Folks,
Below my name, from CDC, answers, as of Wednesday, to virtually all questions about the flue your pts might have. From Bill Lawson: "Wonder if this outbreak produces an increase in schizophrenia as did the pandemic of 1918.”
Last night’s WPS CME “What is ‘Number Needed to “Treat” anyway’?,” speaker, Leslie Citrone, provided the same definition of evidence-based medicine WPS asked, successfully, that the APA adopt: relevant scientific evidence with clinical judgment and patient values and preference. The focus of the talk was Number Needed to Treat [NTT], calculated by fA = frequency of A. fB = frequency of B. NTT = 1/fA – FB. For example, if drug A achieves remission in 50% of MDD pts and drug B is achieves remission 20% of MDD pts, then the NTT = 1/[.0.5-0.2] = 1/0.3 = 3.3. The rules of the NTT is that one round off upward, so the NTT = 4. Thus, you need to treat 4 pts for one patient to benefit. “A” and “B” can also be untoward events evaluated the same way. One of the major benefits of this approach is putting studies in prospective. Some much published studies have an NTT above a hundred, meaning
that one pt would, in theory, would benefit if the treatment were applied in comparison to the alternative above the hundred -- which may be irrelevant to a practice unless the issue is deaths. Thus, when we see a treatment recommended or a side effect emphasized, we can apply the NTT to test clinical significance.
From this week’s meeting of A. Acad. of Neurology: Engaging in activities that exercise the brain, like reading, use of computers, and knitting in mid-life cut the risk that people will develop memory loss in their 70s or 80s by more than one-third. If your pt has already turned 70 or 80, it's not too late to benefit from exercises that tax the brain. Watching more than seven hours of TV a day, on the other hand, was linked to a higher than average chance of memory loss. Each time a new atypical antipsychotic was introduced in the 1990s, there were suggestions that the med might help with deficit signs [poorly named “negative signs” by some], including the cognitive deficits. Cynics, however, usually claimed that the new med looked better only because the comparison group was on high-dose haloperidol. Online AJP, 15Apr09, has a meta-center study, EUFEST, that claims the cynics were not only correct, but that low-dose haloperidol improved deficits signs as much as the newer antipsychotics.
AstraZeneca paid for a recent supplement to the J of Clin Psychiatry on GAD. Medications mentioned for GAD, listed alphabetically with FDA approved ones underlined: Alprazolam [0.75-4.0 mg/d], FDA approved Bupropion [100-400 mg/d] Buspirone [10-60 mg/d], FDA approved Diazepam [15-40 mg/d], FDA approved Duloxetine [30-120 mg/d], FDA approved Escitalopram [5-20 mg/d, FDA approved Hydroxyzine, FDA approved Imipramine [25-300 mg/d] Lorazepam [2-6 mg/d] FDA approved Mirtazapine [15-45]
Paroxetine [10-50 mg/d], FDA approved Pregabalin [150-600 mg/d] Quetiapine [50-150 mg/d] Riluzole mentioned, which I guess can be considered for those with an office in Potomac [costs, $35/d]. Sertraline [25-200 mg/d] Trazodone [50-400 mg/d] Trifluoperazine, FDA approved, a reminder that first generation antipsychotics were commonly used for GAD in the 60s, 70s and early 80s. Venlafaxine ER [37.5-225 mg/d], FDA approved CBT and Well-Being Therapy are also regarded as effective for GAD If the pt also has depressive signs, most do, the three benzodiazepines listed supra, do not do as well as the antidepressants. Chromium picolinate “may be effective for atypical depression with GAD.” Gabapentin and second generation antipsychotics other that quetiapine “need further study.” Where is fluoxetine, which I’ve been prescribing for years for GAD? “Not better than placebo.” Now they tell me. Current issue of the Washingtonian features Ken Gorelick, who many of you know. In the face of advanced brain cancer, he continues the positive outlook we’ve known since he came to Saint Es four decades ago.
For your roller-deck: There is a Family Justice Center, 600 Jefferson Street, 5th Floor, Rockville, MD 20852, part of the County’s Sheriff’s government, a "one stop shop" where domestic violence victims can access the legal system along with victim and other human services. Other people who would like assistance with domestic violence should continue to call: 240.777.4673, 24 hour crisis line, or 240.777.4195, intake line (regular business hours). Clients may also walk into the Crisis Center, 1301 Piccard, First Floor, 24 hours a day.
Roger
Interim Guidance for Clinicians on Identifying and Caring for Patients with Swine-origin Influenza A (H1N1) Virus Infection Objective: This document provides interim guidance for clinicians who might provide care for patients with swine-origin influenza A (H1N1) or suspected swine-origin influenza A (H1N1) virus infection. It will be periodically updated as information becomes available. Transmission Transmission of swine-origin influenza A(H1N1) is being studied as part of the ongoing outbreak investigation, but limited data available indicate that this virus is transmitted in ways similar to other influenza viruses. Seasonal human influenza viruses are spread from person to person primarily through large-particle respiratory droplet transmission (e.g., when an infected person coughs or sneezes near a susceptible person). Transmission via large-particle droplets requires close contact between source and recipient persons, because droplets do not remain suspended in the air and generally travel only a short distance (<1 meter) through the air. Contact with respiratory-droplet contaminated surfaces is another possible source of transmission. Because data from swine-origin influenza viruses are limited, the potential for ocular, conjunctival, or gastrointestinal infection is unknown. Since this is a novel influenza A virus in
humans, transmission from infected persons to close contacts might be common. All respiratory secretions and bodily fluids (diarrheal stool) of swine-origin influenza A (H1N1) cases should be considered potentially infectious.
