Day: 01/22/2011

Crimean-Congo hemorrhagic fever

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Crimean-Congo hemorrhagic fever: A viral disease characterized by hemorrhage (bleeding) and fever.

Crimean-Congo hemorrhagic fever (CCHF) is a severe disease with a high mortality (death) rate. The geographical distribution of the virus, like that of the tick that carries it, is widespread. CCHF has been found in Africa, Asia, the Middle East and Eastern Europe.

The CCHF virus infects a wide range of domestic and wild animals that serve as reservoirs for the virus. Ticks carry the virus from animal to animal and from animal to human. The most important source for acquisition of the virus by ticks is infected small vertebrate animals on which the ticks feed. Once infected, the tick remains infected through its lifespan. The mature tick transmits the infection to large vertebrates such as livestock (cattle, sheep and goats). Humans acquire the virus from direct contact with their blood or other infected tissues from livestock during this time, or they may become infected from a tick bite. The majority of cases of CCHF have occurred in those involved with the livestock industry, such as agricultural workers, slaughterhouse workers and veterinarians.

The onset of symptoms from CCHF is sudden with fever, myalgia (aching muscles),dizziness, neck pain and stiffness, backache, headache, sore eyes and photophobia (sensitivity to light). There may be nausea, vomiting and sore throat early on, accompanied by diarrhoea and abdominal pain. Over the next few days, the patient may experience sharp mood swings and become confused and aggressive. The agitation may be replaced by sleepiness, depression and lassitude, and the abdominal pain may localize to the right upper quadrant (over top of the liver) with detectable liver enlargement. Other signs may include tachycardia (fast heart rate), lymphadenopathy (enlarged lymph nodes), and a petechial rash (a rash caused by bleeding into the skin), both on internal mucosal surfaces, such as in the mouth and throat, and on the skin. The petechiae (bleeding spots) may give way to ecchymoses (bruises, like a petechial rash, but covering larger areas) and other hemorrhagic (bleeding) phenomena such as melena (bleeding from the upper bowel, passed as altered blood in the feces), hematuria (blood in the urine), epistaxis (nosebleeds) and bleeding from the gums. There is usually evidence of hepatitis. The severely ill may develop hepatorenal (liver and kidney) failure and pulmonary (lung) failure.

The mortality (death) rate from CCHF is about 30% with death, when it occurs, usually coming in the second week of the illness. In those patients who recover, improvement generally begins on the ninth or tenth day after the onset of illness.

Diagnosis of CCHF is performed in specially-equipped biosafety laboratories by what is called enzyme-linked immunoassay (ELISA). Patients with fatal disease do not usually develop a positive ELISA test and in these individuals, as well as in patients in the first few days of illness, diagnosis is achieved by virus detection in blood or tissue samples.

Treatment involves monitoring to guide volume and blood component replacement is required. The antiviral drug ribavirin has been used with apparent benefit.

There is no safe and effective vaccine widely available for human use against CCHF. The tick vectors are numerous and widespread and tick control with acaricides (chemicals intended to kill ticks) is only a realistic option for well-managed livestock production facilities.

Persons living in endemic areas should use personal protective measures that include avoidance of areas where tick vectors are abundant and when they are active (Spring to Fall); regular examination of clothing and skin for ticks, and their removal; and use of repellents. Persons who work with livestock or other animals in the endemic areas can take practical measures to protect themselves. These include the use of repellents on the skin (e.g. DEET) and clothing (e.g. permethrin) and wearing gloves or other protective clothing to prevent skin contact with infected tissues or blood. When patients with CCHF are admitted to the hospital, there is a risk of nosocomial spread of infection. In the past, serious outbreaks have occurred in this way and it is imperative that adequate infection control measures be observed to prevent this disastrous outcome. Patients with suspected or confirmed CCHF should be isolated and cared for using barrier nursing techniques. Specimens of blood or tissues taken for diagnostic purposes should be collected and handled using universal precautions. Sharps (needles and other penetrating surgical instruments) and body wastes should be safely disposed of using appropriate decontamination procedures. Healthcare workers are at risk of acquiring infection from sharps injuries during surgical procedures and, in the past, infection has been transmitted to surgeons operating on patients to determine the cause of the abdominal symptoms in the early stages of (at that moment undiagnosed) infection. Healthcare workers who have had contact with tissues or blood from patients with suspected or confirmed CCHF should be followed up with daily temperature and symptom monitoring for at least 14 days after the putative exposure.

