[hnn] HealthNet News #596, 27/Dec/04
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Number 596 HEALTHNET NEWS Dec. 27, 2004
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This weekly bulletin is supported by generous charitable
contributions from individuals and institutions
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COMMENTARY
By Malcolm Bryant, MD, MPH
INFECTIOUS DISEASES
1. Clinical features of S. mansoni myelopathy
2. Avian influenza moves into zoos and wildlife
3. Nonhuman primates as food and pets in Central Africa
QUALITY OF CARE
4. Appendicitis -- problems inside and outside the hospital
5. Touch vs. talk for low back pain
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EDITORS: Ramnik Xavier, MD Malcolm Bryant, MD, MPH
Harvard Medical School Management Sciences for Health
Jill Durocher Leela McCullough, Ed.D
SATELLIFE SATELLIFE
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Dear Colleagues,
Whether you celebrate Christmas, Hanukkah, Kwanza, or Ânone of
the aboveÂ, this time of the year is always a time of celebration
and reflection. I hope that it finds everyone well, and that you
are able to take some time during this season to be with family
and friends.
Osteoarthritis is a common problem for which there are few real
solutions. Degenerative joint disease is only really treatable
by replacement of the joint, and this is not an option for the
vast majority of sufferers, even in wealthy western countries in
North America and Europe. Thus people rely on symptomatic
treatments  usually anti-inflammatory drugs. When I was a
medical student it was usually Aspirin in high doses, but with
the problem of gastro-intestinal bleeding and associated morbidity
and mortality, there has always been a search for better anti
inflammatory drugs that do not cause the bleeding. (It is
estimated that NSAIDS cause 14,000 to 16,000 deaths a year in the
United States alone).Every year seems to see a new NSAID on the
market claiming to do what its predecessors did not, or could not.
Ibuprofen and Naproxen were the standbys for a long time (but
still caused a measure of GI bleeding), so the advent of COX2
inhibitors seemed to be a great breakthrough. They may not have
had much difference in their pain-relieving capability, but they
did not seem to cause GI bleeding.
Then came VioxxÂs withdrawal, and now it seems that other COX2
inhibitors are also implicated in causing significant vascular
morbidity and mortality. Physicians were being recommended to
go back to the old standby Naproxen until this week another study
suggests that Naproxen may also cause significant risk of vascular
complications. Although there are some questions about the
validity of the findings, it does create a real dilemma for
doctors and other prescribers everywhere. There is no easy
answer, and doctors and patients are going to have to use their
individual assessments of pain suffered, mobility lost, and risks
posed by the different drugs to make a choice that fits the best
need.
It is interesting that coincidental with the furor over NSAIDs,
this week the Annals of Internal Medicine published a paper
demonstrating that treatment with acupuncture needles
significantly reduced pain and eased movement for patients with
arthritic knees who were taking pain medicine. The study, funded
by the National Institutes of Health is the largest and most
rigorous study to date of the ancient treatment. This study did
not look at pain in other joints (although there are other smaller
studies to suggest that pain relief is not as good for hip or neck
pain). Most importantly, of course, the acupuncture did not
reverse the degenerative disease, and so can only provide
temporary relief at best. However, it is good to note that newest
is not always best. Acupuncture has been practiced for over 2,000
years and will probably be around for another 2,000. I doubt that
anyone will even remember the phrase COX-2 inhibitors in 2,000
years!
Malcolm Bryant, MD, MPH
Management Sciences for Health
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1. Clinical features of S. mansoni myelopathy
Summary by: Pierre L. A. Bill, FCP, FRCP
SO: Journal Watch Neurology December 10, 2004
CO: © Massachusetts Medical Society 2004
http://www.jwatch.org
Summary: Few data exist on myelopathy associated with Schistosoma
mansoni infection. These researchers describe clinical features in
13 patients with an inflammatory myelopathy and either
(1) positive S. mansoni serology in blood, CSF, or both, or
(2) ova in the stool.
