4/13/11
AAP Endorses CDC's Rabies Vaccine Dose Regimen
News Author: Laurie Barclay, MD
CME Author: Charles P. Vega, MD
April 1, 2011 — The American Academy of Pediatrics (AAP) endorses the recommendations of the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) for postexposure prophylaxis (PEP) to prevent human rabies. The new recommendations call for lowering the number of doses from 5 to 4 of human diploid cell vaccine or purified chick embryo cell vaccine, according to the AAP Committee on Infectious Diseases Policy Statement published online March 28 and appearing in the April issue of Pediatrics.
"The incubation period (1–3 months) is long enough to render immunization a highly effective strategy for ...PEP," write AAP Committee on Infectious Diseases 2010-2011 chairperson Michael T. Brady, MD, and colleagues. "Approximately 20 000 to 30 000 persons receive PEP in the United States each year, and 1 to 3 cases of human rabies occurs annually. ...Keys to effective PEP have included prompt washing of the wound with copious amounts of soap and water, infiltration of human rabies immunoglobulin into and around the wound, and a 5-dose schedule of intramuscular vaccine administered over 28 days."
Because human rabies vaccine was in limited supply in 2007, the ACIP convened a rabies work group to review vaccination options and underlying evidence and then accepted its recommendations to implement a 4-dose regimen.
The new, recommended dosing regimen is that vaccine should be given on day 0 (first day of prophylaxis) and on days 3, 7, and 14 after the first dose. The first dose should be given as soon as possible after exposure, but if signs and symptoms of rabies are not present, the vaccine regimen may be started weeks to months after the exposure.
Individuals with immunosuppression should continue to receive the 5-dose regimen. No changes were made to recommendations for the use of human rabies immunoglobulin.
The statement authors note that use of the reduced-dose schedule could result in a $16 million cost savings to the United States healthcare system, based on preliminary economic assessments.
"The induction of rabies-neutralizing antibody is a surrogate for an adequate immune response to vaccination and was achieved in all subjects (~1000) by day 14, when the fourth dose of cell-derived rabies vaccine was given," the statement authors write concerning the evidence supporting their recommendations. "From observational studies that included persons likely exposed to confirmed rabid animals and with imperfect adherence to the 5-dose vaccine schedule, the Rabies Working Group estimated that more than 300 persons in the United States received only 3 or 4 doses annually, and there were no resulting cases of human rabies. Although human PEP failures do occur rarely worldwide, no cases have been attributed to the lack of receipt of the fifth rabies vaccine dose on day 28."
The statement authors have disclosed no relevant financial relationships.
Pediatrics. 2011;127:785-787. Full text
regards, taniafdi ^_^
Long Working Hours May Predict Heart Disease Risk
News Author: Laurie Barclay, MD
CME Author: Penny Murata, MD
April 4, 2011 — In low-risk, working populations, information on working hours may improve risk prediction of coronary heart disease (CHD) on the basis of the Framingham risk score, according to results from the Whitehall II cohort study reported in the April 5 issue of the Annals of Internal Medicine.
"Long working hours are associated with increased risk for ...CHD," write Mika Kivimäki, PhD, from University College London, United Kingdom, and colleagues. "Adding information on long hours to traditional risk factors for CHD may help to improve risk prediction for this condition."
The goal of this study was to assess whether adding information on long working hours could enhance the ability of the Framingham risk model to predict CHD in a low-risk, employed population.
Between 1991 and 1993, a total of 7095 adults (2109 women and 4986 men) aged 39 to 62 years who were working full time at civil service departments in London and who had no history of CHD underwent baseline medical examination, including measurement of working hours and the Framingham risk score. Prospective follow-up for incident CHD continued until 2004, with coronary death and nonfatal myocardial infarction determined from medical screenings every 5 years, hospital data, and registry linkage.
During median follow-up of 12.3 years, 192 participants had incident CHD. Compared with participants working 7 to 8 hours per day, those working 11 hours or more per day had a 1.67-fold increased risk for CHD (95% confidence interval [CI], 1.10 - 2.55), after adjustment for their Framingham risk score. Adding working hours to the Framingham risk score increased sensitivity, with net reclassification improvement of 4.7% (95% CI, 0.3 to 9.1; P = .034) because of better detection of persons in whom CHD later developed.
"Information on working hours may improve risk prediction of CHD on the basis of the Framingham risk score in low-risk, working populations," the study authors write. "The findings may not be generalizable to populations with a larger proportion of high-risk persons and were not validated in an independent cohort."
Additional limitations of this study include failure to account for changes in risk factors or medications during follow-up.
