CDC Health Information for International Travel
The 2014 edition of
the CDC’s famed encyclopedia, better known as the "Yellow Book," on
prevention and treatment of travel-related diseases is now available. To order: http://wwwnc.cdc.gov/travel/page/yellowbook-home-2014.
Investigators Cite Top 10 Strategies to Improve Patient Safety
Following certain strategies could save the lives of the many patients
who die in US hospitals because of unsafe practices by health care
workers, a team of investigators report in a supplement of the Annals of Internal Medicine. Each year, diagnostic errors result in the deaths of an estimated 44 000
to 80 000 patients, and many thousands die because of teamwork and
communication errors affecting their care or because they do not receive
necessary evidence-based interventions. Nearly 68 000 patients die from
complications associated with bed sores, a largely preventable
To address such problems, a team of investigators from RAND Health;
Stanford University; the University of California, San Francisco; and
Johns Hopkins University, commissioned by the federal Agency for
Healthcare Research and Quality, examined evidence supporting useful
measures and issued their “top 10” list of evidence-based strategies to
improve patient safety. These include
In an accompanying editorial,
several of the investigators noted that further research is needed on a
variety of issues, such as developing better measures of harm and
context, organizing a safety program, and integrating systems
engineering approaches into clinical environments. “A decade ago, our
early enthusiasm for patient safety was accompanied by a hope, and some
magical thinking, that finding solutions to medical errors would be
relatively straightforward,” they wrote. Acknowledging the naivete of
that point of view, they went on to say, “Making patients safe requires
ongoing efforts to improve practices, training, information technology,
Medication Adherence Increased By Automated Phone And Mail Notices
Patients newly prescribed a cholesterol-lowering medication were more
likely to pick it up from the pharmacy if they received automated phone
and mail reminders, according to a study published in the Archives of Internal Medicine.
This is one of a few published studies to examine strategies for
reducing primary nonadherence, which occurs when patients do not pick up
The study of 5,216 Kaiser Permanente Southern California patients found
that those who received an automated reminder were 1.6 times more likely
to fill prescriptions for cholesterol-lowering statins than those who
didn't receive a reminder. Informational and encouraging phone calls
were automatically generated if a patient did not pick up his or her
medication within one or two weeks of a doctor's appointment where a
prescription was written. One week after the telephone call, researchers
sent a reminder letter to patients who still had not picked up their
prescription. When systems for automated outreach exist, the expense of
outreach is relatively small. Expenses for both these prompts totaled
$1.70 per participant in the study. After the intervention, the
percentage of patients who picked up their prescriptions increased from
26 to 42 percent.
"Getting patients to take the well-proven medicines their physicians prescribe for them will ultimately reduce their risk of heart attacks and stroke,"
said Stephen F. Derose, MD, of the Kaiser Permanente Southern
California Department of Research & Evaluation. "This automated
intervention is a good way to very efficiently reach a large number of
people and improve their health outcomes."
Medication nonadherence occurs when a patient does not follow a
clinically prescribed medication course, endangering his or her own
health and possibly necessitating more aggressive treatment or
hospitalizations later. Previous studies estimated that in the United
States each year medication nonadherence contributes to approximately
125,000 deaths and costs the health care system $290 billion. One in
three patients prescribed a medication by their health care provider
never pick it up from the pharmacy, and, among those who do, nearly 3 in
4 Americans do not take prescription drugs according to providers'
Although this study examined medication adherence exclusively among
patients at Kaiser Permanente Southern California receiving their first
prescription for a statin drug, the low-cost method is likely to be
viable for large populations, other chronic conditions, and other
medications. Based on the results of the study, Kaiser Permanente
Southern California implemented a new regional outreach program in April
2012. The program has sent reminders to about 2,200 members each month.
"Given the prevalence of the problem, especially among patients with
chronic conditions, minor improvements in medication adherence among
groups of people should yield significantly better health outcomes for
patients and savings for hospitals and health systems," said Derose.
