On a day when the 355th mass shooting this year in the USA occurred in San Bernardino, California, it seems appropriate to discuss gun violence.
A recently accepted publication in the American Journal of Medicine compared morality data from the USA to other high-income countries, and found the following:
The US homicide rates were 7.0 times higher than the aggregated rates of all other high-income countries.
The overall US suicide rate is average
Unintentional firearm deaths were 6.2 times higher in the US.
The overall firearm death rate in the US from all causes was 10.0 times higher.
Bottom line: As stated in the article: “The US has an enormous firearm problem compared to other high-income countries with much higher rates of homicide and firearm-related suicide.”
There are two main models of Emergency Medical Services (EMS) Systems
Franco-German
Anglo-American
Sickle Cell Disease (SCD) is a hemoglobinopathy that is considered a relatively rare disease in the United States, affecting about 90,000-100,000 individuals.
Globally, SCD affects millions, primarily in West and Central Africa.
Acute presentations of SCD include:
The bottom line:
The World Health Organization (WHO) has just released a report on the current status of road traffic safety globally.
From a postive perspective, road traffic deaths are stabilzing even though the number of motor vehicles are rapidly increasing.
The bottom line- injuries are preventable. Continued policy efforts, laws with enforncement, can save lives. Specific life saving legislation includes:
Overall, suicide is the 15th leading global cause of death. However, it is the 2nd leading cause among 15-29 year olds
Suicides are preventable. Interventions to decrease suicides include:
If you are interested in learning about the current status of emergency medicine in a specific country, it can be difficult to find up-to-date information. One excellent resource for country specific details is the American College of Emergency Physicians’ (ACEP) International Ambassador Program.
This program has Emergency Medicine Ambassadors (U.S. emergency physicians), Liaisons (in-country emergency physicians) and Representatives (U.S. emergency physicians in training) for many countries around the world. Additionally, there are country specific reports that give annually updated information about emergency medicine in each country.
Included on the website are links to send emails to the Ambassadors, Liaisons and Representatives in order to request more detailed information.
To learn more, see: http://www.acep.org/IntlAmbassador/
Which infectious disease listed as Class A agents occur naturally, though sporadically within the U.S?
Small pox no longer occurs naturally and other viral hemorrhagic fevers occur in tropical settings.
Injuries are a leading cause of morbidity and mortality globally
Injuries are the leading cause of preventable death in travelers
Bottom Line: Stay safe while travelling. The same safety habits used in the US, such as wearing your seatbelt or not drinking and driving, are important patterns while traveling.
Introduction: As discussed in previous Pearls, Middle East respiratory syndrome coronavirus (MERS-CoV) is a recently emerged respiratory viral infection that is caused by a single stranded, positive-sense RNA novel coronavirus.
Updates:
As of August 12th, 2015, WHO has received reports of:
The current reported case fatality rate is approximately 36%
Recent outbreaks have included
Bottom Line:
MERS-CoV is significantly contagious respiratory virus with high lethality. It is spread primarily as an airborne virus, though the CDC currently recommends both standard contact and airborne precautions. There is currently no vaccine and only supportive treatment is advised.
Don’t be a vector or have your emergency department be a nidus of infection! Take appropriate precautions, including:
Introduction
Obtaining quality information about emergency care in low- and middle-income countries (LMIC) is challenging. Data is sparse and often of low quality and the number of peer reviewed publications is limited.
In order to address this, Obermeyer et. al. just published in the WHO Bulletin a systematic review of emergency care in 59 low- and middle-income countries. In this article, the authors systematically reviewed 195 reports related to 192 facilities. The search included English or French articles from 1990 found within PubMed, CINAHL and World Health Organization (WHO) databases.
Burden of Emergency Care
Most articles were from emeregncy departments (EDs) in academically-affiliated hospitals in urban areas. Median mortality in the EDs was 1.8% (interquartile range, IQR: 0.2–5.1%), though in sub-Saharan Africa it was 3.4% (IQR: 0.5–6.3%). The median number of patients seen per year was 30,000 (IQR: 10 296–60 000). The facilities were staffed primarily by physicians-in-training or by physicians whose level of training was unspecified. There were very few providers specialized in emergency care.
