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April 23rd, 2012 posted by Paul Rega, MD, FACEP April 23, 2012 @ 7:44 pm

IO: The way to go…..

http://www.acepnews.com/single-view/08983da812439394dc1f58fdec732d22.html?tx_ttnews[tt_news]=1259

When Veins Fail, Go to Bone

By: MICHELE G. SULLIVAN, Elsevier Global Medical News

04/18/12

“…..Intraosseous (IO) access was pioneered during World War I, and it’s aged well- although peripheral IVs pushed it out of the limelight for several decades. But IO access remains the standard of care in emergency situations where IVs can’t be used…..

A 1988 review of 33 pediatric cardiac arrests showed that IO is the quickest way to go. Although a successful IO attempt took about 5 minutes, compared with 3 minutes for a peripheral IV, the success rate for an IO placement was much greater- 83% vs. 17%, said Dr. Ellison of the University of Pennsylvania, Philadelphia (Am. J. Emerg. Med. 1988;6:577-9)…..

For the most part, however, IO access is very safe. Studies conducted in the late 1980s and early 1990s show an overall complication rate of less than 1%. Osteomyelitis occurred in 0.6%, and cellulitis or skin abscess developed in 0.7%. No evidence of bone deformity or growth arrest was seen in long-term follow-up studies…..”



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April 23rd, 2012 posted by Paul Rega, MD, FACEP @ 7:41 pm

Measles — United States, 2011

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http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6115a1.htm?s_cid=mm6115a1_e

What is already known on this topic?  Achievement of measles elimination was declared in the United States in 2000, but the disease remains poorly controlled in much of the world. Cases of measles are imported regularly into the United States.

What is added by this report?  During 2011, 222 cases of measles and 17 outbreaks were reported in the United States, an increase compared with cases and outbreaks reported during 2001–2010. Importations accounted for 72 (32%) cases, including 52 (72%) cases among U.S. residents who had traveled abroad recently. Among patients who were U.S. residents, 85% were unvaccinated or had unknown vaccination status and were eligible for measles, mumps, and rubella (MMR) vaccination.

What are the implications for public health practice?  MMR vaccine is highly effective in preventing measles and its complications. Rapid public health response and high 2-dose MMR vaccine coverage are essential in preventing measles outbreaks and sustaining elimination in the United States. One dose of MMR vaccine is recommended routinely for all children at age 12–15 months, with a second dose at age 4–6 years. Adults without evidence of measles immunity should receive 1 MMR vaccine dose, whereas 2 doses are recommended for unvaccinated health-care personnel, international travelers, and students attending post–high school educational institutions.

Measles — United States, 2011

Weekly

April 20, 2012 / 61(15);253-257

In 2000, the United States achieved measles elimination (defined as interruption of year-round endemic measles transmission) (1). However, importations of measles into the United States continue to occur, posing risks for measles outbreaks and sustained measles transmission. During 2011, a total of 222 measles cases (incidence rate: 0.7 per 1 million population) and 17 measles outbreaks (defined as three or more cases linked in time or place) were reported to CDC, compared with a median of 60 (range: 37–140) cases and four (range: 2–10) outbreaks reported annually during 2001–2010. This report updates an earlier report on measles in the United States during the first 5 months of 2011 (2). Of the 222 cases, 112 (50%) were associated with 17 outbreaks, and 200 (90%) were associated with importations from other countries, including 52 (26%) cases in U.S. residents returning from abroad and 20 (10%) cases in foreign visitors. Other cases associated with importations included 67 (34%) linked epidemiologically to importations, 39 (20%) with virologic evidence suggesting recent importation, and 22 (11%) linked to cases with virologic evidence of recent importation. Most patients (86%) were unvaccinated or had unknown vaccination status. The increased numbers of outbreaks and measles importations into the United States underscore the ongoing risk for measles among unvaccinated persons and the importance of vaccination against measles (3).