"Furthermore, it is important to clarify whether long working hours are a marker of CHD risk or are also a causal risk factor," the study authors conclude. "In the first case, information on working hours could contribute to risk prediction but not preventive treatment. In the second case, the clinical benefits of avoiding long working hours would need to be shown."
The Medical Research Council; British Heart Foundation; Bupa Foundation; and the National Heart, Lung, and Blood Institute and National Institute on Aging of the National Institutes of Health supported this study. Disclosures of the study authors can be viewed at the Annals of Internal Medicine Web site .
http://www.medscape.org/viewarticle/740131?src=cmemp
regards, taniafdi ^_^
Want Job Satisfaction? Choose Geriatrics
Eric Widera, MD
I am often asked by my patients, medical students, residents, and even my colleagues, "Why did you choose to go into geriatrics?" The answer is not simple. Much like the patients I care for, my reasons for practicing geriatrics are complex and nuanced. They have a great deal to do with my underlying values as a physician. That said, I will do my best to describe why I chose Geriatrics and why medical trainees should consider it as a career path.
The oldest of the US "baby boomers" generation turned 65 on January 1, 2010. Every day for the next 19 years thereafter, another 10,000 baby boomers will turn 65. To put this in perspective, this is the equivalent of a Boeing 747 airplane full of baby boomers turning 65 every hour. By 2030, the country's population of "senior boomers" will double to an estimated 71 million individuals.
Unfortunately, we are poorly prepared to meet the healthcare needs of this growing population. As they age, baby boomers will likely develop at least 1 chronic medical condition. These conditions will often present in atypical and subtle ways that may go unnoticed by many healthcare providers. These patients may also develop 1 or more common geriatric syndromes such as falls, delirium, dementia, incontinence, polypharmacy, and frailty. Over time, these individuals will become more dependent on a fragmented healthcare delivery model where services are often delivered by multiple providers without any meaningful care coordination.
This increased demand for healthcare services is being met by a dramatic shortage of physicians with expertise in the care of older adults. Currently, only about 7000 physicians in the United States are certified geriatricians[1]; by 2030, the nation will need an estimated 36,000 geriatricians.[2] However, only about 250 new geriatricians are graduating yearly from US fellowships programs. In other words, even as a planeload of baby boomers is landing at our healthcare system's doorstep every hour, the newly certified geriatricians would barely fill half that plan in an entire year.
Why aren't more new physicians choosing to specialize in geriatrics? Part of the reason may be the costs incurred with extra years of training, as well as the relatively low income compared with fields like cardiology or radiology. The complicated nature of caring for older patients, their families, and their caregivers may also turn away medical students and residents from careers in geriatrics, especially if they train in environments that are ill equipped to deal with this population.
But there are many reasons why a new physician should consider a career in geriatrics. Perhaps the most important reason is that geriatricians make a positive impact in the lives of others. This includes our elderly patients, as well as family caregivers who are increasingly relied upon by our healthcare system. The training provided by a geriatrics fellowship gives physicians the knowledge and skills to care for older adults with multiple complicated medical, psychological, and social problems. We are taught how to care for complex patients in a holistic, interdisciplinary, and systems-based manner; this involves learning strategies for successful aging, learning how to manage progressive functional disability, and learning how to care for those at the end of life.
The heart of geriatrics revolves around listening to the stories that our patients tell, and building meaningful and deep relationships. Not only are these stories and relationships integral to providing care for the elderly, they also are what keep me going as a physician by constantly inspiring me.
As a career path, geriatrics is also notable for its versatility. We practice in many different settings, ranging from academic medical centers to private practice clinics, to rural health centers. Some geriatricians also see patients at home or in long-term care facilities, either as a consultant or as a primary care physician. Geriatricians may spend additional time training to become expert educators or researchers. This is a field that carries with it many possibilities, and it has the resources and mentorship for future trainees to succeed.
These are just a few reasons why geriatricians, myself included, love their jobs.[3] In fact, there are good data to support this.[4-6] In a large, nationally representative sample of physicians from 33 different specialties, geriatrics was ranked first in job satisfaction.
