Non –communicable diseases (NCDs), primarily cardiovascular diseases, cancer, respiratory diseases and diabetes, are significantly increasing globally. According to the WHO, cardiovascular diseases alone account for 17.5 million deaths annually- the most of any NCD.

If someone has return of spontaneous circulation after cardiac arrest, but does not have ST-elevations on their post-arrest ECG, should you emergently activate the cath lab?

In a just released systematic review and meta-analysis in Resuscitation, Dr. Millin and colleagues found that almost one third of patients successfully resuscitated without ST elevation on their ECG had a culprit lesion that would benefit from emergent intervention.

Bottom Line: While this is not definitive proof to emergently activate the cath lab for a NSTEMI, it is another strong indication that post cardiac arrest patients without ST elevation may benefit from emergent percutaneous coronary intervention.

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Bottom Line:

• Cancers figure among the leading causes of morbidity and mortality worldwide, with approximately 14 million new cases and 8.2 million cancer related deaths in 2012.
• The number of new cases is expected to rise by about 70% over the next 2 decades.
• More than 30% of cancer deaths could be prevented by modifying or avoiding key risk factors

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Zika virus and its transmission is currently an important infectious disease topic in the United States and the Western Hemisphere.  With domestic spread in the Continental United States, and the likely further spread to other parts of the southern United States, continued vigilance by healthcare providers remains important.

What are the signs and symptoms of Zika?

Most common signs and symptoms are:

• Fever
• Rash
• Arthralgias
• Conjunctivitis (generally nonpurulent)

Other symptoms can include

• Myalgias
• Headaches
• Retro-orbital pain
• Gastrointestinal upset

Symptoms can generally last 2 to 7 days.  Most individuals will have minimal or no significant symptoms and may not seek medical care. These symptoms are similar to other arboviruses, such as dengue or chikungunya. Potential serious complications include Guillian Barre syndrome.

Of course, the main concern remains infection of pregnant women and the impact that Zika has on the developing fetus, especially for the brain.

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July 2016 was the hottest month ever recorded. As the temperature of the planet continues to rise, changes in infectious disease patterns of transmission are likely to occur. Many formerly exotic diseases, such as Zika, West Nile, malaria and cholera are spreading to new areas. Some of these are now found in the United States. Below is a table (from M. L. Wilson) that exemplifies how environmental changes can impact infectious diseases.

Bottom Line: Remain vigilant for unusual infectious diseases, especially among travelers.  However recognize that many diseases have the potential to spread to the U.S., especially considering ongoing environmental changes.

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An Arbovirus is a virus transmitted primarily by an arthropod

• Comes from ARthropod-BOrne virus
• Arthropods include: mosquitos, ticks, sandflies
• Can have rare person-to-person transmission
  • Blood borne
    • Transfusion, sharing needles
  • Organ transplantation
  • Breast feeding
  • Intrauterine
  • Sexual transmission

There are a number of major arbovirus families:

• Family Bunyaviridae
  • Rift Valley, Crimean–Congo hemorrhagic
• Family Flaviviridae
  • Dengue, West Nile, Zika, Yellow Fever
• Family Reoviridae
  • Equine encephalosis
• Family Togaviridae
  • Chikungunya, Western equine encephalitis

The main viral family that causes substantial human disease is the Flaviviridae family.

• Protection against mosquito bites is the best way to minimize risk for Flaviviridae infections if you are traveling in an area with these diseases.