Confirmed measles cases in the United States are reported by state and local health departments to CDC using a standard case definition.* A measles case is considered confirmed if it is laboratory-confirmed or meets the clinical case definition (an illness characterized by a generalized rash lasting ≥3 days, a temperature of ≥101°F [≥38.3°C], and cough, coryza, or conjunctivitis) and is linked epidemiologically to a confirmed case. Laboratory confirmation of measles is made by detection in serum of measles-specific immunoglobulin M (IgM), a significant rise in measles immunoglobulin G (IgG) level, isolation of measles virus, or detection of measles virus by nucleic acid amplification from a clinical specimen. Cases are considered importations if exposure to measles virus occurred outside the United States 7–21 days before rash onset and rash occurred within 21 days of entry into the United States, with no known exposure to measles in the United States during that time.

For this report, U.S. residents were classified as eligible or ineligible for measles, mumps, and rubella (MMR) vaccination according to the Advisory Committee on Immunization Practices recommendations for measles vaccination (3). Vaccine-eligible patients were defined as U.S. residents who 1) were unvaccinated or had unknown vaccination status, 2) did not have any contraindications for vaccination, and 3) were either born after 1957 and aged ≥12 months without previous documentation of presumptive evidence of immunity to measles† or aged 6–11 months with recent history of international travel.

During 2011, a provisional total of 222 measles cases were reported from 31 states (Figure 1). The median age of the patients was 14 years (range: 3 months to 84 years); 27 (14%) were aged <12 months, 51 (26%) were aged 1–4 years, 42 (21%) were aged 5–19 years, and 76 (39%) were aged ≥20 years. Most patients were unvaccinated (65%) or had unknown vaccination status (21%). Of the 222, a total of 196 were U.S. residents. Of those U.S. residents who had measles, 166 were unvaccinated or had unknown vaccination status, 141 (85%) were eligible for MMR vaccination, 18 (11%) were too young for vaccination, six (4%) were born before 1957 and presumed immune, and one (1%) had previous laboratory evidence of presumptive immunity to measles. Among the 141 patients who were unvaccinated and eligible for MMR vaccination, nine (6%) were infants aged 6–11 months and had recent history of international travel; 14 (10%) were aged 12–15 months, the age recommended for receiving the first dose of MMR vaccine; and 66 (47%) were aged 16 months through 19 years. Of those 66 patients, 50 (76%) had not been vaccinated because of a philosophic, religious, or personal objection.

Among the 70 (32%) measles patients who were hospitalized, 17 (24%) had diarrhea, 15 (21%) were dehydrated, and 12 (17%) had pneumonia. No cases of encephalitis and no deaths were reported.

Of the 222 U.S. measles cases, 200 (90%) were associated with importations, of which 72 (36%) were importations from other countries, 67 (30%) were linked epidemiologically to importations, 39 (20%) had virologic evidence (i.e., isolation of a viral genotype known to circulate in a country with measles) that suggested recent importation, and 22 (11%) were linked to cases with virologic evidence of recent importation. The source of measles acquisition in 22 cases was not determined through contact tracing or viral isolation (i.e., linking the patient to a country with measles or isolation of a viral genotype known to circulate in a country with measles). Importations were reported during 31 of the 52 reporting weeks (Figure 2). Among the 72 cases of measles importation, 52 were linked to U.S. residents who had traveled abroad, and 20 were linked to foreign visitors. Almost half (46%) of the 72 measles importations occurred among persons who acquired the disease in the World Health Organization (WHO) European Region (Table).

Seventeen outbreaks accounted for 112 (50%) of the 222 cases. The median outbreak size was six cases (range: 3–21 cases), and outbreaks lasted a median of 18 days (range: 6–69 days).

Measles was laboratory confirmed in 200 (90%) cases: 94 (47%) by detection of measles-specific IgM and measles virus nucleic acid, 69 (35%) by detection of IgM only, and 37 (19%) by detection of measles virus nucleic acid only. Six genotypes of measles virus were identified among samples collected: D4, D9, D8, B3, G3, and H1 (Table).

Reported by

Div of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC. Corresponding contributor: Huong McLean, PhD, hmclean@cdc.gov.

Editorial Note

Measles elimination has been maintained in the United States for more than a decade through high population immunity secondary to high MMR vaccination coverage. Coverage with 1 dose has been >90% among children aged 19–35 months since 1996. The increase in measles importations and outbreaks during 2011 serves as a reminder that measles remains endemic in many parts of the world and unvaccinated U.S. residents continue to place themselves and others in their communities at risk for measles and its complications.

