (EM) is one of the newest specialties in the world with a 30-year history in the United States, and a 10-year history in South Africa.  EM training programs have recently launched in Ghana, Tanzania, Ethiopia, and in Botswana.  The conference was a good opportunity to compare notes, share experiences, and discuss future collaboration.  We even have our own medical journal now, the African Journal of Emergency Medicine, and my team from Botswana co-authored a paper describing the history of our work:
Development of Emergency Medicine in Botswana

Alongside academic EM training programs, we are all working to build acute care, emergency, and pre-hospital services in our respective countries.  The sustainability of these models will depend on the success of our advocacy in demanding these services from the health systems in which we work.  New international campaigns focusing on road traffic injuries (the decade of action for road safety launched this year) and non-communicable diseases will hopefully overlap with and reinforce our efforts…

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Ultrasound-guided Thoracentesis Reduces the Rate of Pneumothorax and Tube Thoracostomy

Posted on November 28, 2011 by Joseph Esherick

Dr. Joseph Esherick Monthly Blog – November 2011

Numerous studies have shown that ultrasound guidance lowers the rate of complications and increases the success rate for virtually every hospital procedure compared with traditional landmark-based techniques.   This has proved to be the case for ultrasound-guided central lines, ultrasound-guided paracentesis, and ultrasound-guided lumbar punctures in obese patients.  This essay will focus on ultrasound-guided thoracentesis which has a decreased rate of pneumothorax and need for tube thoracostomy compared with the blind approach.

Pleural effusions affect nearly 1.5 million people each year in the United States.  Many of these people require thoracentesis for pleural fluid analysis to either determine the etiology of their pleural effusions or as a therapeutic procedure to relieve dyspnea and hypoxia.  Examination of the pleural space with sonography is best carried out using a convex array 3.5- to 5 MHz probe.[1]   Ideally, the patient is in the sitting position and sonography should identify the uppermost extent of the pleural effusion and the location of the diaphragm.  The depth of insertion can also be approximated by using the depth markers on the ultrasound screen.  At this point, a mark can be made on the posterior thorax just above the rib at the optimal site for thoracentesis.  The thoracentesis can then be carried out in standard fashion with the patient in the same sitting position.   Alternatively, the convex array probe can be placed in a sterile sheath and the thoracentesis can be performed using real-time ultrasound guidance.  The complication rate is identical with either technique for ultrasound-guided thoracentesis… Continue reading →

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Moustaches for Men’s Health

Posted on November 4, 2011 by Rebecca Rockel

With the help of the Prostate Cancer Foundation, LiveStrong and the Movember Foundation, November marks the 5th annual, Movember.  Movember is an annual, Global event that takes place each November, involving the growing of moustaches, also known as “Mos,” to help raise funds and awareness for prostate cancer and other cancers that affect men.

To participate, men, also known as “Mo Bros”, register at www.movember.com .  They begin Movember 1st clean shaven and for the rest of the month, they “groom, trim and wax their way into the annals of fine moustachery.”  In essence, Mo Bros become walking, talking billboards for the entire month of November. Through their actions and words they raise awareness around the often ignored issue of men’s health.

Movember was actually started in Melbourne Australia in 1999 and was then named “Novembeard.”  Since then, the movement has spread and in 2007 the Movember Foundation began launching events in Ireland, Canada, Cyprus, Czech Republic, Denmark, Greece, Spain, the United Kingdom, Israel, South Africa and the United States.

In 2010, over 64,500 US Mo Bros and the women in their lives, affectionately named “Mo Sistas,” got on board, raising $7.5 million USD.

Big steps have been taken towards changing attitudes and habits relating to men’s health around the world, but there is still much to be done to spark conversation and spread awareness of men’s health issues.

Jones & Bartlett Learning is committed to helping patients and caregivers understand more about their disease.  Our patient education series offers authoritative, practical answers to readers’ questions about their health concerns, symptoms, diagnosis, treatment options, quality of life, sources of support and much more.  Below are a few of our best-selling and forthcoming Men’s Health titles:

100 Q&A About Men's Health, Johns Hopkins Patients' Guide to Prostate Cancer, 100 Q&A About Prostate Cancer

Click for more information on JBLearning’s Patient Education titles.