• Just the Facts:

  • 112.5-million blood donations globally and half of these come from High-income countries

  • High-income countries more often use blood for supportive care during surgery, in traumas or therapy for malignancies

  • Low and middle-income countries more often use blood to manage pregnancy-related complications or in severe childhood anemia

  • General availability of blood is based on the donation rate

    • High-income countries have 33.1 donations/1000 people

    • Middle-income countries have 11.7 donations/1000 people

    • Low-income countries have 4.6 donations/1000 people

  • 70 countries reported collecting fewer than 10 donations per 1000 people and half of these countries were in the African region

  • Disease prevalence in the region is reflected in the transmission rate of transfusion-transmissible infections (TTI)

Table 1. Prevalence of TTIs in blood donations (Median, Interquartile range (IQR)), by income groups

Submitted by: Dr. Laura Diegelmann

There are many definitions for a disaster.  Per the International Federation of Red Cross and Red Crescent Societies (IFRC), they define a disaster as:“…a sudden, calamitous event that seriously disrupts the functioning of a community or society and causes human, material, and economic or environmental losses that exceed the community’s or society’s ability to cope using its own resources. Though often caused by nature, disasters can have human origins.”

However, in the heat of the moment, a shorter definition is easier to remember. The IFRC also define a disaster as:

• DISASTER = (VULNERABILITY+ HAZARD ) / CAPACITY

A shorter, more practical definition is:

• DISASTER = Needs > Resources

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In consideration of the recent shootings in Orlando, Florida, how common are intentional homicides globally?

• Homicides were the 22^nd leading cause of death globally in 2004
  • They are projected to be the 16^th leading cause by 2030

• There were an estimated 437,000 intentional homicides across the world in 2012
  • This was an average global homicide rate of 6.2/100,000

• The highest regional homicide rate was in the Americas (North, Central and South) at 16.3/100,000 in 2012
  • Asia had the lowest rate of 2.9/100,000

• Almost four times as many men as women die from violence each year
  • However, women overwhelmingly die from intimate partner violence or from family members

Please keep the families and friends of the victims of the Orlando events, as well as the many emergency workers who helped them, in your thoughts and prayers.

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As we head into the summer travel season, it is important to know what potential dangers lurk out there for the unwary traveler.  While injuries are usually the primary cause for death and disability for Americans abroad, what about other diseases?

The Centers for Disease Control and Prevention (CDC) has a webpage with travel health notices. 

They are three types of notices:

• Warning Level 3: Avoid Nonessential Travel
  • High risk to travelers

• Alert Level 2: Practice Enhanced Precautions
  • Increased risk in defined settings or associated with specific risk factors; certain high-risk populations may wish to delay travel to these destinations

• Watch Level 1: Practice Usual Precautions
  • Usual baseline risk or slightly above baseline risk for destination and limited impact to the traveler

Currently, there are a number of Level 1 watches and Level 2 alerts for different countries, but no Level 3 warnings.  Many of the Level 2 alerts relate to Zika virus, but there are others for MERS, Yellow Fever and Polio.

To see more, go to: http://wwwnc.cdc.gov/travel/notices

The classification of blast injuries was first described by Zuckerman in 1941 and is still widely used today. This system organizes injuries by the mechanism through which they are sustained and classifies them as primary, secondary, tertiary and quaternary. These injuries may occur in isolation or in combination with each other.

The term quinary blast injury has also been used to describe delayed effects of explosions, such as infections, radiation exposure, and other toxic exposures.

Author: R. Gentry Wilkerson

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Why are selfie deaths on the rise?

People travel everywhere now with their camera equipped smart phones.  Capturing a selfie while travelling is very common.  This leads to more distracted people and lack of situational-awareness.

Where and how do these deaths occur?

Selfies taken from a height, on a bridge, near motorized traffic, during thunderstorms, at sporting events and near wild animals

Other information:

• So far in 2016 India has reports more selfie deaths than any other country
• In 2015 more people were killed taking a selfie then by shark attacks
• Countries have taken action by creating no selfie zones in at risk areas

Submitted by Dr. Laura Diegelmann

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The terms and concepts of “waiver of informed consent’ versus “exception from informed consent” are often confused.  Within the U.S., these concepts are not the same.