Kaiser Permanente can deliver transformational health research in part
because it has the largest private electronic health system in the
world. The organization's integrated model and electronic health record
system securely connect 9 million people, 533 medical offices, and 37
hospitals, linking patients with their health care teams, their personal
health information, and the latest medical knowledge. It also connects
Kaiser Permanente's epidemiological researchers to one of the most
extensive collections of longitudinal and de-identified medical data
available, facilitating studies and important medical discoveries that
shape the future of health and care delivery for patients and the
medical community. This research is a part of Kaiser Permanente's
broader efforts to understand and prevent medication nonadherence.
Previous Kaiser Permanente research includes:
ECG Screening Unnecessary
Adults with no symptoms and few risk factors for heart
disease shouldn’t routinely be screened with resting or exercise ECG according
to the US Preventive Services Task Force. In an update to a similar recommendation
it made in 2004, the task force said studies show that up to 3% of asymptomatic
adults with abnormalities on an exercise ECG test underwent angiography, which
could trigger myocardial infarction or stroke. Adults at intermediate or high
risk of a myocardial infarction or other heart problem should receive
treatment, not screening, the task force added.
Antibiotic Use Can Be Reduced By Shared Decision-Making Between Doctors And Patients
A training tool that helps physicians involve patients in decision-making can reduce the use of antibiotics for acute respiratory infections, according to a study published in CMAJ (Canadian Medical Association Journal).
Antibiotics are prescribed too often for acute respiratory infections,
even though many are not bacterial infections and therefore will not
respond to antibiotic use. Overuse of antibiotics is a health concern
and may be contributing to antibiotic resistance.
Researchers conducted a cluster randomized trial to determine the impact
of a shared decision-making training program called DECISION+2 on the
use of antibiotics. Shared decision-making, in which a health care
professional and patient make a decision together based on evidence and
patient preferences, has been shown to be effective when benefits of
treatment are not clearly evident for all patients.
The study was divided into two groups, one group of 181 patients who
consulted 77 physicians in 5 family practice teaching units using
DECISION+2 and a control group of 178 patients who consulted 72
physicians in 4 family practice teaching units. DECISION+2 included an
online tutorial followed by an interactive workshop.
"After the intervention, patients in the DECISION+2 group were
significantly less likely than patients in the control group to report a
decision to use antibiotics immediately after consultation," writes Dr.
France Légaré, Research Centre of Centre Hospitalier Universitaire de
Québec and Department of Family Medicine and Emergency Medicine,
Universitaire Laval, Québec, with coauthors. "The reduction in decisions
to use antibiotics was observed in all intervention teaching units,
while an increase was seen in 3 of 4 teaching units in the control
The results of this study are similar to those from an earlier pilot study that looked at the feasibility of this larger trial.
"These studies indicate that a combination of live and media education
are generally effective in changing physician performance in the context
of antibiotic use for acute respiratory infections," write the authors.
"These findings are important given the debate and widespread
skepticism about the effect of medical education on the performance of
physicians in the practice setting."
Hold Off on Antibiotics for Sinus Infection, Guidelines Urge
Between 90% and 98% of sinus infections won't respond to antibiotics,
so doctors should hesitate before reaching for the prescription pad,
according to new guidelines for the treatment of rhinosinusitis from the
Infectious Diseases Society of America.
"There is no simple test that will easily and quickly determine
whether a sinus infection is viral or bacterial, so many physicians
prescribe antibiotics 'just in case,'" commented Anthony Chow, MD, of
the University of British Columbia in Vancouver, who chaired the panel
that developed the guidelines.
But, he added in a statement, "if the infection turns out to be viral
-- as most are -- the antibiotics won't help and in fact can cause
harm by increasing antibiotic resistance, exposing patients to drug side
effects unnecessarily and adding cost."
The guidelines, published online in Clinical Infectious Diseases,
offer primary care physicians 18 recommendations to help ensure
appropriate treatment, ranging from how to tell bacterial from viral
infections to when to call in a specialist.
Although most cases are viral, the guidelines suggest suspecting a bacterial cause when:
Where a bacterial cause is likely, the guidelines suggest prompt treatment with an antibiotic.