Crimean-Congo hemorrhagic fever (CCHF) was first discovered in the Crimea in 1944. In 1956 a similar illness was identified in the Congo. And in 1969 it was recognized that the virus causing Crimean hemorrhagic fever was the same as that responsible for the illness identified in the Congo. Linkage of the 2 place-names resulted in the current name for the disease and the virus that causes it.

 

LVADs for End-Stage Heart Failure: An Alternative to Transplants

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More than 5 million Americans have heart failure, a progressive and often lethal condition that weakens the heart and saps its pumping power. The mainstays of treatment — including drug therapy, lifestyle modification, and surgery to implant pacemakers or defibrillators — can be quite effective at managing symptoms of mild to moderate heart failure.

But what about the estimated 150,000 Americans who suffer from chronic, severe heart failure?

Doctors traditionally have had little to offer these patients in the way of lifesaving treatment, short of a heart transplant. But with only about 2,100 donor hearts available each year, the demand for hearts inevitably outweighs the supply. And some patients are simply too old to qualify for a transplant. For them, what’s the alternative?

There’s now an option that could change the outlook for many with severe heart failure: implantable mechanical pumps called left ventricular-assist devices (LVADs or sometimes simply VADs.)

These devices were once just used as a “bridge” — a temporary stopgap to keep heart failure patients alive until they could get a heart transplant. But now, they have become so effective that doctors use them as a treatment in themselves. LVADs are now an alternative to heart transplants, permanently augmenting the action of a heart’s main pumping chamber.

“With the new devices, there finally appears to be a real, practical solution to advanced heart failure,” says Clyde W. Yancy, MD, president of the American Heart Association, medical director of the Baylor Heart and Vascular Institute at Baylor University Medical Center in Dallas, and a noted expert on heart failure. “This has been a 40-year pursuit of a mechanism that can take over for a heart that is failing. This is big news.”

The Evolution of LVADs

LVADs have been around in some form since the 1960s, but have been used primarily as a temporary treatment to give the patient’s heart a chance to improve or to keep the patient alive long enough for a donor heart to be found.

First-generation LVADs are limited by their considerable bulk and poor durability. The large size increases the risk of implantation surgery and makes the device unsuitable for smaller patients.

Recent research has demonstrated the superiority of the newer rotary, or “continuous-flow,” LVADs, which are smaller and more durable than their predecessors.

Continuous-Flow LVADs

Continuous-flow LVADs consist of a pump implanted in the abdominal wall linked with tubes to the patient’s aorta and left ventricle. A power cord emerging through the abdominal skin leads to a control unit worn on the belt, which, in turn, is attached to battery packs worn in a shoulder harness.

One study of 200 patients with advanced heart failure showed that both the older LVADs and the new continuous-flow LVADs improved exercise tolerance and quality of life. That’s significant, Yancy says, given that even people with well-treated heart failure tend to have seriously impaired quality of life.

 

2 Genes May Be Linked to Heart Disease

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Study Also Shows People With Type O Blood May Have Some Protection Against Heart Attack
doctor checking elderly man's heart

Jan. 14, 2011 — Investigators have identified two new genes associated with heart disease that could lead to better ways of recognizing those at risk and preventing heart attacks in some.

The findings also suggest that people with type O blood have some natural protection against heart attacks, even when they also have plaque-clogged arteries.

Researchers analyzed the DNA of close to 12,400 people who had coronary artery disease (CAD) and 7,400 people who did not. In an effort to identify genes specific for heart attack, they also compared the DNA of almost 5,800 CAD patients who had a history of heart attack with 3,600 patients who had no such history.

 

Type O Blood Suggests Protection

The initial analysis led to the discovery of ADAMTS7, a gene linked to the buildup of plaque in the arteries leading to the heart, says study researcher Muredach P. Reilly, MD, of the University of Pennsylvania. The secondary analysis led to the identification of an association at the ABO blood group gene.

When arterial plaque was present, the same enzyme found in people with type O blood appeared to offer protection against heart attack. But this does not mean people with type O blood can ignore other risk factors for heart disease, Reilly says.