Incubation period The estimated incubation period is unknown and could range from 1-7 days, and more likely 1-4 days. Persons with confirmed Swine-origin influenza A (H1N1) virus infection A confirmed case of S-OIV infection is defined as a person with an acute febrile respiratory illness with laboratory confirmed S-OIV infection at CDC by one or more of the following tests: 1. real-time RT-PCR 2. viral culture Case definitions for Probable and Suspected cases can be found at: http://www.cdc.gov/swineflu/casedef_swineflu.htm Clinicians should suspect swine-origin influenza A (H1N1) in persons with an acute febrile respiratory illness who Have had close contact with a person who is a swine-origin influenza confirmed case or Traveled to a community in the United States or internationally where there are one or more confirmed swine-origin influenza cases (Updated information about areas with confirmed human cases of swine-origin influenza A (H1N1) can be found at http://www.cdc.gov/swineflu/investigation.htm.) or Reside in a community where there are one or more confirmed swine-origin influenza A (H1N1) cases. Clinical Findings Patients with uncomplicated disease due to confirmed swine-origin influenza A (H1N1) virus infection have experienced fever, headache, upper respiratory tract symptoms (cough, sore throat, rhinorrhea), myalgia, fatigue, vomiting, or diarrhea. Complications There is insufficient information to date about clinical complications of this variant of swine-origin influenza A (H1N1) virus infection. Among persons infected with previous variants of swine influenza virus, clinical syndromes have ranged from mild respiratory illness, to lower respiratory tract illness, dehydration, or pneumonia. Deaths caused by previous variants of swine influenza have occasionally occurred. Although data on the spectrum of illness is not yet available for this new variant of swine-origin influenza A(H1N1), clinicians should expect complications to be similar to seasonal influenza: exacerbation of underlying chronic medical conditions, upper respiratory tract disease (sinusitis, otitis media, croup) lower respiratory tract disease (pneumonia, bronchiolitis, status asthmaticus), cardiac (myocarditis, pericarditis), musculoskeletal (myositis, rhabdomyolysis), neurologic (acute and post-infectious encephalopathy, encephalitis, febrile seizures, status epilepticus), toxic shock syndrome, and secondary bacterial pneumonia with or without sepsis. Groups at high risk for complications There are insufficient data available at this point to determine who is at higher risk for complications of swine-origin influenza A (H1N1) virus infection. At this time, the same age and risk groups who are at higher risk for seasonal influenza complications should also beconsidered at higher risk for swine-origin influenza complications . Groups at higher risk for seasonal influenza complications include: Children less than 5 years old; Persons aged 50 years or older; Children and adolescents (aged 6 months–18 years) who are receiving long-term aspirin therapy and who might be at risk for experiencing Reye syndrome after influenza virus infection; Pregnant women; Adults and children who have chronic pulmonary, cardiovascular, hepatic, hematological, neurologic, neuromuscular, or metabolic disorders; Adults and children who have immunosuppression (including immunosuppression caused by medications or by HIV); Residents of nursing homes and other chronic-care facilities. Reporting suspect swine-origin influenza A (H1N1) virus infection Clinicians should contact their state public health department to report suspected cases of swine-origin influenza A (H1N1) virus infection and to obtain information on what clinical and epidemiological data to collect and specimen shipment protocols in their state. Testing for swine-origin influenza A (H1N1) virus Clinicians should consider testing suspected cases of swine-origin influenza A (H1N1), especially those with severe illness, by obtaining an upper respiratory specimens, such as a nasopharyngeal swab or wash, or nasal wash/aspirate, or tracheal aspirate, to test for swine-origin influenza A (H1N1) virus. Specimens should be tested by the state public health laboratory. Interim guidance on specimen collection ,processing, and testing for patients with suspected swine-origin influenza A (H1N1) virus infection can be found at: http://www.cdc.gov/swineflu/specimencollection.htm Treatment for swine-origin influenza A (H1N1) The swine-origin influenza virus is susceptible to both oseltamivir and zanamivir. It is resistant to amantadine and rimantadine. Interim guidance on antiviral treatment for swine-origin influenza A (H1N1) can be found at: http://www.cdc.gov/swineflu/recommendations.htm Additional Therapy Additional therapy such as antibacterial agents, should be used at the discretion of the clinicians given the patients clinical presentation. For antibacterial treatment of pneumonia, clinical guidance for community-acquired pneumonia should be followed and can be accessed at http://www.journals.uchicago.edu/doi/pdf/10.1086/511159?cookieSet=1.  For hospitalized patients with severe community-acquired pneumonia (CAP) requiring intensive care unit admission, menthicillin-resistent Staphylococcus aureus (MRSA) infection should be suspected and treated empirically in addition to other causes of CAP if they have 1) necrotizing or cavitary infiltrates or 2) empyema. Infectious period The duration of shedding with swine-origin influenza A (H1N1) virus is unknown. Therefore, until data are available, the estimated duration of viral shedding is based upon seasonal influenza virus infection. Infected persons are assumed to be shedding virus from the day prior to illness onset until resolution of symptoms. Persons with swine-origin influenza A (H1N1) virus infection should be considered potentially contagious for up to 7 days following illness onset. Persons who continue to be ill longer than 7 days after illness onset should be considered potentially contagious until symptoms have resolved. Children, especially younger children, might be contagious for longer periods. Infection Control Measures Guidance on infection control during care of patients with confirmed or suspected swine-origin influenza A (H1N1) virus infection can be found at: http://www.cdc.gov/swineflu/guidelines_infection_control.htm Antiviral Chemoprophylaxis Guidance on pre-exposure and post-exposure chemoprophylaxis with antiviral agents for swine-origin influenza A (H1N1) virus can be found at: http://www.cdc.gov/swineflu/recommendations.htm Additional Information Additional information on swine-origin influenza can be found at: http://www.cdc.gov/swineflu/ |
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