Many previous guidelines had suggested empiric therapy with the
beta-lactam antibiotic amoxicillin, but an increasing proportion of
respiratory pathogens now produce beta-lactamase, which breaks down the
So, the new guidelines say, initial therapy should add clavulanate, a beta-lactamase inhibitor, to the amoxicillin.
The recommendation applies to both adults and children.
Because of increasing rates of drug resistance, the guidelines also
recommend not using other common antibiotics, including azithromycin
(Zithromax), clarithromycin (Biaxin), and trimethoprim-sulfamethoxazole
The new guidelines also say that a shorter treatment time for adults
-- five to seven days, rather than 10 to 14 -- is long enough to
treat a bacterial infection without encouraging resistance.
Children should still be treated for 10 days to two weeks, the guidelines say.
Regardless of the cause of the infection, the guidelines discourage
decongestants and antihistamines, which don't help and in some cases can
make symptoms worse.
On the other hand, nasal steroids can help ease symptoms in people who have sinus infections and a history of allergies.
Saline nasal irrigation might help relieve some symptoms, the
guidelines say, although it might not be as helpful in children because
of the discomfort of the therapy.
Official Food Allergy Treatment Guidelines - Protocol Designed To Aid Physicians In Diagnosis
A collaborative, government-led effort to guide and standardize diagnosis, treatment and management of food allergies has resulted in the release of an official set of recommendations for physicians.
The guidelines were published online by the Journal of Allergy and Clinical Immunology (JACI), and available online here. They were developed by the National Institutes of Health and leading researchers and clinicians, professional and patient advocacy organizations, and the American Academy of Allergy, Asthma & Immunology, among others.
Food allergies are among the most common medical conditions, believed to affect three out of 100 Americans, and the number of affected people has been steadily rising in the last 20 years for reasons not well understood, scientists say.
"Paradoxical as it may be, up until now we have lacked uniform guidelines based on hard scientific evidence about how to diagnose and treat these very common conditions that affect the lives of millions of people," said Robert Wood, M.D., one of the six lead authors on the guidelines and director of the Division of Allergy & Immunology at Johns Hopkins Children's Center.
The guidelines, available here, are designed for use by specialists, primacy-care physicians and other healthcare staff. They consolidate the latest available data into straightforward and consistent protocols for diagnosis and treatment.
"Because the guidelines will give physicians a uniform and consistent pool of information on the latest and most effective diagnostic and therapeutic approaches, patients are more likely to get the most-up-to-date care regardless of where they seek care," Wood says.
Some topics covered in the guidelines include:
Recommendations for X-rays in Low Back Pain
X-rays are unnecessary for the routine management of low back pain outside of the setting of red flags. In the setting of red flags, x-rays at the first visit are usually recommended to assist in ruling out these possible conditions (e.g., fracture, neoplasias, infection, etc.). Even when red flags are suspected, judgment is recommended and it should not be mandatory to order x-rays in all cases. In the event that there is low back pain without improvement over four to six weeks, x-rays may be recommended to rule out other possible problems. Those with subacute low back pain that is not improving or chronic low back pain should have x-rays at least once for purposes of ruling out other conditions. X-rays are non-invasive, moderately costly, and have a low risk of adverse effects, other than their considerable exposure to ionizing radiation. Thus, x-rays are recommended for certain situations. The figure below shows the radiation dosage from common medical tests.
Updated Clinical Practice Guidelines:
Pediatric Preventive Health
Child Immunization (Ages 0-6)
Adolescent Immunization Schedule (Ages 7-18)
Adult Immunization Schedule (over 18)
Congestive Heart Failure
Human Immune Deficiency Virus i aidsinfo.nih.gov
Adult Preventive Health
Chronic Kidney Disease
Coronary Artery Disease
Chronic Obstructive Pulmonary Disease
Child and Adolescent Obesity
Child and Adolescent Hypertension
Intranasal Monovalent Vaccine Administration Instructions
Administration of the Intranasal Influenza A (H1N1) 2009 Monovalent Vaccine can be confusing, leading to incorrect dosing. Influenza A (H1N1) 2009 Monovalent Vaccine Live, Intranasal is indicated for the active immunization of individuals 2-49 years of age against influenza disease caused by pandemic (H1N1) 2009 virus.Dosage and administration instructions for intranasal H1N1 monovalent vaccine is available here.
