Google Flu Trends
Seasonal influenza epidemics are a major public health concern, causing tens of millions of respiratory illnesses and 250,000 to 500,000 deaths worldwide each year. In addition to seasonal influenza, a new strain of influenza virus against which no previous immunity exists and that demonstrates human-to-human transmission could result in a pandemic with millions of fatalities. Early detection of disease activity, when followed by a rapid response, can reduce the impact of both seasonal and pandemic influenza. One way to improve early detection is to monitor health-seeking behavior.

Google Flu Trends provides near real-time estimates of flu activity based on internet search queries. Google Flu Trends, collects and provides data on search traffic for flu information on a daily basis by detecting and analyzing certain flu-related search terms. Doctors can monitor internet search traffic about the flu to know when to expect a rise in patients coming in complaining of flu-like symptoms or looking for a flu shot.  

Google Flu Trends: http://www.google.org/flutrends/

A Win for Urgent Care!
The American Academy of Urgent Care Medicine, in an Amicus Brief, was successful in striking down a court ruling in the state of Michigan that held that an Urgent Care physician should be held to the same standards of care as that of an Emergency Medicine physician practicing in an emergency department. The original ruling would have had many ramifications for those physicians who operate Urgent Care centers, not only in MI, but also had the potential of spreading this type of doctrine to other states.

The AAUCM wishes recognizes and thank Alexandra Ritucci, ESQ, on this successful accomplishment!

10-Fold Increase Over 2-Year Period In The Use Of Retail Medical Clinics
Use of retail medical clinics located in pharmacies and other retail settings increased 10-fold between 2007 and 2009, according to a new RAND Corporation study. The determining factors in choosing a retail medical clinic over a physician's office were found to be age, health status, income and proximity to the clinic. No link between availability of a primary care physician and retail clinic use was found.

The RAND team used data from a commercially-insured population of 13.3 million to describe trends in retail clinic usage. Of that number, 3.8 million enrollees made at least one clinic visit between 2007 and 2009. During the study period, the rate of utilization increased from a monthly tally of 0.6 visits per 1,000 enrollees in January 2007, to 6.5 visits per 1,000 enrollees in December 2009.

The strongest predictor of retail clinic use was proximity. Other key predictors are gender (females were more likely to visit clinics than males), age (retail clinic patients tended to be between the ages of 18 and 44; those over 65 were excluded from the study), higher income (those from zip codes with median incomes of more than $59,000 were more likely to use retail clinics than lower income groups), and good health (those with a chronic health complaint were less likely to use retail clinics).

"We identified 11 simple acute conditions that can be easily managed at a retail clinic," said J. Scott Ashwood, the study's lead author. "These conditions, which include upper respiratory infection, bronchitis, ear infection, flu, and conjunctivitis, were the most common seen at retail clinics." The researchers found no correlation between retail clinic use and the number of primary care physicians in the community. "It appears that those with a higher income place more value on their time, and will use clinics for convenience if they have a simple health issue such as a sore throat or earache," said Dr. Ateev Mehro

How this trend will affect the rising cost of health care is unclear? Care initiated at retail clinics is 30 percent to 40 percent less expensive than similar care provided at a physician office, and 80 percent less expensive than such care provided in an emergency room. "If the growth in retail clinic visits that we noted represents substitution for other sources of care, then the increase in retail clinic use could lead to lower costs," Ashwood said. "However, if these visits represent new utilization or induced demand -- in other words, patents are seeking care when they would have otherwise stayed home -- then costs could increase. Answering these questions requires additional study."

Finding a Robust Urgent Care EMR – Peer Reviews
In cooperation with the AAUCM, KLAS Research is putting together a comprehensive review of EMR systems for urgent care centers.

Since the key findings from this research will be of interest, all healthcare providers who participate will receive a complimentary summary of the results.

Whether you utilize an EMR today, or are planning to purchase an EMR down the road, would you be willing to share some insight?

Please use this link to contribute your thoughts.  All responses are aggregated and appreciated.