• Waiver or alteration of informed consent is for minimal risk research and requires the following 4 conditions:
  • Research involves no more than minimal risk to the subjects;
  • Waiver or alteration will not adversely affect the rights and welfare of the subjects;
  • Research could not practicably be carried out without the waiver or alteration; and
  • Whenever appropriate, the subjects will be provided with additional pertinent information after participation

• Exception from informed consent (EFIC) is permissible for emergency research:
  • Rarely used, only for true emergencies
  • Recognition that there are times/conditions when informed consent is not feasible
    • Length of potential therapeutic window is defined (i.e.- short window)
  • Must hold the potential for direct benefit for the subject
  • Requires special protections and conditions, in addition to the regular ethical review
    • Including a community consultation process

Bottom line:

Waiver of Informed Consent ≠ EFIC

• Exception from informed consent (EFIC) is rarely used and is only for true, life threatening situations.  It requires substantial review and special steps to obtain.
• Waiver of informed consent is commonly used for retrospective chart reviews and similar minimal risk research.

These are the rules and regulations for the U.S. The regulations for emergency research in other countries may or may not be similar to these.

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As noted previously, injuries cause substantial morbidity and mortality globally.  How does it vary by age group?

The following table shows that unintentional injuries are the leading cause of death for individuals 1-44 years of age. Even when they are not the leading cause of death, injuries cause substantial mortality in all age groups.

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Emergency medicine remains a relatively young and developing specialty in most parts of the world.  However, it is growing in popularity, especially in the U.S.  How competitive is it currently?

For the recent 2016 Match, there were 2476 applicants for 1895 categorical emergency medicine positions from 174 programs.

• Of the 1895 incoming residency positions, 1894 were filled within the Match!
• The vast majority (78.4%) were filled by senior medical students coming directly from U.S. medical schools.

Bottom Line: Emergency medicine remains a highly desired and competitive specialty in the U.S.

Congratulations to all the incoming interns for the 2016-2017 year!

Cutaneous larva migrans (CLM) is an acquired dermatosis

• Seen in patients returning from the tropics
  • Often seen in patient with a history of sunbathing or in barefoot beachgoers
• Caused by the larvae of various nematode parasites of the hookworm family (Ancylostomatidae), with Ancylostoma braziliense the most frequently found in humans.

Clinical manifestations:

• Linear, serpentine erythematous lesions
• Intense pruritus
• Will often heal spontaneously over weeks or months without treatment

Treatment:

• Thiabendazole (applied topically)
  • Oral alternatives include other anti-parasitic medications such as albendazole, ivermectin
  • Oral thiabendazole as a single dose can be used, but is less effective than albendazole or ivermectin
• Consider antibiotics if there is secondary bacterial infections
• Freezing the leading edge has been previously used, but is considered ineffective and painful.

Bottom Line:

• Consider CLM the next time a patient complains of a linear, erythematous itchy rash after returning from their all-inclusive stay in a Caribbean resort

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While the flu season this year has been mild, it is still important to recognize which patients are at high risk for flu-related complications:

• Children < 5 years old
  • Especially children < 2 years old
• Adults > 65 years old
• Pregnant women
  • Including women up to 2 weeks post-partum
• Residents of long-term care facilities, such as nursing homes
• American Indians and Alaskan Natives
• Patients with certain medical conditions, including:
  • Respiratory diseases, such as asthma and COPD
  • Neurological and neurodevelopmental conditions
  • Heart disease, including CHF and CAD
  • Blood disorders (e.g. sickle cell disease)
  • Endocrine and metabolic disorders (e.g. diabetes)
  • Kidney or liver diseases
  • People <19 years old on long-term aspirin therapy
  • Morbid obesity (BMI > 40)
  • Immunocompromised, (e.g. chronic steroids, transplant patients, AIDS patients, chronic steroid use)

During the influenza season, when admitting a patient who 1) has respiratory symptoms and 2) is at high risk for influenza complications, consider testing them for influenza.

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What are the criteria for dengue hemorrhagic fever?