The increase in importations reflects recent increases in the incidence of measles in countries visited by U.S. travelers. The source of almost half of the measles importations in 2011 was the WHO European Region, which reported >30,000 cases of measles, including 27 cases of measles encephalitis, a complication that often results in permanent neurologic sequelae, and eight measles-related deaths in 2011. Five countries (France, Italy, Romania, Spain, and Germany) accounted for more than 90% of cases reported to the European Centers for Disease Prevention and Control (4). Although measles has been eliminated in the Region of the Americas since 2002 and considerable progress has been achieved in global measles control, measles is still common in many countries. Importations of measles virus into the United States will likely continue and cause outbreaks in communities that have clusters of unvaccinated persons. Maintenance of high MMR vaccination coverage is essential to prevent measles outbreaks and sustain measles elimination in the United States. Despite the relatively small number of reported cases in the United States, the public and the health-care providers must remain vigilant. A drop in MMR vaccination coverage in a community can increase the risk for large, sustained measles outbreaks, as experienced recently in Canada and France (4,5), or reestablishment of endemic transmission, as experienced in the United Kingdom (6).

Occasionally, measles cases are reported without apparent links to importations, but virologic evidence suggests recent importation of an undetected case or chain of cases. Given travel patterns, the highly infectious nature of measles virus, and limitations of surveillance systems, not every importation of measles virus into the United States is detected. Therefore, collection of samples for virus detection is extremely important. Genetic characterization of viruses can help to confirm or suggest the likely source of imported viruses because measles genotypes are distributed heterogeneously in regions that have not yet eliminated measles (7,8).

Health-care providers play an important role in maintaining elimination of measles in the United States. Patients with measles frequently seek medical care; therefore, health-care providers should maintain a high awareness of measles and suspect measles in persons who have a febrile rash illness and clinically compatible symptoms (e.g., cough, coryza, or conjunctivitis) and who recently have traveled abroad or have had contact with travelers. Providers should implement isolation precautions immediately and promptly report suspected measles cases to their local health department to limit spread to other susceptible persons, including those who cannot be vaccinated because of medical contraindications or those too young for vaccination. In several outbreaks during 2011, despite seeking medical care, the source case was not identified until after the first or second generation of cases was reported. Misdiagnosis and delayed reporting resulted in missed opportunities to prevent additional cases because of delayed implementation of control measures. Nevertheless, for most cases, early reporting by providers and rapid control efforts by state and local public health agencies have prevented measles transmission and limited the size of outbreaks.

Health-care providers should encourage vaccination of all eligible patients, including children and adults. MMR vaccine is recommended routinely for all children at age 12–15 months, with a second dose at age 4–6 years. Two doses of MMR vaccine also are recommended for unvaccinated health-care personnel, international travelers, and students attending post–high school educational institutions. Other adults without evidence of measles immunity should receive 1 dose of MMR vaccine (3). In addition, providers should remind their patients who plan to travel internationally of the increased risk for measles and potential exposures during bus, train, or air travel and at large international events or gatherings (e.g., Euro 2012 and the 2012 Summer Olympics), and of the importance of vaccination. All persons aged ≥6 months who will be traveling outside the United States and are eligible to receive MMR vaccine should be vaccinated before travel. Children aged ≥12 months should receive 2 doses of MMR vaccine separated by at least 28 days, before travel (3).