Mosquitoes With West Nile Virus Appearing In Various Parts of the US
The Connecticut Department of Public Health's State Mosquito Management Program has announced that mosquitoes in Bridgeport tested positive for West Nile Virus on June 21st - the first cases identified by CAES (Connecticut Agricultural Experiment Station) in 2011. Tennessee - the state's Public Health Laboratory confirmed WNV in mosquitoes in Memphis, Nashville and Knoxville. State officials urge citizens to use repellants and take other precautions to prevent mosquito and other insect bites. Abelardo C. Moncayo, PhD, director of the Vector-Borne Diseases program for the Tennessee Department of Health, said: "These positive tests tell us that individuals bitten by mosquitoes in Tennessee could be at risk for contracting West Nile Virus. We can help control mosquito populations and lessen the risk of infection by emptying containers with standing water, keeping doors and windows screened, and wearing mosquito repellent when outside." Authorities inform that Tennessee is the 10th state so far in 2011 to show positive tests for WNV in mosquitoes, horses or birds. Officials in South Dakota inform that peak WNV transmission occurs from mid-July through mid-September. There have been over 1,700 human cases reported in the state since 2002, including 26 deaths. Ohio - two mosquito pools in the City of Columbus tested positive for WNV. No human cases have been reported in the state so far. According to the CDC's "2011 West Nile Virus Human Infections in the United States", up to June 28th there has been one human case of WNV infection, reported in Mississippi - a non-neuroinvasive disease case.

AAUCM, AMA, Other Groups Say Proposed Rules for Demonstrating Meaningful Use Are Unrealistic
Medical associations are warning that overly strict meaningful use criteria proposed by the Dept. of Health and Human Services for the next phase of the Medicare and Medicaid electronic medical records incentive program could dissuade physicians from participating. While stage 1 requires that 40% of all permissible prescriptions be transmitted electronically, stage 2 would increase the threshold to 50%. The American Medical Association and 38 other members of organized medicine sent a letter outlining their concerns to the Office of the National Coordinator for Health Information Technology, which is developing the objectives for the program.

States Working to Implement Medicaid Provisions of ACA
Medicaid programs will expand and change significantly over the next few years, largely because of the Affordable Care Act (ACA). An additional 16 million newly eligible people are expected to enroll in Medicaid by 2014. At that point, Medicaid programs also will have implemented a new method to calculate income, as well as new eligibility and enrollment systems that coordinate with the health insurance exchanges that will be established through the ACA. While many of these changes do not take place until 2014, many states already have begun working toward implementation. Given the dire budget situation in many states, however, these implementation efforts have been a challenge. Since 2008, states have confronted declining revenues and been forced to make multiple budget cuts, closing almost $230 billion in budget gaps between fiscal years 2009 and 2011. Because Medicaid is one of the top line items in most state budgets, states have cut funding for those programs for several years. To make the problem worse, Medicaid spending is "countercyclical." As the economy declines, the number of eligible enrollees increases while funding decreases, contributing to the overall budget pressures. While state lawmakers are forced to control Medicaid spending, their options for cutting program costs are somewhat limited by federal requirements. For example, the maintenance of effort requirements tied to the federal stimulus bill and the ACA prohibit states from reducing eligibility levels. As a result, states have implemented other measures, including provider payment cuts. States also have eliminated optional benefits, increased deductibles and/or copayments for certain services, and expanded or created new Medicaid managed care plans. Several states have focused on reducing pharmaceutical costs by implementing formularies, requiring generic substitution or limiting the number of covered prescriptions. The ACA includes several opportunities for states to receive federal funding to explore new Medicaid strategies. For example, the Department of Health and Human Services (HHS) will award state grants for the Medicaid Incentives for Prevention of Chronic Diseases Program, which rewards Medicaid beneficiaries for participating in prevention programs that positively impact their health. HHS also has awarded "early innovator" grants to seven states for designing and implementing the information technology (IT) infrastructure needed to operate the health insurance exchanges, including the means of coordinating with state Medicaid programs. Additionally, the ACA includes several Medicaid demonstration projects that states can pursue, such as pediatric accountable care organizations, the emergency psychiatric care demonstration project and the payment system demonstration project. Federal funding is tied to several of these projects. The ACA also provides grant opportunities or increases in the states' federal medical assistance percentage, or FMAP, for implementing such innovative programs as the community first choice option or home- and community-based services. Recognizing the enormous tasks ahead for the states, HHS and the Centers for Medicare & Medicaid Services (CMS) have signaled their commitment to working with them as they implement the ACA. For example, CMS indicated it will provide an enhanced federal match to states for developing and administering the IT infrastructure for their new eligibility and enrollment systems. In a recent letter to the nation's governors, HHS Secretary Kathleen Sebelius said the Obama administration will work hard to identify cost drivers for the states and offered several suggestions to help states save money, including cutting optional benefits, managing care for high-cost enrollees, controlling pharmaceutical spending and addressing program integrity. States will continue to be the laboratory for innovation. The AMA's Advocacy Resource Center provides tools and resources to state medical societies to support their state legislative and regulatory efforts, including implementation of the ACA. Visit the Advocacy Resource Center website for more information.

