Internal Medicine Doctor

Disease/Infection News

The World Health Organisation (WHO) says as from now the new influenza virus, currently tagged 'swine flu' will be known as influenza A(H1N1).

The WHO is coordinating the global response to human cases of influenza A (H1N1), monitoring the situation, providing up to date information on the potential threat of an influenza pandemic, tracking the situation as it evolves and offering access to both technical guidelines and useful information for the general public.

In the latest update as of the 30th April 2009, 11 countries have officially reported 257 cases of influenza A (H1N1) infection.

In the United States there are 109 laboratory confirmed human cases, including one death, in Mexico there have been 97 confirmed human cases of infection, including seven deaths, 1 in Austria, 19 in Canada, 3 in Germany, 2 in Israel, 1 in the Netherlands, 3 in New Zealand, 13 in Spain, 1 in Switzerland and 8 in the United Kingdom - none of these laboratory confirmed cases have been fatal.

The WHO has raised the worldwide pandemic alert level to Phase 5 but at present the WHO has not advised any restriction of regular travel or closure of borders but does say however that it would be 'prudent' for people who are ill to delay international travel and for people developing symptoms following international travel to seek medical attention, in line with guidance from national authorities.

The WHO also reiterates that there is no risk of infection from this virus from consumption of well-cooked pork and pork products and recommends that people wash their hands thoroughly with soap and water on a regular basis and seek medical attention if they develop any symptoms of influenza-like illness.

In U.S. the Centers for Disease Control and Prevention (CDC) has also confirmed 109 cases - 50 in New York, 26 in Texas, 14 in California, 10 in South Carolina, 2 each in Kansas and Massachusetts, and 1 each in Indiana, Ohio, Arizona, Michigan and Nevada.

Across the U.S. almost 300 schools are closed and many events have been cancelled or postponed.

Disease/Infection News

According to the latest available research, should a global influenza pandemic become a reality, small stockpiles of a secondary flu medication, provided they are used early enough in local outbreaks, could extend the effectiveness of large primary stockpiles of drugs such as Tamiflu.

Tamiflu (oseltamivir) has been stockpiled by many countries anxious to be prepared should a flu pandemic strike, but the problem according to an international team of researchers, is that influenza viruses can become resistant to antiviral drugs, and the widespread use of a single drug is likely to increase the risk that a resistant strain will emerge.

The concern is that if such a strain were to spread widely, the effectiveness of antiviral drugs such as Tamiflu in treating infected patients, as well as their ability to slow the spread of a pandemic, would be greatly reduced.

The international research team, led by Joseph Wu of the University of Hong Kong, included scientists from the UK and the U.S. who used a mathematical model to represent the global spread of an influenza pandemic.

The team found that treating just the first 1% of the population in a local epidemic with a secondary drug, rather than with oseltamivir, could substantially delay the development of resistance to oseltamivir and this reduction in resistance was predicted to benefit not only local populations, but also those in distant parts of the world where the pandemic would subsequently spread through air travel.

The team say in the current emerging swine flu situation, the secondary drug could be Relenza (zanamivir), the only other approved drug to which the new H1N1 strain has been found to be susceptible.

This strategy say the researchers could be as effective because it delays use of the primary stockpiled drug until a certain proportion of the local population (about 1.5% according to the model) has been infected with virus that remains susceptible to the primary drug - with drug-sensitive virus in the majority as people recover from infection and develop immunity, only a minority of further infections are likely to be resistant to the primary drug.

The researchers say technically, such a delay could be achieved by postponing the launch of any antiviral intervention, but because even a short delay would mean denying antiviral drugs to people who would benefit from them, the researchers instead propose the deployment of a small stockpile of a secondary antiviral during the early phase of the local epidemic.

The model was prepared before the current swine flu crisis, and considered two possible strategies, "early combination chemotherapy" (treatment with two drugs together while both are available, assuming that clinical trials show such a combination to be safe for patients) and "sequential multi-drug chemotherapy" (treatment with the secondary drug until its stockpile is exhausted, then treatment with the primary drug).

The researchers say while either strategy could be effective in principle, only the sequential strategy would be practical in responding to the currently emerging H1N1 swine flu, because the safety of combining zanamivir with oseltamivir (for combination therapy) is not established.

After simulating the impact of these strategies in a single population, the researchers then introduced international travel data into their model to investigate whether these two strategies could limit the development of antiviral resistance at a global scale.

They say this analysis predicted that, provided the population that was the main source of resistant strains used one of the strategies, both strategies in distant, subsequently affected populations would be able to reduce the consequences of resistance, even if some intermediate populations failed to control resistance.

The research is published in PLoS Medicine.

Medical Research News

Australian researchers have discovered that many critically ill patients in intensive care are deficient in vitamin D.

A small study by researchers at the Garvan Institute of Medical Research in Sydney, has found that as many as 45% of patients in an intensive care unit were vitamin D-deficient.

The lead author of the study Dr. Paul Lee, an endocrinologist and research fellow at the Institute says the sicker the patients were, the lower their vitamin D levels and he says it is unclear whether this is just an association, or whether vitamin D deficiency itself contributes to the severity of the disease.

Vitamin D is a fat-soluble vitamin that is naturally present in only a few foods - some fish, such as salmon and tuna, cheese, egg yolks and some mushrooms - vitamin D is also found in fortified milk and cereals.

The best natural source is when sunlight strikes the skin and triggers vitamin D production in the body.