The patients presented with pain and paresthesias in the back and
lower limbs, weakness, urinary incontinence, and fever. Clinical
findings were variable and included flaccid areflexic paraplegia,
spastic paraplegia, or signs suggesting a lumbosacral
radiculopathy. Sensory changes were consistent with the level of
the cord affected. All patients had abnormal MRI findings,
consisting of T2 hyperintense signals in the mid- or lower
thoracic cord and, in those with myeloradiculopathy, enlargement
of the lower cord or conus, and thickening and enhancement of the
lumbosacral roots. Antischistosomal antibodies were absent in 1
patient and present in the CSF of 5 patients and in the blood of
12 patients. CSF abnormalities included a mild, mainly lymphocytic
pleocytosis, raised CSF protein, and elevated IgG index. Ova were
found in the stools of two patients (one had negative schistosomal
serology). Eosinophilia in blood, CSF, or both was noted in three
patients. In one patient who died, autopsy showed granulomas
containing ova in the spinal cord and an adult worm in a
leptomeningeal vein. The remaining patients improved on
corticosteroids and praziquantel; one patient underwent a
laminectomy.
Comment: Schistosomal myelopathy usually occurs early in the
course of the infection and rarely months or years after initial
infection. The clinical picture is variable, but the conus
medullaris is the most commonly affected site. Finding
antischistosomal antibodies in blood or CSF is expected, but not
invariable, and some infected patients may not show ova in stools
or urine. Few reports exist on MRI abnormalities. In an
appropriate clinical setting, enlargement, a T2 hyperintense
signal, and multifocal enhancement of the conus/lower cord should
suggest schistosomiasis. As most patients respond to treatment
with steroids and praziquantel, treatment should not be delayed.
Where schistosomiasis is prevalent, a high index of suspicion is
required for patients presenting with acute paraparesis and
sphincter dysfunction. In nonendemic areas, a history of travel
to an endemic area may be the clue to the diagnosis.
Source: Carod Artal FJ et al. Schistosoma mansoni myelopathy,
Clinical and pathologic findings.
Neurology 2004 Jul 27; 63: 388-91.
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2. Avian influenza moves into zoos and wildlife
Summary by: Mary E. Wilson, MD
SO: Journal Watch Infectious Diseases December 10, 2004
CO: © Massachusetts Medical Society 2004
http://www.jwatch.org
Avian influenza H5N1 has caused more than 30 human and 100 million
bird deaths in Southeast Asia. Researchers recently investigated
the unexpected deaths of two tigers and two leopards at a zoo in
Suphanburi, Thailand, in December 2003, during an avian influenza
outbreak occurring nearby.
Necropsy of the animals revealed pulmonary consolidation and
multifocal hemorrhage in many organs; one leopard and one tiger
showed evidence of encephalitis. Lung samples from all four
animals tested positive by PCR for H5N1. Immunohistochemical
examination of tissue showed that alveolar and bronchiolar
epithelial cells expressed influenza virus antigen. Influenza A
virus isolated from lung samples was sequenced. Phylogenic
analysis showed the virus to be virtually identical to the H5N1
found in poultry; it had not reassorted with mammalian influenza
viruses before infecting the felids. Prior to becoming sick, the
zoo animals had been fed fresh chicken carcasses from a local
slaughterhouse. They had been vaccinated against feline
panleukopenia 2 weeks before dying; three animals tested positive
for this virus at necropsy but had no lesions suggesting its
presence.
Comment: These findings document that the host range of the H5N1
virus extends to non-domestic cats. Other recent investigations
have shown that domestic cats can be infected and can transmit
infection horizontally. The zoo animals presumably became infected
by eating uncooked, infected birds. The authors raise the
possibility that the live feline panleukopenia virus vaccine could
have had an immunosuppressive effect, but no findings supported
infection with this virus as a primary cause of death. And now
more than 100 Bengal tigers have died at a zoo near Bangkok after
eating raw meat from chickens apparently infected with the H5N1
virus.
Source: Keawcharoen J et al. Avian influenza H5N1 in tigers and
leopards. Emerging Infectious Diseases 2004 Dec
10: 2189-91.
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3. Nonhuman primates as food and pets in Central Africa
Summary by: Mary E. Wilson, MD
SO: Journal Watch Infectious Diseases December 10, 2004
CO: © Massachusetts Medical Society 2004
http://www.jwatch.org
Summary: Nonhuman primates have been linked to the transmission
of several microbes that are pathogenic in humans, including
immunodeficiency viruses, monkeypox, herpesvirus B, and Ebola
virus. In the context of an HIV-prevention campaign, investigators
recently assessed the frequency and nature of contacts (e.g.,
hunting, butchering, eating) with nonhuman primates among
residents of 17 remote villages in Cameroon. Sites were chosen
to represent a variety of habitats (e.g., savannah and forest),
all in proximity to wild game populations. Trained interviewers
individually administered questionnaires to 3971 participants
(age range, 16-97 years; 54% men).