References

  1. Katz SL, Hinman AR. Summary and conclusions: measles elimination meeting, 16–17 March 2000. J Infect Dis 2004;189(Suppl 1):S43–7.
  2. CDC. Measles—United States, January–May 20, 2011. MMWR 2011;60:666–8.
  3. CDC. Measles, mumps, and rubella—vaccine use and strategies for elimination of measles, rubella, and congenital rubella syndrome and control of mumps: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1998;47:(No. RR-8).
  4. European Centre for Disease Prevention and Control. Surveillance report: European monthly measles monitoring, 21 February 2012. Stockholm, Sweden: European Centre for Disease Prevention and Control; 2012. Available at http://ecdc.europa.eu/en/publications/publications/sur_emmo_european-monthly-measles-monitoring-february-2012.pdf Adobe PDF fileExternal Web Site Icon. Accessed April 6, 2012.
  5. Ministere de Santé et Services sociaux Quebec. Measles. Quebec, Canada: Ministere de Santé et Services sociaux Quebec; 2012. Available at http://www.msss.gouv.qc.ca/en/sujets/prob_sante/measles/measles.phpExternal Web Site Icon. Accessed April 6, 2012.
  6. Editorial team. Measles once again endemic in the United Kingdom. Euro Surveill 2008;13.
  7. Rota PA, Brown K, Mankertz A, et al. Global distribution of measles genotypes and measles molecular epidemiology. J Infect Dis 2011;204(Suppl 1):S514–23.
  8. World Health Organization. Measles virus nomenclature update: 2012. Wkly Epidemiol Rec 2012;87:73–80.

 

 
The figure above shows the origin of reported measles cases in the United States during 2011. During 2011, a provisional total of 222 measles cases were reported from 31 states.
 
TABLE. Countries where imported measles was acquired, by World Health Organization (WHO) region, number of cases (n = 72), and genotype — United States, 2011
WHO region No. of cases Country No. of cases Genotype identified*
African 4 EthiopiaKenyaNigeria 121 B3B3 (2)B3
Americas 2 CanadaDominican Republic† 11 D4
Eastern Mediterranean 3 JordanPakistan 12 D4
European 33 BulgariaFranceFrance/Germany/Spain§

France/Italy§

France/Italy/Spain/Germany§

France/Spain/United Kingdom§

France/United Kingdom§

Italy

Poland

Romania

Romania/Hungary§

Spain

United Kingdom

1131

1

1

1

1

4

1

1

2

1

5

D4 (5), G3D4D4

D4 (3)

D4

D4 (2)

D4 (3)

South-East Asia 19 BangladeshIndiaIndonesia 1162 D4, D8 (5)
Western Pacific 11 ChinaMalaysiaPhilippines

Philippines/Vietnam/Singapore/Malaysia§

226

1

H1D9 (2)D9 (4)


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April 23rd, 2012 posted by Paul Rega, MD, FACEP @ 7:38 pm

VTE & Air Pollution: A link???????

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Martinelli N, Girelli D, Cigolini D, Sandri M, Ricci G, et al. (2012)

Access Rate to the Emergency Department for Venous Thromboembolism in Relationship with Coarse and Fine Particulate Matter Air Pollution.

PLoS ONE 7(4): e34831. doi:10.1371/journal.pone.0034831

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3324538/pdf/pone.0034831.pdf



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April 23rd, 2012 posted by Paul Rega, MD, FACEP @ 7:37 pm

P. aeruginosa isolates in ultrasound gel

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http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6115a3.htm?s_cid=mm6115a3_e

What is already known on this topic?  Medical gels have been linked to outbreaks of infection in several reports, including reports of gels contaminated at the site of packaging. As a result, Health Canada in 2004 issued recommendations for minimizing the risk for infection from medical gels. No such guidelines exist in the United States.

What is added by this report?  An outbreak of seven cases of Pseudomonas aeruginosa respiratory tract infection and nine instances of respiratory tract colonization was linked to contaminated ultrasound gel. P. aeruginosa isolates found in 10 patients, one of four opened gel bottles in use in the operating room, and one of two unopened, sealed gel bottles were found to be more than 99% similar by molecular typing.

What are the implications for public health practice?  Because of the risk that an ultrasound gel might be contaminated with P. aeruginosa or other bacteria, single-use, sterile products should be used for invasive procedures and procedures involving contact with nonintact skin or mucous membranes.

