In this issue:

News Briefs:
Brushing, Flossing Battle Against Diabetes? Heart Disease?
Hormonal Diabetes Treatment Shows Promise
Increases in Prescription Drug Sales and Expenses Reported
Study Suggests Effective Once-a-Year Osteoporosis Treatment

Numbers Experiencing Cardiac Death Before Hospital Arrival Remain High

Potential Hunter Hazard

Notes from Iowa's State Epidemiologist's Office:
Influenza Update

Triage Without Vital Signs Misses Key Information

Factoids

Cool Web Sites

Quotable Quotes

ERDOCS listserv

How to get in touch with us; questions; sponsorship

News Briefs

Brushing, Flossing Battle Against Diabetes? Heart Disease?
Brushing and flossing teeth may also help stave off diabetes, according to a study released on March 8, 2002.

A supervising scientist in the study went on to speculate that gumdisease may even be more important than obesity or age as a factor in the onset of diabetes in adults. More than 16 million Americans have Type 2 diabetes, representing nearly 90 percent of the cases of diabetes in the US.

In the study presented at a meeting of the International Association of Dental Research in San Diego, glucose control was measured in 75 members of Pueblo Indian communities in Santa Fe, New Mexico, who had both Type 2 diabetes and severe gum disease, after treatment with various antibiotic regimens.

Researchers found that results showed blood sugar levels could be reduced and kept at a lower level most effectively with a single dose of oral antibiotic and repeated application of a topical antibiotic to the gums. The effects were equal to and independent of those induced by diabetes medication.

In another study, the University of Buffalo researchers showed that using antibiotics to treat gum disease decreased two markers of inflammation throughout the body. The inflammatory markers are associated with the development of atherosclerosis and other chronic diseases. Can a connection to reduction in heart disease be far behind?

Health experts have said the United States could see the number of diabetes cases swell to 29 million over the next 50 years.

Hormonal Diabetes Treatment Shows Promise
A pilot study, published in this week's issue of The Lancet, shows the ntestinal hormone known as glucagon-like peptide or GLP-1 may eventually become a new treatment alternative in Type 2 diabetes. The hormone is associated with insulin production and is found in lesser concentrations in people with type 2 diabetes.

Danish researchers treated 20 patients with the disease with either IV injections of the hormone or saline placebo for 6 weeks. They found patients who received GLP-1 improved in several major areas used to measure diabetic function -- without any reported side effects.

Improvements included:

• Fasting and eight-hour average blood glucose levels decreased
• Participants lost an average of about 4 lbs in body weight
• Appetite was reduced
• Insulin sensitivity and cell function improved

Increases in Prescription Drug Sales and Expenses Reported
Television advertising, aging baby boomers and the greater use of expensive new medications drove prescription drug sales up 17.9 percent last year, a newly released study reported. Americans paid about $208 billion last year for prescription drugs - almost double that spent in 1996, according to NDCHealth, a health care information company.

But at the same time, drug companies slowed the rapid pace of some other promotional spending. The companies spent 6 percent more last year on sales representatives, consumer advertising and meetings with doctors, according to the study. In 2000, those promotional costs rose more than 19 percent and 234 percent in 1999.

The total number of prescriptions increased 6.6 percent, to 3.3 billion, last year. Prescriptions for antidepressants rose 10 percent with more than seven million people taking an antidepressant last year - up 700,000 from 2000.

Total drug sales grew at a much faster pace because of price increases by manufacturers and greater use of expensive new medicines produced through biotechnology.

But the companies continue to increase the number of consumer ads. The pharmaceutical producers spent $2.8 billion last year on consumer advertising, an increase of 12 percent (though in 2000, consumer advertising increased 31.5 percent).

The most advertised drug last year was Celebrex, for arthritis, followed closely by Vioxx, its competitor. The next-highest advertising costs went to promote Allegra and Claritin, and Viagra. Pfizer sharply increased advertising of Viagra because two new medicines for impotence, which will be the drug's first competitors, are reportedly nearing approval.

Marketing expenses increased in an industry that had 81,600 sales representatives last year, an increase of 45 percent since 1998.Companies held 370,300 meetings and events for doctors last year - an increase of almost 18 percent.

Study Suggests Effective Once-a-Year Osteoporosis Treatment
A single intravenous dose of medicine a year rather than a pill a day may be enough to prevent osteoporosis in more than 10 million Americans currently diagnosed with it. The finding came out of a preliminary one-year study of a bisphosphate called zoledronic acid (Zometa), which is approved for use in cancer patients to help stop calcium loss. An additional five years of study are projected to definitively determine this route of treatment's effectiveness.

Over the course of one year, 351 women in New Zealand, Australia, Switzerland, Belgium, France, Italy, Germany, Austria, Sweden and Canada were given four five-minute intravenous infusions three months apart. One-sixth of the women got a placebo in all four; the others had at least one IV with zoledronic acid in it. All five drug treatment schedules had about the same results, and all were better than the placebo. The drug was found to slow the rate of bone loss and increase bone density, and the effect persisted for at least a year after treatment, long after measurable levels of the medication had disappeared. Bone density was 4.3 percent to 5.1 percent higher in the spine and 3.1percent to 3.5 percent higher in the hip than it was for patients on placebo.