Scientists Discover Mutation That Could Cause H1N1 To Spread Faster
Scientists at the Massachusetts Institute of Technology have examined H1N1 and discovered that a single mutation could make the flu more dangerous. They found that the 2009 H1N1 virus, like the first version of the 1918 virus, had a protein structure that did not bind efficiently to cells in the human respiratory tract. In their study in the journal PLoS ONE, the researchers describe how they were able to create a version of H1N1 with a single mutation that greatly increased the virus' binding strength. Moreover, the MIT team noted that further testing showed the mutated version of the virus spread rapidly in ferrets that were used as a model for the human response to influenza.

Study Finds Growing Lack Of Teamwork Between ED, Primary Care Physicians
Coordination between ED physicians and PCPs is often disjointed, according to a study by the Center for Studying Health System Change. Researchers interviewed 21 pairs of ED physicians and PCPs who practiced at the same hospital in 12 communities and found numerous hindrances to teamwork. For example, the availability of more hospitalists and fewer PCPs hinders ED physicians and PCPs from developing close working ties. Moreover, there are technological barriers, with ED physicians and PCPs often using electronic health systems that cannot talk to each other. Lastly, there are financial barriers, such as when follow-up care discussions go unreimbursed and distract both ED physicians and PCPs. The study authors recommend a wide range solutions focusing on better coordination.


Jackson Healthcare is proposing a new federal law in March 2011 to address the high cost of defensive medicine.

This is not a traditional tort reform approach that seeks to limit or “cap” physician liability.  It proposes a no-fault system that benefits physicians in three important ways:

• Prevents anyone from suing physicians personally for medical malpractice.
• Eliminates the hassles of physicians defending themselves against  lawsuits.
• Protects physicians from being personally financially liable and indefinitely tied up in court. 

In essence, this proposal would be similar to the workers’ compensation system.  It would:

• Create a separate administrative agency to oversee malpractice claims,

• Move medical malpractice cases out of civil court system;

• Ensure contested cases are reviewed by a physician panel, rather than a public jury

Here’s how you can help…

STEP 1:  Review the proposal clicking through the next several slides

STEP 2:  Give us your opinion in the survey following the proposal

After you've taken the survey, please pass this onto your colleagues, and encourage them to take the survey.

Click here to begin...

One In Three US Adults May Have Pre-Diabetes, CDC Reports
Approximately one of three American adults may have so-called pre-diabetes, a 39% jump over 2008 estimates, according to a report released by the Centers for Disease Control and Prevention.  According to this new CDC data, half of all Americans over the age of 65 are prediabetic and 27% have diabetes. Minorities are still at higher risk compared with Caucasians: 16 % of American Indians/Alaska Natives, more than 12% of African-Americans and nearly 12% of Hispanic adults now have diabetes, compared with a little more than 8% of Asian-Americans and 7% of non-Hispanic whites. In 2008, the CDC estimated that 23.6 million Americans had diabetes and an additional 57 million adults had prediabetes.

FDA Approves Head Lice Treatment For Children And Adults
The Food and Drug Administration approved Natroba (spinosad) Topical Suspension 0.9% for the treatment of head lice infestation in patients ages 4 years and older. Natroba provides another option for the topical treatment of head lice infestations, which are especially prevalent in the pediatric population. Natroba is a topical drug product and should be applied only to the child's scalp or hair.

Global Fees Reach MA: Urgent Care Centers Are No Longer the Target of This Cost-Reduction Phenomenon
Blue Cross Blue Shield of Massachusetts and the Beth Israel Deaconess Physician Organization have signed an alternative quality contract, thereby covering 40 percent of Blue Cross HMO members under so-called "global payments." The move is a signal that global payments, a system designed to reward doctors for keeping patients healthy and reducing the number of medical procedures, is gaining traction among Massachusetts doctors, reports the Boston Business Journal. The agreement sets a global, or fixed, payment per patient adjusted for age, sex, and health status as well as payments tied to performance on quality measures, health outcomes and patient care experiences. The contract's global payment covers all services received by a patient, including primary, specialty and hospital care, Blue Cross officials said in a statement.   Now, instead of getting paid for every visit, test and procedure, doctors at Beth Israel will receive a budget to care for their Blue Cross HMO patients. If the physicians group goes over-budget, they split the loss with Blue Cross. If they come in under budget, they share the surplus, based on how much they improved the care of patients with certain conditions. If the doctors can't show improvement in patients' conditions or that patients are getting more preventative tests, they don't share the surplus. Beth Israel is the largest physicians group to join the Blue Cross payment system since the insurer started advocating for this contract two years ago. "It's rooted in a group that initially was skeptical," Blue Cross CEO Andrew Dreyfus told WBUR. "It took a long time for the group to come around and I think by the way our discussions with them improved (the contract)." This new way of paying for healthcare already seems "very encouraging," Dreyfus said. "Quality is improving at a faster rate with physicians who are practicing under our new payment model than with physicians who are outside of our payment model."