Pseudomonas aeruginosa Respiratory Tract Infections Associated with Contaminated Ultrasound Gel Used for Transesophageal Echocardiography — Michigan, December 2011–January 2012

Weekly

April 20, 2012 / 61(15);262-264

In late December 2011, the Department of Epidemiology at Beaumont Health System (BHS) in Royal Oak, Michigan, noted an increase in the number of positive respiratory cultures in one surgical intensive-care unit (ICU), prompting further investigation. The increase in positive cultures was attributed entirely to Pseudomonas aeruginosa. Investigation by BHS staff members found that all of these positive cultures were related to use of ultrasound transmission gel from a single manufacturer during transesophageal echocardiography. Seven patients were infected with P. aeruginosa based on National Healthcare Safety Network (NHSN) criteria (1), and nine were colonized. Cultures from one open and one unopened bottle of the gel grew P. aeruginosa closely related to the outbreak strain based on molecular typing via repetitive extragenic palindromic polymerase chain reaction (rep-PCR). The Oakland County Health Department, the Michigan Department of Community Health, and the Food and Drug Administration (FDA) were notified of the findings. On January 23, all implicated ultrasound gel in multiuse bottles was removed from BHS facilities and replaced with a single-use, sterile ultrasound gel for all potentially invasive procedures. On April 18, FDA issued a Safety Communication* advising health-care professionals and facilities not to use certain lot numbers of the ultrasound transmission gel and further advising that the only ultrasound gel that is sterile is unopened gel in containers labeled as sterile. To date, no further respiratory cultures have been positive for P. aeruginosa.

Surveillance for nosocomial infection at BHS is driven by results of clinical microbiology cultures. Positive cultures are reviewed using a combination of microbiology reports and paper or electronic medical records to determine infections and colonizations. Initial review found P. aeruginosa in respiratory specimens taken from endotracheal tubes in 10 patients in a single surgical ICU in December. No cultures of these patients’ surgical sites or blood grew P. aeruginosa. The same unit had averaged less than three respiratory tract cultures positive for P. aeruginosa monthly during the preceding 11 months and had only one infection by NHSN criteria during that period.

Review of the 10 P. aeruginosa cultures revealed that all patients had undergone cardiovascular surgery. No clustering by operating room, surgeon, operating room staff member, ICU room number, or nursing staff was observed. Because all isolates were from the respiratory tract, the initial focus included a review of postoperative nursing and respiratory-care practices, respiratory therapy equipment management, and anesthesia practice and equipment management. No clustering by respiratory medications administered was observed. Discussion with operating room staff members revealed that a unique aspect of these patients’ surgeries included the use of an intraoperative transesophageal echocardiogram (TEE). TEEs involve the insertion of a probe with an ultrasound conducting tip into a patient’s esophagus and are used during cardiovascular surgery to aid in visualization of the posterior of the heart. The TEE probe is coated with a coupling gel and then inserted by an anesthesiologist before surgical incision. Their duration of placement depends on the specific procedure being performed. Environmental cultures of TEE probes, storage tubes, and work surfaces were performed, and all TEE probes were inspected. All cultures were negative, and only one probe had a mechanical defect; this probe was removed from use.

Intensified surveillance (performing respiratory tract cultures on all mechanically ventilated patients in this surgical ICU) during January 6–20 identified six additional patients colonized with P. aeruginosa (of the 20 patients tested). All six of these patients also had undergone cardiovascular surgery. Surveillance respiratory cultures from another surgical ICU identified only one patient colonized (of the 11 patients tested) with P. aeruginosa; this isolate had a different antibiotic susceptibility pattern from those of the 16 isolates found earlier. Of the 16 patients identified during the outbreak, two had pneumonia, five had tracheobronchitis, and nine had respiratory tract colonization only. Time from surgery to identification of a positive culture from a respiratory tract specimen ranged from 2 to 14 days (median: 5 days). The patients had undergone various surgical procedures. Those who had undergone valvular surgery alone (n = 13) were at significantly higher risk (relative risk = 5.7, 95% confidence interval = 1.75–18.86) for Pseudomonas infection or colonization than those who had undergone coronary artery bypass grafting alone (n = 32) (Table). The investigation noted that patients undergoing valvular surgery have TEE probes in place during nearly the entire procedure, whereas those undergoing coronary artery bypass grafting had shorter durations of TEE use. A review of operative times found that procedures lasting ≥5 hours (n = 70) were more frequently associated with P. aeruginosa infection or colonization (relative risk = 6.4, 95% confidence interval = 0.89–46.45) than procedures lasting <5 hours (n = 30).