Vitamin D is essential for the body's calcium absorption in the gut and bone growth and health - a shortage of vitamin D means bones can become thin, brittle, or misshapen.

Vitamin D prevents rickets in children and osteomalacia in adults and together with calcium, helps protect older adults from osteoporosis.

Vitamin D also plays a roles in the immune system and the reduction of inflammation and some experts believe vitamin D deficiency is increasingly being linked to adverse health outcomes.

For the study, the researchers measured vitamin D levels in 42 people being treated in an intensive care unit and found almost half were vitamin D-deficient.

The researchers say three patients died during the study and it was found that they had the lowest levels of vitamin D in the study group.

Dr. Lee says that vitamin D is involved in controlling blood sugar levels, calcium levels, heart function, gastrointestinal health and in defending against infection.

While the researchers are unable to explain the exact cause of the vitamin D deficiency, they suggest an absence of sun exposure could play a role, as could a lack of dietary intake of vitamin D. Dr. Lee says it may be that the tissue demand for vitamin D is increased during infection, metabolic disturbances and inflammation and vitamin D may therefore be used up during critical illness.

He says this hypothesis and the relationship between vitamin D and critical illness needs more research as vitamin D deficiency is likely to be common in seriously ill patients.

While some experts agree that more research is called for, some suggest that further studies need to be done to see if replacing the lost vitamin D would benefit these patients.

They say it is known that in stable situations, vitamin D deficiency has a potential link to mortality, and vitamin D replacement does improve outcomes, but they say it is too early to tell from this study, if there would be a mortality benefit from vitamin D replacement and for immobile patients, there is a risk of creating calcium levels that are too high.

In the current study, 10 patients were given vitamin D supplements, and no protective effect was found.

The study results were published in letter form in the April 30th issue of the New England Journal of Medicine.

Miscellaneous News

President Obama on Wednesday held a town hall meeting in Missouri and a news conference in Washington, D.C., to discuss progress on issues such as health care during the first 100 days of his presidency, the Washington Post reports.

Referring to criticism about the cost of major initiatives he has proposed, including health care reform, Obama said, "I know you've been hearing all these arguments about, 'Oh, Obama is just spending crazy, look at these huge trillion-dollar deficits.'" He added, "Well, let me make a point. ... We inherited a $1.3 trillion deficit -- that wasn't me," and "there is almost uniform consensus among economists that in the middle of the biggest ... financial crisis since the Great Depression, we had to take extraordinary steps."

In addition, Obama said that he was most surprised "by the number of critical issues that appear to be coming to a head all at the same time" and that he was "sobered by the fact that change in Washington comes slow. That there is still a certain quotient of political posturing and bickering that takes place even when we're in the middle of really big crises" (Shear et al., Washington Post, 4/30).

He said he would pursue bipartisan compromise when possible, but acknowledged that his party would be able to act without Republican support on issues it believes to be the most important. He said he has told Republican leaders, "Look, on health care reform, you may not agree with me that we should have a public plan. That may be philosophically just too much for you to swallow. On the other hand, there are some areas, like reducing the costs of medical malpractice insurance, where you do agree with me" (Babbington, AP/Houston Chronicle, 4/30).

When asked about specific plans aimed at helping black communities, which have higher unemployment rates than white communities, Obama said the economic stimulus package passed earlier this year will direct more money to community health centers, and extend unemployment aid and health coverage for people who have been laid off (AP/Newark Star-Ledger, 4/29).

NPR's "Morning Edition" on Thursday reported on Obama's 100-days comments, as well as prospects for compromise on major policy initiatives (Williams/Inskeep, "Morning Edition," NPR, 4/30).

Healthcare News

The Veterans Health Administration's open-source electronic health records system could be an effective and low-cost option for non-Veterans Affairs hospitals that are seeking to implement such a system but have been held back by the cost, the Wall Street Journal reports.

A recent survey in the New England Journal of Medicine found that fewer than 2% of the 5,000 non-VA hospitals in the U.S. have a full-fledged EHR system. Many facilities have said they cannot afford such a system, which can cost between $20 million and $100 million to implement, according to the Journal.

However, because the Veteran's Health Information Systems and Technology Architecture, or VistA, was developed over a 20-year period with several billions in taxpayer dollars, its source code is now part of the public domain. That means software developers can use the code at no cost and introduce additional features without restrictions. As a result, although the software still costs money to install and maintain, it frequently costs less than other options from private companies.

In addition, VistA, which is now used at more than 1,400 VA medical facilities, offers a standardized program that facilitates seamless transfer of patients' records between different hospitals and facilities, a benefit that private commercial vendors of EHR systems do not provide. The standardized software also reduces implementation costs and potential errors for users, according to the Journal. Furthermore, VistA provides the same benefits of most other EHR systems, which advocates say will reduce medical costs, medical and prescription errors, and increase efficiency and quality of care.

Kenneth Kizer -- chair of Medsphere and former undersecretary for health at VA, who oversaw the development of VistA -- said his company can implement its OpenVistA system "in one-third the time and for about one-third the cost" of other private companies that offer proprietary systems. Medsphere is one of several startups that has begun using VistA's open-source platform. However, Dan Garrett, a PricewaterhouseCoopers consultant, said that while VistA could be beneficial for some hospitals, the system's advantages have not been widely proven commercially like those offered by private companies.

The Journal profiled one hospital in Texas that has been using VistA, which cost the hospital $7 million to implement (Landro, Wall Street Journal, 4/30).