FDA Okays Sixth Seasonal Flu Vaccine
The FDA has approved the seasonal influenza subtype A and B vaccine Agriflu for patients ages 18 and older. The approval was based on a demonstration that the vaccine created levels of antibodies in blood likely to be effective in flu prevention. Side effects in Agriflu's clinical trials included pain, swelling and redness of injection site, headache, muscle ache, and malaise. The drug should not be administered to patients with severe allergies to eggs or any other vaccine ingredient. The new vaccine is not approved for prevention of the 2009 H1N1 virus. seasonal flu. The drug is distributed in single dose, prefilled syringes for single injection in the upper arm. Agriflu is the sixth drug approved for vaccination against the 2009-2010 seasonal influenza virus. The drug was made available through the agency's accelerated approval pathway, which makes devices and products for serious or life-threatening diseases available sooner than usual if they demonstrate safety and efficacy.
New Guidelines on Breast Cancer Screenings Creates Controversy
New advice from the U.S. Preventive Services Task Force: biennial screening mammography for women 50 and older, saying most women in their 40s should not routinely get mammograms. They also recommending against clinicians teaching women how to perform breast self-exams. This is a reversal of previous guidelines recommending annual mammograms beginning at age 40 and promoting self-examination. The new guidelines are sharply challenged by the American Cancer Society who will continue to recommend mammograms to women 40 and over. The American College of Obstetricians and Gynecologists also believes there is still significant benefit to women in their 40s to have routine mammograms.
Diagnostic Imaging Question: Which radiologic test should be ordered first for the evaluation of suspected urolithiasis in the pediatric age group?
Answer: Although not as accurate as computerized tomography (CT), ultrasound (US) identified almost all clinically important renal stones in children presenting with suspected urolithiasis. The benefits of US include no ionizing radiation and lower costs. Stronger evidence from a randomized trial comparing outcomes from similar children initially undergoing either US or CT scanning is needed before setting a standard of practice.
FDA Approves HPV Vaccine for Men and Boys
The FDA approved Merck's Gardasil vaccine against human papillomavirus (HPV) for boys and men, the same day that it okayed .. Gardasil was approved for males ages 9 to 26 for prevention of genital warts. The approval did not address claims that the vaccine in this population may help prevent transmission to girls and women. The agency also approved the first competitor for Gardasil since the latter came on the market in 2006. GlaxoSmithKline's Cervarix was cleared for use in girls and women, 9 to 26 years old. Gardasil is given as three injections over a six-month period. Headache, fever, pain at the injection site, itching, redness, swelling, and bruising were the most common side effects observed in the clinical studies.
Allergy Groups Issue Guidelines for Vaccine AEs
New guidelines state that an adverse reaction seemingly associated with a recently-received vaccine should not automatically preclude receiving that same vaccine in the future. Patients who have a suspected allergy to a vaccine or its components should be evaluated by an allergist or immunologist. Most of these patients will eventually be able to receive the vaccine suspected of causing the problem.In many cases, patients who have had adverse reactions following vaccination have been advised to avoid future immunization. But, although there are some adverse reactions to vaccines that constitute absolute contraindications to administration of future doses, most such reactions do not preclude subsequent immunization. Future immunization would be contraindicated in patients who develop Guillan-Barré syndrome within six weeks of influenza vaccination and in those who develop encephalopathy after receiving the pertussis vaccine. Conversely, patients with mild local reactions - such as swelling, redness, and soreness - and constitutional symptoms - such as fever - should not be excluded from vaccination in the future.
Allergic or IgE-mediated reactions to vaccines are more often caused by the components of vaccines, rather than the immunizing agent itself. The most common culprits are gelatin and egg protein, although reactions to yeast, latex from vial stoppers and syringe plungers, neomycin, and thimerosal have been recorded. Thus, a history of allergy to gelatin should be obtained from any individual before giving them a gelatin-containing vaccine. Additionally, vaccines with high amounts of egg protein, including influenza vaccines, should be given to egg-allergic patients only after evaluation by an allergist. Most of these patients can still receive a flu vaccine.