More than 60% of participants reported butchering nonhuman
primates; approximately 30% reported hunting them. Women were
slightly more likely than men to butcher these animals, and men
were far more likely than women to hunt them. Approximately 11% of
participants kept nonhuman primates, primarily monkeys, as pets.
Most participants reported eating nonhuman primates
(>80%, monkeys, >45%, chimpanzees; >35%, gorillas).
Comment: Although, as the authors point out, hunting nonhuman
primates is officially forbidden, it is widely practiced. Thus,
rural villagers who depend on game for animal protein have
frequent contact with nonhuman primates. Earlier, the same
research group found evidence of simian retrovirus infections in
Cameroonian villagers who had direct contact with blood and
tissues of nonhuman primates. Characterization of the types of
contacts and of the different practices of men and women may
allow development of educational interventions to reduce risky
exposures. Villagers will also need economic resources to obtain
alternative sources of protein. Researchers in many countries
handle nonhuman primates and their tissues but are educated about
the risks involved and typically use barrier protection.
Source: Wolfe ND et al. Exposure to nonhuman primates in rural
Cameroon. Emerging Infectious Diseases 2004 Dec
10:2094-9.
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QUALITY OF CARE
4. Appendicitis -- problems inside and outside the hospital
Summary by: F. Bruder Stapleton, MD
SO: Journal Watch Pediats and Adolescent Med December 13, 2004
CO: © Massachusetts Medical Society 2004
http://www.jwatch.org
Summary: To investigate factors related to negative appendectomy
and appendiceal rupture, the most frequent complications in
suspected appendicitis, researchers retrospectively reviewed
24,411 appendectomies performed in children (age range, 5 to 17
years) at 36 children's hospitals.
The median negative appendectomy rate was 3% (range, 1%-12%); it
was lower in the 5 to 12-year age group than in the 13 to 17-year
age group, and it was unrelated to health insurance or race. Girls
had a 58% greater risk for a negative appendectomy than boys, and
older girls had a greater risk than younger girls. For every 1000
appendectomies performed at any hospital, the rate of negative
appendectomies decreased by 50%. The median appendiceal rupture
rate was 35% (range, 22%-62%). A greater risk for appendiceal
rupture was found in Asian children and in children with public
health insurance. Hospital volume of appendectomy was not related
to rupture. There was no relation between the rate of negative
appendectomy and the rate of appendiceal rupture.
Comment: This fascinating analysis points out the need to improve
early diagnosis and access to medical care before presentation at
the hospital. The rate of appendiceal rupture is unacceptable and
cannot be addressed by improved hospital performance. The rate of
negative appendectomy is affected by gynecologic symptoms in
adolescent girls, but this rate can and should be reduced by
referring children who may need appendectomy to hospitals with
high volumes of this procedure.
Source: Ponsky TA et al. Hospital- and patient-level
characteristics and the risk of appendiceal rupture and
negative appendectomy in children.
JAMA 2004 Oct 27, 292:1977-82.
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5. Touch vs. talk for low back pain
Summary by: Keith I. Marton, MD
SO: Journal Watch October 22, 2004
CO: © Massachusetts Medical Society 2004
http://www.jwatch.org
Summary: Millions of people with low back pain undergo physical
therapy (PT), despite poor evidence of efficacy. Now, British
investigators have randomized 286 adults with mild-to-moderate
low back pain of at least 6 weeks' duration to standard PT or an
advice intervention (1 hour with a physical therapist that
involved an examination plus counseling on staying physically
active). Patients with or without leg pain were included.
Eighty-two percent of people in each group received the intended
treatment. Patients in the PT group had a median of five PT
sessions; only 18% of the advice group received more than one
counseling session. Two hundred patients (70%) provided follow-up
information at 12 months. In intention-to-treat analyses, the two
groups showed similar improvements on a standard disability index
at 2, 6, and 12 months. Moreover, on eight domains of general
health (each assessed at these 3 time points), only a few
outcomes favored PT. However, on patients' global assessments of
overall benefit, highly significant differences were found that
favored PT at all time points.
Comment: For mild-to-moderate low back pain, a series of PT
sessions offered little advantage over one-time advice from a
physical therapist, according to standardized assessment scales.
However, when patients were asked simply whether they derived
benefit, they clearly favored PT. The reason for this disparity
between validated outcome measures and patient perception of
overall benefit is unclear and deserves further study.
Source: Frost H et al. Randomised controlled trial of
physiotherapy compared with advice for low back pain.
BMJ 2004 Sep 25; 329:708-11.
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