The Global Fee structure is good for the insurance companies, but not healthy for the public and physicians. The public needs to keep in mind that once an individual is assigned a "fixed dollar amount" to their visit, there is no incentive for a physician or health care system to invest in new diagnostic technologies and/or diagnostic tests, that will not be reimbursed. When purchasing insurance, always ask your insurance company, on what basis will my doctor be reimbursed? Do they endorse Global Fees? If so, walk away. They are only looking at their bottom line. We have not seen any data that shows that health care insurances are reducing premiums with this tactic.

CT Imaging Study May Increase Acute Abdominal Pain Patients' Confidence In Physician's Diagnosis
ED patients who have acute abdominal pain are four times more confident that doctors have correctly diagnosed their conditions when a CT imaging study is used to facilitate diagnosis, according to a study published in the online version of the Annals of Emergency Medicine. Researchers from the University of Medicine and Dentistry of New Jersey surveyed 1,168 patients with non-traumatic abdominal pain and found that 20% were confident in a diagnosis based on patient history and physical exam only. But 90% of patients reported confidence in their diagnosis when the medical evaluations also included blood work and a CT scan.

Will consumer driven algorithms be the next phase vs. as opposed to scientific based processes?

Signs Of Flu Season Upon Us, CDC Officials Announce

The first signs that the flu season is upon us have arrived, says the CDC. In some states, for example Georgia, reported cases of flu have suddenly risen so rapidly that state authorities are referring to a "regional outbreak". It seems that the virus strains identified so far closely match those used in this year's vaccinations, which is good news for those who had the jab.

The CDC has announced December 5 to 11th as National Influenza Vaccination Week. The aim is to stress the importance of vaccinations and to get as many people as possible immunized.

In a communiqué, the CDC wrote:

During the 2010-2011 flu season, three influenza strains are expected to be present. Health authorities say every person aged 6 months or more should be vaccinated. Having the flu jab does not only protect you, but also those around you.

The three flu strains that will be circulating during the current/coming flu season, according to the CDCs' Advisory Committee on Immunization Practices, are:

• An A/H3N2 strain

• A B strain

• The H1N1 (2009) pandemic strain, which for a while was informally termed "swine flu"

The current vaccine protects against these three strains. The CDC says 160 vaccines have been distributed throughout the USA.

Dr. Anne Schuchat, Assistant Surgeon General of the U.S. Public Health Service and CDC's Director of the National Center for Immunization and Respiratory Diseases, said:

"The new vaccination recommendation shows the importance of preventing the flu in everyone. People who do not get vaccinated are taking two risks: first, they are placing themselves at risk for the flu, including a potentially long and serious illness, and second, if they get sick, they are also placing their close contacts at risk for influenza."

Howard K. Koh, M.D., M.P.H.,Assistant Secretary for Health, said:

"The bottom line is, anyone - even healthy people - can get sick from the flu. Lead the way to better health for all by getting your flu shot."

The CDC says that the National Influenza Vaccination Week must engage at-risk audiences - people who have not yet been immunized, individuals who are hesitant or unsure whether having the jab is good for them.

Useful Tool for Docs: http://www.nccc.ucsf.edu/

An Open Letter to the Health Care Insurance Industry

Dear Insurance Carriers:

InQuicker.com, an online ER and Urgent Care check-in system, encourages patients "tired of waiting for hours in the ER waiting room" to check in on the web before they arrive, skipping the hours in the waiting room.  

With story after story of emergency room overcrowding flooding the news ^1,2,3,4,5,6, the question arises as to why this web site – and its participating hospitals – are advocating treatment for non-emergencies? It seems that the emergency medicine community is sending a mixed message; on one hand they purport that the emergency room is intended for life-and-limb treatment, i.e., emergencies, yet they are encouraging patients to come to the emergency room for non-emergency care when perhaps those patients would be better served at an urgent care center.  