Report all adverse events following immunization to the Vaccine Adverse Event Reporting System established by the CDC and FDA even if there is uncertainty regarding the cause.
Seasonal Influenza Information Guide
Annual vaccination against seasonal influenza is recommended for
· All persons who want to reduce their risk of becoming ill with influenza or of spreading it to others
· All children and teens ages 6 months through 18 years
· All persons age 50 years and older
· All children and teens receiving long-term aspirin therapy
· All women who will be pregnant during the influenza season
· Adults and children with any of the following conditions:
o a chronic disorder of the pulmonary (including asthma) or cardiovascular (except hypertension) system
o a chronic disease of the blood. liver. or kidneys; immunosuppression (e.g., including that caused by medications. HIY); or metabolic disorder (e.g., diabetes)
o a neurologic or n uromuscular disorder (e.g., cognitive dysfunction)
· All residents of nursing homes or other chronic-care facilities
· All healthcare personnel
· All household contacts (including children) and caregivers of (1) children ages 0-59 months (especially younger than 6 months; (2) adults age 50 years and older; and (3) persons with high risk medial conditions
· Persons planning to travel to an area of the world with influenza activity (e.g., to the tropics at any time of the year)
Contraindications and Precautions
· Do not give influenza vaccine to a person who has had an anaphylactic reaction to a prior dose of the vaccine or any of its components (e.g., eggs). Minor illnesses with or without fever do not contraindicate use of influenza vaccine.
· Do not give nasal spray LAIV to persons who are younger than age 2 years; age 2 through 4 years with possible reactive airways disease (e.g., history of recurrent wheezing or a recent wheezing episode*); age 50 years or older; pregnant; have a chronic disease that is an indication for routine influenza vaccination; or are a child or teen receiving long-term aspirin therapy. Injectable TIV is preferred for persons who have close contact with severely immunosuppressed persons during periods when the immunocompromised person requires protective isolation.
· Guillain-Barré syndrome within 6 weeks following a previous dose of influenza vaccine is a precaution for vaccination with TIV or LAIV.
*Ask parents of children 2-4 years: “In the past 12 months, has a healthcare provider ever told you that your child had wheezing or asthma?” If yes, do not give LAIV; instead give TIV.
Vaccine Dosing and Administration
· TIV: Give 0.25 mL if age 6-35 monyhs; give 0.5 mL if age 3 years or older. Give 1M with a 22-25g, 1-1½” needle. Choose vaccine according to patient’s age (i.e., FluZone: 6 months and older; Fluvirin: 4 years and older; Afluria, Fluarix, and FluLaval: 18 years and older).
· LAIV (FluMist): Give 0.2 mL (0.1 mL sprayed into each nostril) to healthy non-pregnant persons ages 2 through 49 years.
· Give 2 doses to all children younger than age 9 years who are receiving influenza vaccine for the first time or who failed to receive the 2nd dose in the preceding year. Separate the 2 doses by at least 4 weeks.
· The most common side effects from TIV are soreness and redness at the injection site, lasting 1-2 days
· The most common side effect from LAIV are runny nose and nasal congestion.
Talking Points with Patients
· Influenza is a serious respiratory disease caused by a virus. It is not the same as the common cold or an intestinal illness.
· An average of 36,000 deaths and more than 200,000 hospitalizations related to seasonal influenza occur in the U.S. each year.
· Vaccination is usually 70-90% effective in preventing influenza in healthy adults and children. Its effectiveness may be lower if the circulating influenza viruses are not matched by the vaccine strains, but vaccinated persons will likely have milder illness.
· Unvaccinated healthy people who get influenza can spread their infection to others who are most vulnerable to its complications.
Timing: Vaccination should begin as soon as vaccine becomes available and should continue until supply is depleted.
Current information on H1NI influenza can be found at www.cdc.gov/h1n1flu
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