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The Rise and Fall of Xigris (Drotrecogin-alfa)

Posted on October 31, 2011 by Joseph Esherick

Dr. Joseph Esherick Monthly Blog – October 2011

Drotrecogin-alfa (DrotAA) has been an integral part of the care bundle for adult patients hospitalized with severe sepsis or septic shock and a high risk of death since 2002.  DrotAA is a synthetic activated Protein C (APC) which has good scientific evidence for why it may be beneficial in patients with severe sepsis and septic shock.  Patients with severe sepsis have abnormal activation of their coagulation pathways and inflammatory system and impaired fibrinolysis, which lead to a procoagulant state.  Normally, APC acts with Protein S to degrade clotting factors Va and VIIa to promote anticoagulation.  However, intrinsic levels of APC are diminished in patients with severe sepsis because of impaired APC synthesis and increased degradation by neutrophil elastases.  Therefore, the theory was that a synthetic APC could benefit patients by decreasing the abnormal clotting which occurs in the micro-circulation.

Severe sepsis and septic shock remains an extremely important problem in critical care medicine.  More than 200,000 people die of sepsis annually in the United States.  When drotrecogin-alfa was initially FDA-approved in 2001, it became the only FDA-approved drug specifically used to treat severe sepsis.  The first large trial which studied DrotAA was the PROWESS trial.1 This was an industry-sponsored, double-blind, placebo-controlled, multicenter trial  that involved 1690 patients with severe sepsis and a “high risk of death”, which was defined as an APACHE II score of 25 or more… Continue reading →

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Do Resident Work Hour Restrictions Improve Either Patient Safety or Postgraduate Medical Education?

Posted on September 28, 2011 by Joseph Esherick

Dr. Joseph Esherick Monthly Blog – September 2011

National resident work hour restrictions were first implemented by the ACGME in 2003.   The debate started initially after the unfortunate death of Libby Zion in 1984 which prompted the state of New York to restrict resident duty hours.   The assumption was that resident fatigue caused the death of Libby Zion.  Among other restrictions, the 2003 regulations restricted resident shifts longer than 30 hours.  The regulations also stipulated that resident physicians must have at least one day in seven off and must have a 10 hour break between work shifts.

In 2008, the Institute of Medicine (IOM) declared that resident duty hour restrictions must be tighter to reduce medical errors and improve resident education.  The IOM proclaimed that resident shifts should not exceed 16 hours unless they are interrupted by a five-hour uninterrupted nap, no shift should exceed 30 hours, and moonlighting hours are counted as a part of the 80-hour weekly maximum.  Based on these recommendations, the ACGME has imposed new 2010 regulations that prohibit first-year residents from working shifts longer than 16 hours, senior residents must work shifts no longer than 24 hours, and shifts must be separated by a 10 hour break.  The assumption that has been made is that these duty hour restrictions will decrease resident fatigue and therefore lead to improved patient safety and improved resident education, which will eventually lead to better graduating physicians.

The reality, however, is these residency duty hour restrictions have led to neither improved patient outcomes nor improved resident education.  The data suggest that the IOMs assumptions are wrong…  Continue reading →

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National Cholesterol Awareness Month

Posted on September 13, 2011 by Rebecca Rockel

September marks the annual observance of National Cholesterol Awareness Month.

Over 100 million adults in the U.S. have high cholesterol. High cholesterol levels are due to a variety of factors including heredity, diet, and lifestyle.

If you or a loved-one have high cholesterol, an invaluable reseource has just been published to help answer your questions and concerns:

Whether you are a newly diagnosed patient or a loved one of someone with this condition, 100 Questions & Answers About Managing Your Cholesterol offers essential information. This easy-to-read guide provides authoritative, practical answers to the most common questions asked by patients. Topics include cholesterol and atherosclerosis, risk factors for high cholesterol and heart disease, diagnosis and testing, and ways to improve cholesterol through diet, exercise, and medications.

To learn more about 100 Questions & Answers About Managing Your Cholesterol, please visit our website at go.jblearning.com/cholesterol.

For more information on the National Lipid Association, please visit their website at www.lipid.org

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Antibiotic Stewardship with the Aid of Procalcitonin Measurements

Posted on August 23, 2011 by Joseph Esherick

Dr. Joseph Esherick Monthly Blog – August 2011

There has been considerable interest in antibiotic stewardship programs over the past decade given the increase in drug-resistant bacteria.  The best way to combat the problem of drug-resistant bacteria is to develop systems which discourage the inappropriate initiation of antibiotics or the unnecessary prolongation of antibiotics.  The measurement of serum procalcitonin levels can aid sound clinical judgment for decisions regarding proper antibiotic use.