• Fever lasting 2-7 days
  • May be biphasic

• Hemorrhagic tendencies
  • Positive tourniquet (aka Rumpel-Leede) test
  • Petechiae, ecchymosis or purpura
  • GI bleeding

• Thrombocytopenia (<100,000/mm³)

• Evidence of plasma leakage
  • Increase in hematocrit >20% above age/sex normal
  • Decrease in hematocrit >20% after volume replacement
  • Signs of plasma leakage
    • e.g. pleural effusions, ascites, hypoproteinemia

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On February 1^st, the World Health Organization declared that Zika was an international public health emergency.  As noted in the Pearl from January 20^th, 2016, Zika is a mosquito-borne RNA flavivirus that is usually asymptomatic.  However, congenital malformations have been seen in pregnant women infected with Zika.

While it is clear that the decision to declare an international public health is a judgement call, what are the criteria for considering this declaration?

Per the WHO, the term Public Health Emergency of International Concern is defined in the IHR (2005) as “an extraordinary event which is determined, as provided in these Regulations:

·         to constitute a public health risk to other States through the international spread of disease; and

·         to potentially require a coordinated international response”. This definition implies a situation that: is serious, unusual or unexpected; carries implications for public health beyond the affected State’s national border; and may require immediate international action.

The responsibility of determining whether an event is within this category lies with the WHO Director-General and requires the convening of a committee of experts – the IHR Emergency Committee.

For Zika, the sequalae of concern are the clusters of microcephaly and Guillain-Barré syndrome suspected to have resulted from Zika infection.

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Zika virus is a mosquito-borne flavivirus. 

• The flavivirus genus includes multiple other human viral infections, including yellow fever, West Nile, dengue and tick-borne encephalitis.
• The primary vector for Zika virus is Aedes aegypti, though Aedes albopictus can also transmit it.

While outbreaks have been previously reported in Africa, Asia and the islands of the Pacific, it was first reported in the Western Hemisphere in May 2015. 

• Per the CDC, as of January 15, 2016, local transmission had been identified in at least 14 countries or territories in the Americas. 
• There has been no local transmission (yet) in the Continental US.

Clinical Disease:

• One in five infected become symptomatic
• Clinical illness is usually mild and lasts for several days or a week
  • Severe disease is uncommon, though Guillain-Barre syndrome has been reported in patients following suspected Zika infection
  • Fatalities are rare
  • Of note: congenital malformations have been seen in pregnant women infected with Zika
• Characteristic clinical findings can include:
  • acute onset of fever,
  • maculopapular rash,
  • arthralgia,
  • conjunctivitis

Diagnosis and Treatment

• Consider the diagnosis in symptomatic travels returning from affected areas
• RT-PCR can be used on serum specimens from the first week of illness
• There is no current commercial test available
• Treatment is symptomatic and supportive
  • No specific antiviral therapy

Prevention

• Avoid mosquito bites
  • Wear long sleeves and pants
  • Use insect repellents when outdoors (such as DEET)
  • Delay travel to known affected areas if you are pregnant

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Every year approximately 265,000 people die from burns

·      The vast majority occur in low- and middle-income countries

o   The rate of child death from burns is 7 times worse in low- and middle-income countries compared to high income countries

·      Almost half of all fatal burns occur in the WHO South-East Asia Region

Non-fatal burns are a leading cause of global morbidity

·      In 2004, almost 11 million individuals worldwide were burned badly enough to require medical attention

Unlike many other unintentional injuries, burns occur:

·      Mainly in the home and workplace

o   Women are at greater risk secondary to open fire cooking

·      Approximately equally among men and women

o   Most other injuries occur more frequently in men

Most burns are preventable.  Developing an effective burn prevention plan involving multiple sectors is important.  Per the WHO, the plan should be broad with efforts to:

·      improve awareness

·      develop and enforce effective policy

·      describe burden and identify risk factors

·      set research priorities with promotion of promising interventions

·      provide burn prevention programmes

·      strengthen burn care

·      strengthen capacities to carry out all of the above.

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