Emergency rooms are designed to treat patients suffering from life threatening injuries or serious illnesses. In contrast, urgent care centers are designed to lighten the load on local emergency rooms by treating non-life threatening injuries. The urgent care center is available for any non-life threatening medical illness or injury, providing direct attention without waiting hours for treatment (whether waiting at home or in the emergency room).  

As an insurance carrier, why should you be concerned about this trend? Treating non-emergency cases in an emergency environment will ultimately have a negative effect on your bottom line. Hospitals and their emergency rooms run up bills and then charge you, the insurance provider, emergency room visit fees and facility fees. In contrast, treatment at an urgent care center costs hundreds if not thousands of dollars less.⁷  

By educating consumers to “Know Where to Go” ⁸ and encouraging your participants to utilize urgent care centers for non-emergency care, you will be promoting better health care, helping to solve the health care crisis and helping your bottom line.  

Sincerely,      
Franz Ritucci, M.D.
President, American Academy of Urgent Care Medicine

1. http://www.emergencymedicineexpert.com/index.php/Latest-News/emergency-room-overcrowding-and-the-dangers.html
2. http://aappolicy.aappublications.org/cgi/content/full/pediatrics;114/3/878 
3. http://jama.ama-assn.org/cgi/reprint/276/6/460.pdf
4. http://intqhc.oxfordjournals.org/content/9/3/225.full.pdf 
5. http://www.bizjournals.com/denver/stories/2006/02/13/focus4.html
6. http://rocnow.com/article/living/201010130339 
7. http://www.wisebread.com/cost-comparison-emergency-rooms-vs-urgent-care
8. http://www.aaucm.org/Patients/SelectUrgentCareCenter/default.aspx

InQuicker.com - Online ER and Urgent Care Check-In System
According to the web site InQuicker.com, patients "tired of waiting for hours in the ER waiting room" can check in on the web before they arrive, skipping the hours in the waiting room.

Emergency medicine seems to be sending mixed messages - on one hand they purport that the ED is for emergency/life and limb treatment, yet they want to see patients that  perhaps would be better served at an urgent care center. Are complaints and data of "overcrowding" in the nation's EDs just noise? It's unfathomable that insurance carriers would support this; if a patient pays out of pocket for non-emergency care  appointment using a system such as InQuicker.com, then the insurance company pays a higher rate for treatment and care! Yet the insurance industry wants urgent care centers to accept global fees for their patients!

What are your thoughts on this? Click Here to send comments to the AAUCM.

Cheap Generics Threaten QA Efforts
Four-dollar generic drug programs may boost access to medications but make it tougher to monitor quality of care, researchers warned.Many pharmacies that offer low-cost generics don't submit claims to insurers when patients pay cash, noted Niteesh K. Choudhry, MD, PhD, and William H. Shrank, MD, MSHS, both of Brigham and Women's Hospital and Harvard in Boston. "The consequences of missing these claims is not insignificant," they cautioned in a perspective piece in the Nov. 11 issue of the New England Journal of Medicine.Eight of the 10 largest retail pharmacy chains, including Wal-Mart, Target, and Walgreens, have programs that charge $4 to $9.99 for a one-month supply or $10 to $12 for a three-month supply of some of the most widely used generic medications. As atorvastatin (Lipitor) and clopidogrel (Plavix) go off patent over the next several years, the role of such programs and their impact on public health will only grow, Choudhry and Shrank speculated. "Lower medication costs should have desirable effects on medication use, especially as the patents on more therapies for chronic conditions expire, and these low-cost programs have been a welcome advance for low-income patients," they noted in the article. However, an ironic side effect of the programs' failure to report filling patients' prescriptions when paid in cash is that these patients would be misclassified as nonusers or "nonadherers" to their medication regimen in the pharmacy claims databases that are increasingly used for quality assurance, Choudhry and Shrank wrote. These databases -- used to target interventions to improve adherence, to evaluate effectiveness and safety of medications outside of clinical trials, for pay-for-performance contracts, and to track utilization and expenditure -- "can contribute to long-term improvements in the healthcare system and may thereby directly benefit both current and future patients," Choudhry and Shank explained in their paper. With healthcare reform coming into play, the need to monitor the performance of health systems is even more pressing, they noted. The simplest solution may be to ensure that pharmacists submit all prescription benefit claims regardless of method of payment, which may require providing an incentive to do so without violating conflict-of-interest or kickback regulations, the researchers suggested. Other possibilities would be to use the electronic systems pharmacies use to record transactions and monitor inventory, to use electronic prescribing data instead of prescriptions filled, or to use electronic health records integrated with pharmacy and insurance claims. "Of course, obstacles related to the cost of maintaining these data, privacy concerns, and incentives for data sharing will need to be overcome," Choudhry and Shank wrote. But, they concluded, "we must be certain not to diminish our ability to measure and improve the quality of U.S. healthcare."