Bottom Line
Based upon available data, there are high patient loads and mortality in LMIC- particularly in sub-Saharan Africa. This report highlights the importance of emergency care and the opportunity for systematic improvement to reduce mortality in these countries.
Every wonder what are the major global killers? Per the World Health Organization, the following were the top 20 causes.
Not unexpected, diseases primarily of the elderly, such ischemic heart disease, stroke and chronic obstructive pulmonary disease are on the top of the list. However, there are others, such as road traffic injuries and HIV/AIDS that could impact anyone.
| Top 20 Causes of Global Mortality, 2012 | ||||
| Rank | Cause | Deaths (000s) | % deaths | Deaths per 100,000 population |
| 0 | All Causes | 55859 | 100.0 | 789.5 |
| 1 | Ischaemic heart disease | 7356 | 13.2 | 104.0 |
| 2 | Stroke | 6671 | 11.9 | 94.3 |
| 3 | Chronic obstructive pulmonary disease | 3104 | 5.6 | 43.9 |
| 4 | Lower respiratory infections | 3052 | 5.5 | 43.1 |
| 5 | Trachea, bronchus, lung cancers | 1600 | 2.9 | 22.6 |
| 6 | HIV/AIDS | 1534 | 2.8 | 21.7 |
| 7 | Diarrhoeal diseases | 1498 | 2.7 | 21.2 |
| 8 | Diabetes mellitus | 1497 | 2.7 | 21.2 |
| 9 | Road injury | 1255 | 2.3 | 17.7 |
| 10 | Hypertensive heart disease | 1141 | 2.0 | 16.1 |
| 11 | Preterm birth complications | 1135 | 2.0 | 16.0 |
| 12 | Cirrhosis of the liver | 1021 | 1.8 | 14.4 |
| 13 | Tuberculosis | 935 | 1.7 | 13.2 |
| 14 | Kidney diseases | 864 | 1.6 | 12.2 |
| 15 | Self-harm | 804 | 1.4 | 11.4 |
| 16 | Birth asphyxia and birth trauma | 744 | 1.3 | 10.5 |
| 17 | Liver cancer | 740 | 1.3 | 10.5 |
| 18 | Stomach cancer | 733 | 1.3 | 10.4 |
| 19 | Colon and rectum cancers | 724 | 1.3 | 10.2 |
| 20 | Alzheimer's disease and other dementias | 701 | 1.3 | 9.9 |
Tuberculosis (TB) remains a deadly scourge killing approximately 1.5 million each year (see Pearl from 7/2/2105). Recognition by astute clinicians in the emergency department is key, as there is no readily available rapid test.
Current testing options:
1) Tuberculin skin test (also known as the Mantoux tuberculin skin test). A small amount of fluid (tuberculin purified protein derivative) is placed intradermally, usually in the left forearm. A positive test means the person was infected with TB. (Alternatively, if they grew up outside the US, they could have been vaccinated with Bacillus Calmette–Guérin or BCG.) A positive test is determined by the size of the reaction, but this can vary depending on the patient’s immune status.
2) Two interferon-gamma release assays or IGRA blood tests are approved for TB. While not readily available in all institutions, this is the preferred method for someone vaccinated with BCG.
Diagnosis of TB disease is based upon:
Treatment:
TB treatment depends on the susceptibility of the organism and the immune status of the patient. For a susceptible organism in a non-HIV patient, the first-line anti-TB agents regimens include
Typical treatment has an initial phase of 2 months, followed by a choice of several options for the continuation phase of either 4 or 7 months. Further information can be found at the CDC website on tuberculosis
Bottom Line
As stated previously, in the emergency department, maintain a strong clinical awareness for tuberculosis for someone with night sweats, cough, chest pain, and intermittent fever lasting for 3 weeks or longer. In particular, consider this diagnosis for someone from a low- or middle-income country or if he or she is HIV positive.