The research appears online in the Jan. 15 issue of The Lancet.

“People with this blood type appear to have some mild protection against heart attack, but genes are just one part of the story,” he tells WebMD.

Having high blood pressure, high LDL “bad” cholesterol, being a smoker, and beingoverweight all contribute to heart attack risk regardless of a person’s blood type.

Gene Variant Linked to Plaque

The newly discovered gene variant ADAMTS7 is one of about a dozen genes associated with heart disease risk identified within the last few years, Reilly says.

“Most are associated with plaque buildup [known medically as atherosclerosis] and not with other known heart disease risk factors,” he says. “This suggests we may have a more targeted approach to preventing this risk factor in the future.”

He adds that the identification of the heart-attack-specific gene variant is especially significant because atherosclerosis is so common in the elderly.

“Almost everybody over the age of 60 or 65 has plaque,” he says. “This marker could help us identify people with plaque who won’t have problems, or at least won’t have them until they are in their 80s or 90s.”

The hope is that the already identified heart-disease-related genes, along with the discovery of others in the near future, will lead to treatments targeted to a patient’s individual risk, genetic researcher Luca A. Lotta, tells WebMD.

The genetic research should also lead to better ways of identifying people at risk.

Lotta is a post-doctoral fellow researching the genetics of heart disease at the University of Milan.

“As of today, the benefits of genome-wide profiling have not been established,” he says. “But as our knowledge of the genetic predisposition for cardiovascular disease and other diseases deepens, the impact and importance of genetic testing will increase dramatically.”

 

A nationwide study of three invasive treatments for trigeminal neuralgia

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Invasive procedures for treatment of trigeminal neuralgia (TGN) include percutaneous radiofrequency thermocoagulation (PRT), partial sensory rhizotomy (PSR), and microvascular decompression (MVD). Using a nationwide discharge registry from The Netherlands, we assessed the frequency of use and patient characteristics, and evaluated treatment failure for each patient undergoing PRT, PSR, or MVD from January 2002 through December 2004. Only patients without a procedure in the year prior were included. Primary outcome was readmission for repeat procedures for TGN or known complications within 1 year. Comparability of patient populations was assessed through propensity scores based on hospital, age, sex, and comorbidity. Conditional logistic regression matched on propensity score was used to calculate relative risks (RR) with 95% confidence intervals (CIs) for repeat procedures or complications. During the study period, 672 patients with TGN underwent PRT, 39 underwent PSR, and 87 underwent MVD. Hospital type was the predominant determinant of procedure type; age, sex, and comorbidity were weak predictors. The RR for repeat procedures for PSR was 0.21 (95% CI: 0.07 to 0.65) and for MVD was 0.13 (95% CI: 0.05 to 0.35) compared with PRT (RR 1). For complications, the RR of PSR was 5.36 (95% CI: 1.46 to 19.64) and of MVD was 4.40 (95% CI: 1.44 to 13.42). Sex, urbanization, and comorbidity did not influence prognosis, but hospital and surgical volume did. In conclusion, although PSR and MVD are associated with a lower risk of repeat procedure than PRT, they seem to be more prone to complications requiring hospital readmission.

source: science direct

Pain relief in office gynaecology: a systematic review and meta-analysis

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Hysteroscopy, hysterosalpingography (HSG), sonohysterography and endometrial ablation are increasingly performed in an outpatient setting. The primary reason for failure to complete these procedures is pain. The objective of this review was to compare the effectiveness and safety of different types of pharmacological intervention for pain relief in office gynaecological procedures. A systematic search of medical databases including PubMed, EMBASE, Cochrane Central register of controlled trials, PsychInfo and CINHAL was conducted in 2009. Randomised controlled trials (RCTs) investigating the use of local anaesthetics, opioid analgesics, non-opioid analgesics and intravenous sedation for pain relief during and after hysteroscopy, HSG, sonohysterography and endometrial ablation were reviewed. Secondary outcomes included adverse effects and failure to complete procedures. Where RCTs were not identified, the best available evidence was sought. Each study was assessed against inclusion criterion. Results for each study were expressed as a standardised mean difference (SMD) with 95% confidence intervals and combined for meta-analysis with Revman 5 software. Meta-analysis revealed beneficial effect of the use of local anaesthetics during and within 30 min after hysteroscopy; SMD −0.45 (95% CI −0.73, −0.17) and SMD −0.51 (95% CI −0.81, −0.21) respectively. No beneficial effect was noted during HSG. One RCT found evidence of benefit for pain relief during hysterosalpingo-contrastsonography; SMD −1.04 [95% CI −1.44, −0.63]. There was no significant difference in failure to complete hysteroscopy due to cervical stenosis between the intervention and control groups (OR 1.31 (95% CI 0.66, 2.59)), but the incidence of failure to complete the procedure due to pain was significantly less in the intervention group (OR 0.29 (0.12, 0.69)). There is evidence of benefit for the use of local anaesthetics for outpatient hysteroscopy and hysterosalpingo-contrastsonography. Local anaesthetics may be considered when performing hysteroscopy in postmenopausal women to reduce the failure rate.