Novartis, maker of Zometa, has begun enrolling patients for two big studies of the drug: a three-year study of 7,500 women who have been through menopause, and a two-year look at 4,500 men and women who already have had a hip fracture from osteoporosis.

Numbers Experiencing Cardiac Death Before Hospital Arrival Remain High

The Centers for Disease Control and Prevention suggests a new national push to recognize the early warning signs of heart attacks. Heart disease continues to be the nation's leading cause of death.

A recent study examined the 729,000 heart disease deaths reported in the US in 1999 and noted the following:

About 47 percent were sudden deaths occurring before the patient could get to a hospital, a significant increase from the 38% in 1989. Women were more likely to die of cardiac arrest prior to hospital arrival (52 percent), contrasted with 42 percent for men.

The risk of sudden heart-disease death appeared to increase with age. For people over 85 years old, 61 percent of the deaths happened before hospital arrival.

The CDC called the numbers "alarming,'' claiming that despite advances in treatment and interventions, public awareness and
health improvement lag behind.

The CDC called for greater awareness of the early warning signs of heart disease and heart attacks, continued work on risk factor reduction, and training more people in CPR, as well as deploying more external defibrillators.

Altogether, the study noted that cardiovascular disease (includes heart attacks, stroke and high blood pressure) kills about 1 million Americans annually.

The National Heart, Lung, and Blood Institute, the American Heart Association, and other organizations recently released
resources aimed at helping Americans react promptly in recognizing a heart attack and so save heart muscle and lives. The resources include a wallet card, a brochure, and a special Web page - are part of a major campaign called, "Act In Time To Heart Attack Signs."

The wallet card and brochure are available in English and Spanish. The wallet card and single copies of the brochure are free from the NHLBI Health Information Center. All materials are available free on the "Act In Time" Web page at www.nhlbi.nih.gov/actintime.

For more, go to:
CDC: http://www.cdc.gov
American Heart Association: http://www.americanheart.com

Potential Hunter Hazard

Wisconsin, last week, issued a press release that reported that studies on deer carcasses from the November 2001 hunt has
confirmed three cases of "chronic wasting disease" (CWD) in deer from Dane and Iowa counties. CWD is a prion disease similar toCreutzfeldt-Jacob disease, "mad cow", and scrapie in sheep, and was first recognized in both deer and elk 16 years ago in Colorado and adjacent areas of Wyoming and Nebraska. There has never been any evidence of transmission from deer to either humans or cattle. The press release notes, "For safety's sake, however, experts suggest that hunters should avoid eating the brain, spinal cord, eyes, tonsils, spleen or lymph nodes of white-tailed deer and elk because the infectious agent tends to concentrate in those tissues." Additional information is available on the web at: http//:www.aphis.usda.gov/vs/cwd.htm.

Notes from Iowa's State Epidemiologist's Office

The Iowa Department of Public Health, in collaboration with a variety of state and local partners, is currently engaged in preparing applications for 2 cooperative agreements - one from the Health Services Resources Administration (HRSA) to strengthen the capacity of hospitals and other emergency medical systems, the other from the Centers for Disease Control (CDC) to strengthen the capacity of state and local public health systems. Though the focus in on strengthening these systems to prepare and respond to bioterrorism, the reality is that there will be more far-reaching benefits, including strengthening state and local public health infrastructure. Stay tuned for more updates on this process.

Influenza Update
Iowa continues to see more cases of influenza being confirmed, though the numbers seem to be declining. Two cases of influenza B have been identified, one in Clinton County and one in Des Moines County. To date, 135 cases have been confirmed, the majority of cases being influenza A(H3N2) (132 cases). School absenteeism is on the decline after a small peak early in February. As always, you can get the most current influenza information in Iowa from either the IDPH web site at http://www.idph.state.ia.us/pa/ic/ic.htm or at the UHL web site at http://www.uhl.uiowa.edu/HealthIssues/Respiratory/index.html.

Nationally, during week 8 (February 17-23, 2002), 752 (25.9%) of 2,902 respiratory specimens tested by World Health Organization (WHO) and National Respiratory Virus Surveillance System (NREVSS) laboratories were positive for influenza. The overall proportion of patient visits to sentinel physicians for influenza-like illness (ILI) was 3.5%, which is above the national baseline of 1.9%. The proportion of deaths attributed to pneumonia and influenza was 8.1%, which is below the
epidemic threshold of 8.3% for week 8. Fourteen state and territorial health departments reported widespread influenza activity, 24 reported regional activity, and 11 reported sporadic influenza activity. You can get up-to-date national influenza updates from the CDC's web site at http://www.cdc.gov/ncidod/diseases/flu/weekly.htm.

Triage Without Vital Signs Misses Key Information

A new study finds the severity of illness among one in 20 patients will be underestimated if vital signs are not considered in the triage decision, according to a study from researchers at the UCLA School of Medicine (published in the March issue of Annals of Emergency Medicine). The study suggests that telephone triage would miss this important aspect of triage. The study looked at 14,285 patients and found 5 percent were retriaged after vital signs suggested a more serious condition. As might be expected, the changes in triage decisions were more often seen in the very young (under age 2) and the elderly (over age 75).