So, why did I choose to go into geriatrics? I've given some general reasons, but it's not a simple answer. Then again, I probably wouldn't be a geriatrician if I liked simple answers.
http://www.medscape.com/viewarticle/737617?src=mp&spon=25
regards, taniafdi ^_^
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4/13/11
Journals
2008 Outbreak of Salmonella Saintpaul Infections Associated with Raw Produce
Fidaxomicin versus Vancomycin for Clostridium difficileInfection
Everolimus for Advanced Pancreatic Neuroendocrine Tumors
Development of Novel Combination Therapies
Heterogeneity of Hemoglobin H Disease in Childhood
Exposure to Environmental Microorganisms and Childhood Asthma
Deep-Vein Thrombosis of the Upper Extremities
Long-Acting Risperidone and Oral Antipsychotics in Unstable Schizophrenia
Diuretic Strategies in Patients with Acute Decompensated Heart Failure
Adolescent BMI Trajectory and Risk of Diabetes versus Coronary Disease
AAP Endorses CDC's Rabies Vaccine Dose Regimen
News Author: Laurie Barclay, MD
CME Author: Charles P. Vega, MD
April 1, 2011 — The American Academy of Pediatrics (AAP) endorses the recommendations of the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) for postexposure prophylaxis (PEP) to prevent human rabies. The new recommendations call for lowering the number of doses from 5 to 4 of human diploid cell vaccine or purified chick embryo cell vaccine, according to the AAP Committee on Infectious Diseases Policy Statement published online March 28 and appearing in the April issue of Pediatrics.
"The incubation period (1–3 months) is long enough to render immunization a highly effective strategy for ...PEP," write AAP Committee on Infectious Diseases 2010-2011 chairperson Michael T. Brady, MD, and colleagues. "Approximately 20 000 to 30 000 persons receive PEP in the United States each year, and 1 to 3 cases of human rabies occurs annually. ...Keys to effective PEP have included prompt washing of the wound with copious amounts of soap and water, infiltration of human rabies immunoglobulin into and around the wound, and a 5-dose schedule of intramuscular vaccine administered over 28 days."
Because human rabies vaccine was in limited supply in 2007, the ACIP convened a rabies work group to review vaccination options and underlying evidence and then accepted its recommendations to implement a 4-dose regimen.
The new, recommended dosing regimen is that vaccine should be given on day 0 (first day of prophylaxis) and on days 3, 7, and 14 after the first dose. The first dose should be given as soon as possible after exposure, but if signs and symptoms of rabies are not present, the vaccine regimen may be started weeks to months after the exposure.
Individuals with immunosuppression should continue to receive the 5-dose regimen. No changes were made to recommendations for the use of human rabies immunoglobulin.
The statement authors note that use of the reduced-dose schedule could result in a $16 million cost savings to the United States healthcare system, based on preliminary economic assessments.
"The induction of rabies-neutralizing antibody is a surrogate for an adequate immune response to vaccination and was achieved in all subjects (~1000) by day 14, when the fourth dose of cell-derived rabies vaccine was given," the statement authors write concerning the evidence supporting their recommendations. "From observational studies that included persons likely exposed to confirmed rabid animals and with imperfect adherence to the 5-dose vaccine schedule, the Rabies Working Group estimated that more than 300 persons in the United States received only 3 or 4 doses annually, and there were no resulting cases of human rabies. Although human PEP failures do occur rarely worldwide, no cases have been attributed to the lack of receipt of the fifth rabies vaccine dose on day 28."
The statement authors have disclosed no relevant financial relationships.
Pediatrics. 2011;127:785-787. Full text
regards, taniafdi ^_^
Long Working Hours May Predict Heart Disease Risk
News Author: Laurie Barclay, MD
CME Author: Penny Murata, MD
April 4, 2011 — In low-risk, working populations, information on working hours may improve risk prediction of coronary heart disease (CHD) on the basis of the Framingham risk score, according to results from the Whitehall II cohort study reported in the April 5 issue of the Annals of Internal Medicine.
"Long working hours are associated with increased risk for ...CHD," write Mika Kivimäki, PhD, from University College London, United Kingdom, and colleagues. "Adding information on long hours to traditional risk factors for CHD may help to improve risk prediction for this condition."
The goal of this study was to assess whether adding information on long working hours could enhance the ability of the Framingham risk model to predict CHD in a low-risk, employed population.
Between 1991 and 1993, a total of 7095 adults (2109 women and 4986 men) aged 39 to 62 years who were working full time at civil service departments in London and who had no history of CHD underwent baseline medical examination, including measurement of working hours and the Framingham risk score. Prospective follow-up for incident CHD continued until 2004, with coronary death and nonfatal myocardial infarction determined from medical screenings every 5 years, hospital data, and registry linkage.
During median follow-up of 12.3 years, 192 participants had incident CHD. Compared with participants working 7 to 8 hours per day, those working 11 hours or more per day had a 1.67-fold increased risk for CHD (95% confidence interval [CI], 1.10 - 2.55), after adjustment for their Framingham risk score. Adding working hours to the Framingham risk score increased sensitivity, with net reclassification improvement of 4.7% (95% CI, 0.3 to 9.1; P = .034) because of better detection of persons in whom CHD later developed.