Health Care Reform: New Perspectives on Contracting and Partnerships
A nationwide survey of contracting executives in hospitals, health plans and multi-specialty physician groups
http://www.meyerconsultinginc.com/Contracting-Survey-Findings.pdf

Analysis: More Americans Abandoning Prescriptions Due To Price
More Americans are abandoning their prescriptions at pharmacies rather than pay higher prices for them, according to a recent analysis of 80 million pharmacy claims conducted by Wolters Kluwer Pharma Solutions. The data showed that this phenomenon increased by 55% during the second quarter of 2010, compared to 2006 statistics. This finding is crucial because conventional wisdom indicated that prescription drugs were not susceptible to economic downturns since sick people must take medication in order recover, yet, this new evidence suggests that people are in fact deciding whether to pick up prescriptions based on price.  This dovetails with the AAUCM suggestions that Urgent Care centers should provide self dispensing to patients at affordable prices where permitted by state regulations.

Doc Shortage to Worsen After Healthcare Reform
A new estimate from the Association of American Medical Colleges (AAMC) pegs the projected physician shortage at 50% worse than it would have been if healthcare reform hadn't passed. By 2015 -- one year after the majority of the provisions in the Affordable Care Act (ACA) will have taken effect -- the nation will be short 63,000 physicians, a figure that includes both primary care doctors and specialists. Previous estimates put the shortage at 39,600. By 2020, there will be 45,000 too few primary care physicians, and 46,000 too few specialists, according to the AAMC. The Affordable Care Act (ACA) contains several provisions that will add an estimated 3,500 new physicians to the work force over the next 10 years, including primary care grants and reshuffling residency programs. However, the ACA provides insurance coverage for an additional 32 million Americans, so the number of new patients seeking medical care will far outweigh the number of doctors trained to provide it. In addition, the Census Bureau projects a 36% growth in the over-65 population in the next decade, which means an influx of Medicare recipients. Couple that with a projection that nearly one-third of all physicians are expected to retire in the next decade, and the "need for timely access to high-quality care will be greater than ever," the AAMC said in a press release. The AAMC said that although medical school enrollment continues to increase, more residency training slots are needed, and Congress should overturn a 1997 law that put a freeze on Medicare-funded residency positions. "Unless Congress supports at least a 15% increase in residency training slots (adding another 4,000 physicians a year to the pipeline), access to healthcare will be out of reach for many Americans," the group said in its press release. The problem will be most pronounced for people living in rural and underserved areas where finding a doctor can already be a difficult task, according to the report. Urgent Care is poised to fill this need!

Drug Updates

Lamictal
The FDA warned that Lamictal (lamotrigine), approved to treat seizures and bipolar disorder, can cause aseptic meningitis, an inflammation of the meninges that cover the brain and spinal cord not caused by bacterial infection. The agency is working with the drug's manufacturer, GlaxoSmithKline, to update the prescribing information and Patient Medication Guide to include information on this risk. The FDA became aware of the association between Lamictal and aseptic meningitis through routine adverse event monitoring and communications with the drug's manufacturer. Since the drug's approval in December 1994 through November 2009, there were 40 cases of aseptic meningitis identified in patients taking Lamictal. The symptoms were reported to occur within 1-42 days after starting Lamictal. Thirty-five of the 40 patients required hospitalization and in most cases, symptoms ended after Lamictal was discontinued. In 15 cases, symptoms, often more severe, returned when patients restarted the drug. For more information, visit www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm222212.htm .