The investigation focused further on manipulations of the respiratory and gastrointestinal tract. An ultrasound transmission gel, Other-Sonic (Pharmaceutical Innovations, Inc., Newark, New Jersey), which was not labeled or sold as a sterile product, was used with TEE probes. The multidose containers of gel were collected and replaced with a single-use, sterile product on January 23. After this change, no additional respiratory cultures with P. aeruginosa were observed.

Molecular typing was performed on the 10 isolates on January 26, and all were determined to be >99% similar by rep-PCR. Cultures of the four previously opened Other-Sonic ultrasound transmission gel bottles removed from the operating room were performed; one of four samples grew P. aeruginosa, and molecular typing revealed it to be highly related (>99%) to the outbreak strain. Five other strains of P. aeruginosa isolated throughout the hospital during the outbreak period also were analyzed and determined to be unrelated to each other or the outbreak strain. Two bottles of sealed, unopened Other-Sonic ultrasound transmission gel subsequently were cultured, one of which grew P. aeruginosa. At this point a health-care system–wide recall of all bottles of Other-Sonic ultrasound transmission gel was initiated, local and state health departments were contacted, and FDA was notified. Additional molecular typing studies (using rep-PCR) showed that the Pseudomonas isolate from the sealed bottle also was >99% similar to the outbreak strain, strongly suggesting contamination of the product during manufacturing, packaging, storage, or shipping.

Reported by

Paul Chittick, MD, Victoria Russo, MPH, Matthew Sims, MD, Susan Oleszkowicz, MPH, Kara Sawarynski, PhD, Kimberly Powell, Jacob Makin, Elizabeth Darnell, Barbara Robinson-Dunn, PhD, Bobby L. Boyanton Jr, MD, Jeffrey Band, MD, Beaumont Health System, Royal Oak, Michigan. Corresponding contributor: Paul Chittick, paul.chittick@beaumont.edu, 248-551-0365.

Editorial note

This report describes an outbreak of Pseudomonas aeruginosa respiratory tract colonization and infection related to the use of contaminated ultrasound transmission gel. Sixteen cardiovascular surgery patients were affected during the outbreak, seven with infection per NHSN criteria, and nine with colonization. Initial investigation suggested the possibility that the TEE probes were the source of the outbreak, given that contaminated TEE probes have been linked to pulmonary infection outbreaks of Legionella previously (2). However, surveillance cultures of the probes were negative, and there was no evidence that all case patients were linked to the use of a particular probe. The ultrasound transmission gel, however, was contaminated with P. aeruginosa. Although contamination during use was initially suspected, the fact that one of two tested bottles of sealed, unopened product was contaminated with P. aeruginosa suggests that the contamination might have occurred before the product reached BHS.

Contaminated ultrasound gels have been associated with outbreaks of infection in various settings and with various organisms, including Klebsiella (3), Burkholderia (4,5), Achromobacter (6), and Staphylococcus aureus (7). Although most of these outbreaks were believed to have occurred from inappropriate use of products, in one circumstance it was determined that the gel had been contaminated at the site of production (4). Although these gels contain parabens or methyl benzoate, which are thought to render them bacteriostatic, some Gram-negative bacteria can degrade these components (4), and investigations of several reported outbreaks suggest extrinsic contamination of gels might easily occur (3,5–7). One study demonstrated that an ultrasound gel had no intrinsic antimicrobial properties (8), and interestingly, results of another in vitro study suggested Pseudomonas spp. might actually survive for shorter periods in ultrasound gel compared with S. aureus or Escherichia coli (9). No ingredient information is available publicly for Other-Sonic ultrasound gel.

Numerous products are available to be used as ultrasound transmission gels. No national guidelines exist in the United States recommending specific types of gel for specific procedures. However, in 2004, Health Canada issued recommendations for minimizing the health risks of using gels (10). These recommendations suggested use of single-use, sterile gels for invasive procedures that pass through a tissue, for all studies involving neonates, for all procedures involving sterile equipment or non-intact skin, and for procedures on intact mucous membranes. The results of this report further support a recommendation for the use of only sterile gels for invasive procedures and procedures involving contact with nonintact skin or mucous membranes. Moreover, because only unopened ultrasound gel containers labeled as sterile should be considered sterile and extrinsic contamination might easily occur, only single-use sterile products should be used for such purposes.