"Information on working hours may improve risk prediction of CHD on the basis of the Framingham risk score in low-risk, working populations," the study authors write. "The findings may not be generalizable to populations with a larger proportion of high-risk persons and were not validated in an independent cohort."
Additional limitations of this study include failure to account for changes in risk factors or medications during follow-up.
"Furthermore, it is important to clarify whether long working hours are a marker of CHD risk or are also a causal risk factor," the study authors conclude. "In the first case, information on working hours could contribute to risk prediction but not preventive treatment. In the second case, the clinical benefits of avoiding long working hours would need to be shown."
The Medical Research Council; British Heart Foundation; Bupa Foundation; and the National Heart, Lung, and Blood Institute and National Institute on Aging of the National Institutes of Health supported this study. Disclosures of the study authors can be viewed at the Annals of Internal Medicine Web site .
http://www.medscape.org/viewarticle/740131?src=cmemp
regards, taniafdi ^_^
Want Job Satisfaction? Choose Geriatrics
Eric Widera, MD
I am often asked by my patients, medical students, residents, and even my colleagues, "Why did you choose to go into geriatrics?" The answer is not simple. Much like the patients I care for, my reasons for practicing geriatrics are complex and nuanced. They have a great deal to do with my underlying values as a physician. That said, I will do my best to describe why I chose Geriatrics and why medical trainees should consider it as a career path.
The oldest of the US "baby boomers" generation turned 65 on January 1, 2010. Every day for the next 19 years thereafter, another 10,000 baby boomers will turn 65. To put this in perspective, this is the equivalent of a Boeing 747 airplane full of baby boomers turning 65 every hour. By 2030, the country's population of "senior boomers" will double to an estimated 71 million individuals.
Unfortunately, we are poorly prepared to meet the healthcare needs of this growing population. As they age, baby boomers will likely develop at least 1 chronic medical condition. These conditions will often present in atypical and subtle ways that may go unnoticed by many healthcare providers. These patients may also develop 1 or more common geriatric syndromes such as falls, delirium, dementia, incontinence, polypharmacy, and frailty. Over time, these individuals will become more dependent on a fragmented healthcare delivery model where services are often delivered by multiple providers without any meaningful care coordination.
This increased demand for healthcare services is being met by a dramatic shortage of physicians with expertise in the care of older adults. Currently, only about 7000 physicians in the United States are certified geriatricians[1]; by 2030, the nation will need an estimated 36,000 geriatricians.[2] However, only about 250 new geriatricians are graduating yearly from US fellowships programs. In other words, even as a planeload of baby boomers is landing at our healthcare system's doorstep every hour, the newly certified geriatricians would barely fill half that plan in an entire year.
Why aren't more new physicians choosing to specialize in geriatrics? Part of the reason may be the costs incurred with extra years of training, as well as the relatively low income compared with fields like cardiology or radiology. The complicated nature of caring for older patients, their families, and their caregivers may also turn away medical students and residents from careers in geriatrics, especially if they train in environments that are ill equipped to deal with this population.
But there are many reasons why a new physician should consider a career in geriatrics. Perhaps the most important reason is that geriatricians make a positive impact in the lives of others. This includes our elderly patients, as well as family caregivers who are increasingly relied upon by our healthcare system. The training provided by a geriatrics fellowship gives physicians the knowledge and skills to care for older adults with multiple complicated medical, psychological, and social problems. We are taught how to care for complex patients in a holistic, interdisciplinary, and systems-based manner; this involves learning strategies for successful aging, learning how to manage progressive functional disability, and learning how to care for those at the end of life.
The heart of geriatrics revolves around listening to the stories that our patients tell, and building meaningful and deep relationships. Not only are these stories and relationships integral to providing care for the elderly, they also are what keep me going as a physician by constantly inspiring me.
As a career path, geriatrics is also notable for its versatility. We practice in many different settings, ranging from academic medical centers to private practice clinics, to rural health centers. Some geriatricians also see patients at home or in long-term care facilities, either as a consultant or as a primary care physician. Geriatricians may spend additional time training to become expert educators or researchers. This is a field that carries with it many possibilities, and it has the resources and mentorship for future trainees to succeed.
These are just a few reasons why geriatricians, myself included, love their jobs.[3] In fact, there are good data to support this.[4-6] In a large, nationally representative sample of physicians from 33 different specialties, geriatrics was ranked first in job satisfaction.
So, why did I choose to go into geriatrics? I've given some general reasons, but it's not a simple answer. Then again, I probably wouldn't be a geriatrician if I liked simple answers.
http://www.medscape.com/viewarticle/737617?src=mp&spon=25
regards, taniafdi ^_^
Subscribe to:
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