As noted in a previous pearl (see 1/7/2015), tuberculosis (TB), caused by Mycobacterium tuberculosis, is the second greatest infectious killer after HIV/AIDS globally. While the incidence and death rate from TB is decreasing, it is still a widespread problem.
Mycobacterium tuberculosis primarily attacks the lungs. However, it can attack any part of the body such as the kidney, spine, and brain. TB is primarily spread person to person through the air, for example when a person with TB coughs, sneezes, speaks, or sings.
Once a person is infected with TB, the likelihood of developing disease is greater if the person:
Classic symptoms for pulmonary TB include:
Other TB symptoms can also include:
Bottom line
In the emergency department, maintain a strong clinical awareness for tuberculosis for someone with night sweats, cough, chest pain, and intermittent fever lasting for 3 weeks or longer. In particular, consider this diagnosis for someone from a low- or middle-income country or if he or she is HIV positive.
Next time: Testing and treatment for TB.
Also see prior pearls on TB: Multidrug Resistant Tuberculosis (MDR TB) (1/21/2015), Tuberculosis (1/7/2015); XDR Tuberculosis (8/14/2013); PPD positive? Good news... (2/6/2013)
While most infections from parasites are associated with poor communities in low-income countries, there are still some important parasitic infections found in the United States.
The U.S. Centers for Disease Control and Prevention (CDC) has identified 5 parasitic diseases as priorities for public health action based upon:
These are
Bottom line:
Remember to keep your differential broad and maintain awareness of these generally unusual but important infections.
Introduction:
As noted in the previous pearl (May 20, 2015), globally diarrheal diseases are the second leading cause of death for children under five- killing approximately 760,000 annually. What can be done to prevent and treat diarrhea, especially among young children?
Prevention of diarrheal illness:
Treatment of diarrheal illness:
Bottom Line
Diarrheal diseases kill hundreds of thousands of children in developing countries each year. Appropriate prevention measures (clean water, improved sanitation) can markedly decrease the burden of disease. Appropriate treatment (ORS) can save lives for pennies.
Background:
While diarrhea in adults can be inconvenient and briefly debilitating, in children it can be fatal. Globally, diarrheal diseases are the second leading cause of death for children under five.
Clinical types of Diarrhea (with common infectious causes):
Clinical assessment:
*Best indicators of hydration status
Next week: Prevention and Treatment
Introduction:
There were approximately 56 million deaths worldwide in 2012. The causes of death vary significantly based upon the income level of the country.
High-income Countries:
Low-income Countries:
Bottom Line:
Acute care services in the US and high-income countries need to acknowledge the growing number of individuals with chronic diseases and the rapidly growing elderly population. In low-income countries, acute care services still need to primarily address maternal/child infections and problems as well as infectious diseases.
A Lancet Commission on Global Surgery has just published a 56 page article about the need to improve access to surgery and anesthesia care. Its five key messages are:
The need for high quality acute care, both for urgencies and emergencies, is clearly an important component of providing “universal access to safe, affordable surgical and anaesthesia care”- the vision of the Commission.
In 2011, approximately 630,00 children under 15 died from unintentional injuries. Injuries are the leading cause of childhood deaths in children over 9 years old. Ninety-five percent of these childhood injuries occur in lower- and middle-income countries.
The 2008 World Report on Child Injury Prevention listed the following as the top five causes of pediatric injury deaths globally:
1) Road Crashes- approximately 260,000/year
2) Drowning- approximately 175,0000/year
3) Burns- approximately 96,000/year
4) Falls- approximately 47,000/year
5) Poisoning (unintentional)- approximately 45,000/year
Many of these deaths occur around the home and could be prevented through proven prevention measures, which include:
· Child appropriate seatbelts and helmets
· Separate children from vehicular traffic
· Limit hot tap water temperature
· Placing medications and potentially harmful household products in child proof containers
· Draining unnecessary water from baths and buckets
· Redesigning nursery furniture, toys and playground equipment
· Strengthening emergency medical services
Background:
Enterovirus D68
Is there a relationship between Enterovirus D68 and the outbreak of acute flaccid myelitis?
Bottom Line