source: science direct

Behavioral indices of ongoing pain are largely unchanged in male mice with tissue or nerve injury-induced mechanical hypersensitivity

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Despite the impact of chronic pain on the quality of life in patients, including changes to affective state and daily life activities, rodent preclinical models rarely address this aspect of chronic pain. To better understand the behavioral consequences of the tissue and nerve injuries typically used to model neuropathic and inflammatory pain in mice, we measured home cage and affective state behaviors in animals with spared nerve injury, chronic constriction injury (CCI), or intraplantar complete Freund’s adjuvant. Mechanical hypersensitivity is prominent in each of these conditions and persists for many weeks. Home cage behavior was continuously monitored for 16 days in a system that measures locomotion, feeding, and drinking, and allows for precise analysis of circadian patterns. When monitored after injury, animals with spared nerve injury and complete Freund’s adjuvant behaved no differently from controls in any aspect of daily life. Animals with CCI were initially less active, but the difference between CCI and controls disappeared by 2 weeks after injury. Further, in all pain models, there was no change in any measure of affective state. We conclude that in these standard models of persistent pain, despite the development of prolonged hypersensitivity, the mice do not have significantly altered “quality of life.” As alteration in daily life activities is the feature that is so disrupted in patients with chronic pain, our results suggest that the models used here do not fully reflect the human conditions and point to a need for development of a murine chronic pain model in which lifestyle changes are manifest.

source: science direct

Are Proton-Pump Inhibitors Safe During Early Pregnancy?

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In a large cohort study, use of PPIs during the first trimester did not increase risk for major birth defects.

 

Symptomatic gastroesophageal reflux disease (GERD) is a common condition associated withpregnancy. Although its prevalence increases with duration of pregnancy, symptoms often occur even in the first trimester. Proton-pump inhibitors (PPIs) are the most effective medical therapy for patients with moderate-to-severe GERD and are widely prescribed to pregnant women. However, safety data about the use of these agents during pregnancy or immediately prior to conception are limited (JW Gastroenterol Mar 29 2005).

To evaluate the association between exposure to PPIs and the risk for birth defects, researchers conducted a retrospective cohort study of live births in Denmark using multiple national registries. The primary analysis assessed PPI exposure to women during the 4 weeks prior to conception through the first trimester of pregnancy (12 weeks). The primary outcome measure was all major birth defects.

Of 840,968 live births, 5082 involved exposure to PPIs during the study period. Exposure was associated with increased risk for birth defects (adjusted prevalence odds ratio, 1.23; 95% confidence interval, 1.05–1.44). However, when exposure was limited to the first trimester only, no significant risk for birth defects remained. In a secondary analysis, exposures to specific PPIs during the first trimester did not increase the risk for birth defects. Of note, omeprazole — the only category C drug (i.e., animal studies have shown risk to a fetus) — was associated with the lowest risk for birth defects, although this result was not statistically significant.

Comment: Given the widespread use of both prescription and over-the-counter PPIs, these data showing an apparent lack of teratogenicity are reassuring. It is interesting that an editorialist suggests that omeprazole should perhaps be the PPI of choice in pregnancy, even though it is a category C drug. Nonetheless, my advice in treating pregnant patients is to make recommendations to the prescribing obstetrician rather than to be the primary prescriber of any agent.

— David A. Johnson, MD

Published in Journal Watch Gastroenterology January 21, 2011