Acknowledgments

Pamela Bozigar, Mary Dietrich, Julie Jordan, MHSA, Paula Keller, MS, Rhea Sautter, MBA, Beaumont Health System, Royal Oak, Michigan.

References

  1. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infection in the acute care setting. Am J Infect Control 2008;
    36:309–32.
  2. Levy PY, Teysseire N, Etienne J, Raoult D. A nosocomial outbreak of Legionella pneumophila caused by contaminated transesophageal echocardiography probes. Infect Control Hosp Epidemiol 2003;
    24:619–22.
  3. Gaillot O, Maruejouls C, Abachin E, et al. Nosocomial outbreak of Klebsiella pneumonia producing SHV-5 extended-spectrum beta-lactamase, originating from contaminated ultrasonography coupling gel. J Clin Microbiol 1998;36:1357–60.
  4. Hutchinson J, Runge W, Mulvey M, Norris et al. Burkholderia cepacia infections associated with intrinsically contaminated ultrasound gel: the role of microbial degradation of parabens. Infect Control Hosp Epidemiol 2004;25:291–6.
  5. Jacobson M, Wray R, Kovach D, Henry D, Speert D, Matlow A. Sustained endemicity of Burkholderia cepacia complex in a pediatric institution, associated with contaminated ultrasound gel. Infect Control Hosp Epidemiol 2006;27:362–6.
  6. Olshtain-Pops K, Block C, Temper V, et al. An outbreak of Achromobacter xylosoxidans associated with ultrasound gel used during transrectal ultrasound guided prostate biopsy. J Urol 2011;185:144–7.
  7. Weist K, Wendt C, Petersen LR, Versmold H, Ruden H. An outbreak of pyodermas among neonates caused by ultrasound gel contaminated with methicillin-susceptible Staphylococcus aureus. Infect Control Hosp Epidemiol 2000;21:761–4.
  8. Muradali D, Gold WL, Phillips A, Wilson S. Can ultrasound probes and coupling gel be a source of nosocomial infection in patients undergoing sonography? An in vivo and in vitro study. Am J Roentgenol 1995;164:1521–4.
  9. Ohara T, Itoh Y, Itoh K. Ultrasound instruments as possible vectors of staphylococcal infection. J Hosp Infect 1998;40:73–7.
  10. Health Canada. Notice to hospitals: important safety information on ultrasound and medical gels. Ottawa, Canada: Health Canada; 2004. Available at http://www.hc-sc.gc.ca/dhp-mps/medeff/advisories-avis/prof/_2004/ultrasound_2_nth-ah-eng.phpExternal Web Site Icon. Accessed April 11, 2012.


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April 23rd, 2012 posted by Paul Rega, MD, FACEP @ 11:51 am

FEMA: Briefing of April 23, 2012

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April 23rd, 2012 posted by Paul Rega, MD, FACEP @ 12:57 am

Here comes the snow……..

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April 23rd, 2012 posted by Paul Rega, MD, FACEP @ 12:43 am

Northeast: Winter makes a comeback

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http://www.reuters.com/article/2012/04/23/usa-weather-northeast-idUSL2E8FM1AB20120423

By Neale Gulley

BUFFALO, N.Y., April 22 (Reuters) – “Winter made a comeback on Sunday as a powerful storm brought rare, late season snow to the northeastern United States, and parts of New England faced the threat of flooding.

After a milder-than-normal winter in most of the country, snow fell late Sunday from the mountains of West Virginia to the southern shores of Lake Erie in Pennsylvania and New York, with as much as one to two feet (.3 to .6 meters) expected over the next 36 hours….”



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April 23rd, 2012 posted by Paul Rega, MD, FACEP @ 12:36 am

North American Plan for Animal and Pandemic Influenza

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http://www.phe.gov/Preparedness/news/Pages/napapi-120402.aspx

FOR IMMEDIATE RELEASE
Monday, April 2, 2012
  Contact: HHS Press Office
(202) 690-6343
 

​​North American countries join forces to prepare for pandemics

A new North American Plan for Animal and Pandemic Influenza supports a faster and more coordinated response to influenza pandemics in North America. President Barack Obama, Mexican President Felipe Calderon, and Canadian Prime Minister Stephen Harper released the plan jointly this week during the North American Leaders Summit as a way to enhance the health and safety of residents of all three nations.
 