Cubicin
The FDA is informing patients and healthcare professionals about the potential for developing eosinophilic pneumonia during treatment with Cubicin (daptomycin), an intravenous antibacterial drug. In 2007, pulmonary eosinophilia was added to the Adverse Reactions, Post-Marketing Experience section of the Cubicin product label. Since then, the Agency has reviewed published case reports of Cubicin-associated eosinophilic pneumonia, and conducted a review of post-marketing adverse event reports from the FDA's Adverse Event Reporting System (AERS). The FDA's review identified seven cases of eosinophilic pneumonia between 2004 and 2010 that were most likely associated with Cubicin. Based on these reviews, the FDA determined that eosinophilic pneumonia can be associated with Cubicin use and requested that the manufacturer of Cubicin include this information in the Warnings and Precautions and Adverse Reactions, Post-Marketing Experience sections of the drug label. Healthcare professionals should closely monitor patients being treated with Cubicin for eosinophilic pneumonia. Patients receiving Cubicin should immediately contact their healthcare professional if they develop a new or worsening fever, cough, shortness of breath, or difficulty breathing. For more information, visit www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm220273.htm.

Simcor
Abbott received FDA approval for two new dosage strengths of Simcor: 40 mg of simvastatin–the most commonly prescribed dose of simvastatin–with either 500 mg or 1,000 mg of niacin extended-release. Simcor is used along with diet in people who cannot control their cholesterol levels by diet and exercise alone. Simcor is approved to raise HDL cholesterol and lower levels of elevated total cholesterol, LDL cholesterol, and triglycerides and is prescribed when treatment with either simvastatin or niacin extended-release alone is not considered adequate. Simcor is already available in the following strengths: 500/20 mg, 750/20 mg and 1,000/20 mg. For more information, visit www.abbott.com.

Influenza Vaccines for 2010-2011 Season
The FDA has announced that it has approved vaccines for the 2010-2011 influenza season in the U.S. Seasonal influenza vaccine protects against three strains of influenza, including the 2009 H1N1 influenza virus, which caused the 2009 pandemic. Because the 2009 H1N1 virus emerged after production began on the seasonal vaccine last year, two separate vaccines were needed to protect against seasonal flu and the 2009 H1N1 pandemic flu virus. This year only one vaccine is necessary. Vaccines for the 2010-2011 seasonal influenza contain the following strains: A/California/7/09 (H1N1)-like virus (pandemic (H1N1) 2009 influenza virus), A/Perth/16/2009 (H3N2)-like virus, and B/Brisbane/60/2008-like virus. The brand names and manufacturers for the upcoming season's vaccines are Afluria (CSL Limited), Agriflu (Novartis Vaccines and Diagnostics), Fluarix (GlaxoSmithKline Biologicals), FluLaval (ID Biomedical Corporation), FluMist (MedImmune Vaccines Inc.), Fluvirin (Novartis Vaccines and Diagnostics Limited), and Fluzone and Fluzone High-Dose (Sanofi Pasteur Inc.).

Each year, experts from the FDA, WHO, CDC, and other institutions study virus samples and patterns collected worldwide to identify strains likely to cause the most illness during the upcoming season. Based on that information and the recommendations of the FDA's Vaccines and Related Biological Products Advisory Committee, manufacturers included the respective three strains in the 2010-2011 vaccines. The closer the match between the circulating strains and the strains in the vaccine, the better the protection against influenza disease. For more information, visit www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm220718.htm.

Many Emergency Department Visits Could Be Managed At Urgent Care Centers and Retail Clinics
Researchers analyzed samples of patient records and found 13.7% of all ED visits could take place at a retail clinic – 7.9% when hours are restricted – and an additional 13.4% of ED visits could take place at a urgent care center — 8.9% when hours are restricted. That is, a total of 27.1% of all ED visits could be managed at a retail clinic or urgent care center — 16.8%  when hours are restricted. Assuming the smallest of each of these savings and assuming that 16.8% of the 104 million ED visits that did not result in a hospital admission in 2006 could take place in one of these alternative settings, the potential savings to the health care system would be approximately $4.4 billion annually, or 0.2% of national health care spending.

Relationship Between Patient Panel Characteristics and Primary Care Physician Clinical Performance Rankings
An intrinsic assumption underlying physician clinical performance assessment is that the measures represent physician performance. However, the same physician may have higher or lower measured quality scores depending on the panel of patients he or she manages. Researchers looked at data from a large academic primary care network; 125,303 adult patients who had visited any of the nine hospital-affiliated practices or four community health centers [at Massachusetts General Practice] between January 1, 2003, and December 31, 2005 report that the primary care doctors who were rated in the top third of measured quality were more likely to care for older patients with greater comorbidity who made more frequent visits to see a primary care physician. Because older patients with more comorbidities are often seen more frequently, they may have stronger relationships with their physicians, and physicians caring for such patients may have more opportunities to complete process measures. Those physicians were also less likely to care for minority, non–English-speaking, Medicaid, and uninsured patients than the doctors in the bottom third of the rankings.