Procalcitonin, the precursor peptide of calcitonin, is released in response to a body’s exposure to bacterial antigens or toxins.  Furthermore, the procalcitonin levels are suppressed by exposure to cytokines activated during viral infections, namely interferon gamma.  We know that the level of procalcitonin elevation is directly correlated with the severity of the bacterial infection.[1] In addition, procalcitonin levels rise within 6-12 hours after symptom onset of bacterial infections and decrease by about 50% per day once a bacterial infection is under control.[2]

A number of randomized controlled trials have led to the development of procalcitonin guided clinical algorithms for various infections which have been used throughout Europe.  These protocols have led to a marked reduction in the use of antibiotics in adult patients treated in a variety of clinical settings with no increase in mortality or morbidity…

Continue reading →

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August is National Immunization Awareness Month

Posted on August 17, 2011 by Rebecca Rockel

With students getting ready to go back to school, and the upcoming flu season fast approaching, August marks the annual observance of National Immunization Awareness Month (NIAM).

The goal of NIAM is to increase awareness about immunizations, and to reach the thousands of people in the U.S.  and the hundreds of thousands around the world who go unprotected from vaccine-preventable diseases that claim the lives of countless people each year. It has been proven that the best defense against contracting common viruses and diseases is for both children and adults to be immunized. In addition, a healthier population reduces healthcare costs, and results in fewer missed work and school days.

5 Key Reasons to Support Immunization Programs:

1. Immunization Saves Lives
Immunization saves more than 3 million lives worldwide each year, and it saves millions more from suffering illness and lifelong disability.

Global distribution of the 1.4 million annual deaths caused by vaccine-preventable (WHO)

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Bedside Ultrasound Increases the Success Rate for Difficult Lumbar Punctures

Posted on July 15, 2011 by Joseph Esherick

Dr. Joseph Esherick Monthly Blog – July 2011

The traditional landmark-guided needle lumbar puncture technique was first described by Heinrich Quincke in 1891[1]This technique utilizes the iliac crest and the posterior lumbar spinous processes to determine the optimal sites for spinal needle introduction in either the L3-4 or the L2-3 interspinous spaces.  The landmark-guided technique of lumbar puncture is usually successful in experienced hands as long as the patient is not obese, pregnant, edematous, or have scoliosis, degenerative joint disease, or a history of lumbar spine surgery.  Patients who have any of these characteristics or conditions can lead to more difficult landmark-guided lumbar punctures.  It is in these cases when bedside ultrasound can increase the success rate of lumbar punctures.[2,3,4,5]    

Ultrasound-guided regional neuraxial anesthesia has been described in the anesthesia literature since 1971.[6]   The literature reports a reduction in the number of attempts, need for repositioning, and interspaces accessed compared with landmark-guided spinal or epidural anesthesia.[7,8]  The use of bedside ultrasound to help guide difficult lumbar punctures has spread to the emergency room, ICU, and the hospital wards over the last 7 years.[9]   Observational studies have demonstrated that lumbar landmarks can be correctly identified using ultrasound about 76% of the time when they are difficult to palpate.[2,3,9] Continue reading →

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Capgras Syndrome: Ever Thought Your Loved One Was an Impostor?

Posted on July 11, 2011 by Rebecca Rockel

Reposted from Huffington Post:
http://www.huffingtonpost.com/carol-w-berman-md/capgras-syndrome_b_888854.html
article by Jones & Bartlett Learning Medicine Author, Carol W. Berman, MD

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Did you ever look at your husband or wife and feel that person is an impostor? Janet, a 24-year-old graduate student, came home from a stressful day at school and found a man she thought was a stranger in her bed.

“Who are you? How did you get into my apartment?” she asked.

She was in no mood to fool around with a strange man who had somehow gained entrance to her apartment and was lounging on her bed in her husband’s blue silk pajamas.

“Very funny. And who are you?”

The man countered. He looked similar to Dave, her husband. In fact, he had short brown hair, dark blue eyes and the same kind of round cheeks as Dave. However, Janet knew in her gut that it wasn’t Dave. Maybe distant relatives or casual friends might believe the man was Dave, but Janet and Dave had been together practically every day for the last three years, and Janet could swear it wasn’t her husband.

As a psychiatrist I treat many bizarre conditions, but this case was one of the strangest. The movie “Invasion of the Body Snatchers,” in which people correctly accuse their loved ones of being impostors, illustrates Capgras’ syndrome. In the movie, the townspeople’s loved ones were actually replaced by extraterrestrials who want to destroy humanity. In Capgras’ syndrome, people falsely believe their loved ones are replaced by duplicates.

Continue reading →

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