Known as NAPAPI, the plan provides, for the first time, a framework for the health, agriculture, security, and foreign affairs sectors of all three countries to collaborate on pandemic preparedness and response. Collaboration among these partners is vital for a faster response to pandemic threats.
 
The countries will collaborate to develop and implement concrete actions that strengthen trilateral emergency preparedness and response capacities and capabilities, such as interconnected systems for surveillance and early warning of disease outbreaks and protocols for transporting laboratory samples. The three countries also will conduct joint epidemiological investigations of viruses that could cause human influenza pandemics, as well as outbreaks of animal influenza that pose a threat to human health.
 
The plan also calls for protecting critical infrastructure in a public health emergency and for developing border policies that do not impose unnecessary restrictions on travel or trade. The plan lays the ground work for mutual assistance during a response, such as sharing personnel as well as vaccines, drugs, diagnostic tests, known collectively as medical countermeasures.
 
“H1N1 provided a stern reminder that diseases don’t respect national borders and can spread rapidly in our interconnected world so protecting health requires cooperation and collaboration among countries,” explained Dr. Nicole Lurie, assistant secretary for preparedness and response in the U.S. Department of Health and Human Services and a rear admiral in the U.S. Public Health Service. “NAPAPI represents a trilateral commitment to enhancing health security across the continent.”
 
The Office of the Assistant Secretary for Preparedness and Response led the U.S. effort to develop the trilateral plan in collaboration with the Departments of State, Agriculture, and Homeland Security and their counterparts in Mexico and Canada. These partners will continue to collaborate on NAPAPI implementation efforts.
 
The plan builds on the 2007 North American Plan for Avian and Pandemic Influenza and is the culmination of efforts begun at the 2009 North American Leaders Summit, in which leaders from the three countries committed to building on the lessons learned from the H1N1 pandemic. NAPAPI complements HHS’s ongoing efforts in global health.
HHS is the principal federal agency for protecting the health of all Americans and providing essential human services, especially for those who are least able to help themselves. The Office of the Assistant Secretary for Preparedness and Response leads HHS in preparing the nation to respond to and recover from adverse health effects of emergencies, supporting communities’ ability to withstand adversity, strengthening health and response systems, and enhancing national health security.
 
The plan is available at www.phe.gov/NAPAPI. Visit www.phe.gov to learn more about ASPR and its international efforts in public health and medical emergency preparedness, response, and recovery.

 

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April 23rd, 2012 posted by Paul Rega, MD, FACEP @ 12:35 am

Mental health care providers and Hurricane Katrina

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Working Through Disaster: Re-establishing Mental Health Care After
Hurricane Katrina
Natalie D. Baker, Martha S. Feldman, and Victoria Lowerson
DISASTER MEDICINE AND PUBLIC HEALTH PREPAREDNESS published 16 April 2012,
10.1001/dmp.2012.12
http://www.dmphp.org/cgi/content/abstract/dmp.2012.12v1?papetoc

Exploring how mental health care providers continued to work during and after Hurricane Katrina…….



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April 23rd, 2012 posted by Paul Rega, MD, FACEP @ 12:34 am

After the Earthquake-Tsunami in American Samoa, 2009

Uncategorized

A Brief Report of Surveillance of Traumatic Experiences and Exposures After
the Earthquake-Tsunami in American Samoa, 2009
Michael E. King, Merritt D. Schreiber, Stephen E. Formanski, Sinclair
Fleming, Tesfaye M. Bayleyegn, and Siitia S. Lemusu
DISASTER MEDICINE AND PUBLIC HEALTH PREPAREDNESS published 16 April 2012,
10.1001/dmp.2012.11
http://www.dmphp.org/cgi/content/abstract/dmp.2012.11v1?papetoc

“…..The most common triage factors reported by survivors referred for mental health services were “felt extreme panic/fear” (93%) and “felt direct threat to life” (93%). The most common factor reported by persons in tsunami-affected communities was “felt extreme panic or fear” (75%)…..”



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