The study's authors contend that more research should be conducted into the importance of each element in traditional triage---the patient's chief complaint, recent history, vital signs, and a limited physical examination, in determining severity.

Impaired Mental Health in Elderly Under-Recognized in Emergency Departments

Assessing and treating mental health impairments in the elderly patient appears to be absent in those being seen in emergency
departments. In a study entitled The Prevalence and Documentation of Impaired Mental Status in Elderly Emergency epartment Patients, published in the March issue of annals of Emergency Medicine, authors recommended additional education for emergency care providers and targeted mental health screening of patients over 70 years of age when visiting the emergency department.

The study looked at 297 elderly patients admitted to emergency departments and, using standardized tests, found 26 percent had some form of mental impairment. Ten percent had evidence of dementia and 16 percent had some degree of cognitive impairment. Almost half (44 percent) received no treatment or referrals for these conditions. Over one-third (37 percent) of the thirty patients with dementia received no specific treatment, hospitalization or referral.

Fredric M. Hustey, MD, of The Cleveland Clinic Foundation and Metro Health Medical Center, Cleveland, Ohio, and co-author stated, "This study found the prevalence of mental health impairments in elderly emergency department patients is significant, yet only a small percentage of patients with delirium or cognitive impairment are being identified and treated in emergency departments."

Such mental impairments (without specific resources and assistance) may increase the risk of falls, failure to properly understand and follow ED discharge instructions and subsequent self-medication errors.

Factoids

The Heart of the Matter
Every twenty seconds, someone in America suffers a heart attack.

Women wait two to four hours longer than men to seek treatment for symptoms of a heart attack.

Every year, more than 250,000 heart attack victims die within one hour of the onset of symptoms -before getting to the hospital

Aspirin or other antiplatelet drugs protect patients who are at high risk of serious vascular events and should be considered routinely for all such patients. This has been shown in a meta-analysis of 287 trials, involving more than 200,000 patients, comparing either an antiplatelet drug with a control or different antiplatelet drugs. Studies showed that antiplatelet therapy-
- reduced the risk of any serious vascular event by about one quarter; - risk of non-fatal heart attack was reduced by one third; -non-fatal stroke by one quarter; - vascular death by one sixth

Cool Web Sites

Catalog Heaven/Hell
http://catalogs.google.com/

Google has created a free tool that let's you search through over
1,300 different mail order catalogs.

The folks at Google didn't just compiled a list of mail order catalogs, they scanned every single page in every one of those
catalogs and placed those pages at google.com. For example, Google's entry for Lands End shows you all 112 pages from the most recent Land's End catalog. Free. If you would rather browse than search, Google's catalog site also lets browse the catalogs by category -- Apparel & Accessories, Electronics, Toys & Games, and so on -- or even browse a complete list of all 1,300 catalogs in Google's database. That last feature -- Browse complete list of catalogs-- can be found in the bottom right corner of the Google catalogs page, or you can jump to that list directly by going to: http://catalogs.google.com/catalog_list

Quotable Quotes

Anonymous:

A 'good' landing is one from which you can walk away. A 'great' landing is one after which they can use the plane again.
--Rules of the Air, #8

Michelangelo (1475-1564) Italian painter, sculptor, architect, poet:

A beautiful thing never gives so much pain as does failing to hear and see it.

George Washington (1732-1799) US president, soldier, surveyor:

My observation is that whenever one person is found adequate to the discharge of a duty . . . it is worse executed by two persons, and scarcely done at all if three or more are employed therein.

To err is nature, to rectify error is glory.

Few men have virtue to withstand the highest bidder.

George Moore (1852-1933) Irish author, poet, dramatist:

A man travels the world over in search of what he needs, and returns home to find it.

The wrong way always seems the more reasonable. Everybody sets out to do something, and everybody does something, but no one does what he sets out to do.

ERDOCS e-mail group (listserv)

As a Clinician providing acute and emergency medical care, you are invited to visit and participate in our new ERDOCS group at eGroups, a free, easy-to-use email group service! You have plenty of experiences to share, questions to ask, concerns and opinions to voice, suggestions, news to post, tips to offer, etc. and can do so within this framework. This is a versatile system for posting things to be sent to a group to peruse, respond to, or simply be aware of. It eliminates conventional mail delays and allows you to review and post at your leisure. (We still have the more open-ended [any visitor can observe/post] discussion group at the ACUTE CARE, INC. web site). Our goal is to give you a variety of feedback and communication tools.

The manager/moderator for this ERDOCS egroup is the webmaster for the ACUTE CARE, INC. website (http://www.acutecare.com/), Paul Hudson. You can subscribe by sending an e-mail indicating your wish to be included to Paul at mailto:paulh@acutecare.com

As this site grows, it will feature news, calendars, links to references, resources, and other useful features. We hope you will support this effort to foster ongoing communication amongst EM providers.