The FDA has a new pamphlet available for physicians to provide to parents on giving over-the-counter medications to their children. To order FREE copies of this brochure for your clinic, call Sherunda Lister at  301-796-3124.

Dengue Information for Clinicians
Dengue infection is caused by any of four distinct but closely related dengue virus (DENV) serotypes (called DENV-1, -2, -3, and -4).  Dengue viruses are flaviviruses, a family which includes other medically important vector-borne viruses (e.g., West Nile virus, St. Louis encephalitis virus, etc.).  Dengue is currently the most frequent cause of acute febrile illness among returning U.S. travelers from the Caribbean, Central and South America, and Asia.  It is widespread throughout the tropics and sub-tropics and an outbreak was recently identified in Key West, Florida.  The primary method of transmission is through the bite of an infected Aedes aegypti. mosquito.  Dengue may also be transmitted from mother to fetus in utero or to neonate at parturition.  Incubation period is 3-14 days.  Infected persons may be asymptomatic in up to 53-89% of cases.  Clinical presentation in those who become ill can range from a mild non-specific febrile syndrome, to classic dengue fever (DF), or in the most severe forms of the disease (2-4% of cases), dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS).  Early clinical recognition and treatment for those who develop DHF or DSS can save lives.   Dengue should be considered when persons that live in or have traveled to a dengue endemic area in the two weeks prior to symptom onset have fever and two of the following signs and symptoms:

• Ache and pains (headache, retro-orbital pain, myalgia, arthralgia)
• Anorexia and nausea
• Rash
• Positive tourniquet test
• Leucopenia Warning sign for severe disease. 
• Warning signs typically manifest after a two to seven day febrile phase and include abdominal pain or tenderness, persistent vomiting, mucosal bleeding, liver enlargement greater than two centimeters, clinical fluid accumulation, lethargy/restlessness, or laboratory results indicating an increase in hematocrit concurrent with a rapid decrease in platelets.

 

Patients at risk for severe disease:
Previously infected with another dengue virus  
Diabetes mellitus
Pregnant women                                                 
Chronic renal failure Infants                                                              
ObesityElderly

Laboratory testing is necessary to confirm whether local transmission is occurring and to identify circulating virus types (PCR).  Serum samples collected during the first five days post onset should be submitted for PCR testing to DOH Tampa Laboratory.  Most convalescent serum samples (>6 days onset) should be submitted for IgM antibody detection by ELISA at a commercial laboratory.  Either PCR or ELISA samples can be collected in a red or tiger top tube.  Your county health department can provide guidance on how and when to submit samples to DOH Laboratories. The Florida Department of Health is relying on physicians to identify suspect cases of dengue and report them to their county health department.  Please contact your county health department by the next business day if you suspect dengue to ensure prompt mosquito control efforts.

Resources:
CDC guidelines for clinical management of dengue infection http://www.cdc.gov/dengue/clinicallab/clinical.html  
More information on the 2009 Key West dengue outbreak: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5919a1.htm                       

Dengue Clinical Sample Submission Guidelines
When dengue is suspected in a patient, a sample should be promptly submitted to either the Dept. of Health or a commercial laboratory such as Quest or LabCorp.  The following categories will help you determine which laboratory is appropriate:

This Year's Flu Vaccine To Include H1N1, Influenza B, and New Strain H3N2
The swine flu, which nearly caused a national panic last year before collapsing by year's end, remains very low across the US, with no indication it will worsen as the fall flu season nears. However, this year, unlike last year, there will be a single vaccine that will cover H1N1, the seasonal influenza B, and a new strain, H3N2. Also, unlike last year when the federal government paid for the swine flu vaccine and set up special locations, this year, the combined vaccine will be disseminated mostly through commercial facilities, including private doctors' offices, clinics and pharmacies.

More ED Crowding Expected Under New Healthcare Law
EDs may grow even more crowded with longer wait times under the nation's new health law. Even though the new measure may help millions of Americans secure insurance, there is already a shortage of front-line family physicians in some places and experts think that will get worse. What's more, people without insurance aren't the ones filling up the nation's EDs. In fact, the biggest users of ED's by far are Medicaid recipients, and the new health insurance law will increase their ranks by about 16 million.

Number of People Visiting Hospital EDs Climbed In Massachusetts
The number of people visiting EDs has climbed in Massach