Cluster of oseltamivir-resistant 2009 pandemic influenza A (H1N1) virus infections on a hospital ward among immunocompromised patients--North Carolina, 2009.

BACKGROUND: Oseltamivir resistance among 2009 pandemic influenza A (H1N1) viruses (pH1N1) is rare. We investigated a cluster of oseltamivir-resistant pH1N1 infections in a hospital ward. METHODS: We reviewed patient records and infection control measures and interviewed health care personnel (HCP) and visitors. Oseltamivir-resistant pH1N1 infections were found with real-time reverse-transcription polymerase chain reaction and pyrosequencing for the H275Y neuraminidase (NA) mutation. We compared hemagglutinin (HA) sequences from clinical samples from the outbreak with those of other surveillance viruses. RESULTS: During the period 6-11 October 2009, 4 immunocompromised patients within a hematology-oncology ward exhibited symptoms of pH1N1 infection. The likely index patient became febrile 8 days after completing a course of oseltamivir; isolation was instituted 9 days after symptom onset. Three other case patients developed symptoms 1, 3, and 5 days after the index patient. Three case patients were located in adjacent rooms. HA and NA sequences from case patients were identical. Twelve HCP and 6 visitors reported influenza symptoms during the study period. No other pH1N1 isolates from the hospital or from throughout the state carried the H275Y mutation. CONCLUSIONS: Geographic proximity, temporal clustering, presence of H275Y mutation, and viral sequence homology confirmed nosocomial transmission of oseltamivir-resistant pH1N1. Diagnostic vigilance and prompt isolation may prevent nosocomial transmission of influenza.

A survey of emergency department 2009 pandemic influenza A (H1N1) surge preparedness--Atlanta, Georgia, July-October 2009.

During August through September 2009, a surge in emergency department (ED) visits for 2009 pandemic influenza A (pH1N1) illness occurred in Georgia, particularly among children. To understand surge preparedness and capacity, we obtained influenza-like illness (ILI) ED visit data from the Georgia State Electronic Notifiable Disease Surveillance System (SendSS) and conducted a retrospective, Internet-based survey among all 26 metro Atlanta ED managers with reference to the period 1 July-1 October 2009. SendSS detected a marked and progressive increase in mean monthly ILI visits from 1 July-1 October 2009, which more than tripled (from 399 to 2196) for the 2 participating EDs that cared for pediatric patients during this time. ED managers reported patient volume surges, resulting in space and supply limitations, especially at pediatric EDs. Most (92%) of the facilities had current pandemic influenza plans. Pandemic planning can help to ensure preparedness for natural and man-made disasters and for future influenza pandemics.

On-scene physician assessment of thromboembolic etiology in out-of-hospital cardiac arrest.

Out-of-hospital cardiac arrest (OOHCA) treatment produces dismal recovery rates. Newer, directed therapies such as thrombolysis may be best considered if possible etiologies can be assessed immediately. We conducted a prospective, pilot, feasibility study of on-scene physician assessments in non-traumatic OOHCA. Physicians responded to the scene and reported likelihood of thromboembolic etiology based on detailed history and physical assessments. Included were 136/148 OOHCAs during the 6-month study period; median age was 69.5 years and 72% were men. Physicians judged 103/136 (76%) of arrests to be of thromboembolic etiology and would have recommended thrombolytic bolus in 83/136 (61%). Among 19 instances of physician-reported contraindications, 17 (90%) were not true contraindications. Median age was lower in the group recommended for thrombolysis. Thromboembolic etiology as judged by on-scene physicians was common and physicians recommended thrombolytic bolus commonly. Contraindications were highly overestimated. These data may be useful in the consideration of innovative, directed therapies such as thrombolysis in attempts to improve outcomes from OOHCA.

Cerebral oximetry in out-of-hospital cardiac arrest: standard CPR rarely provides detectable hemoglobin-oxygen saturation to the frontal cortex.

Favorable neurological survival in out-of-hospital cardiac arrest (OOHCA) may be influenced by cerebral perfusion during resuscitation. Cerebral oximetry (COx) provides a portable, noninvasive, real-time index of cerebral perfusion that has not been studied in OOHCA. This study examined the feasibility of using COx to measure cerebral perfusion during OOHCA. As a secondary aim, we tested the hypothesis that cerebral perfusion, measured by COx, would decrease with hyperventilation. Subjects were patients with medical OOHCA. A physician responded to the scene of cardiac arrest calls and applied an INVOS 3000 COx probe (Somanetics) to the frontal skull. In a cross-over design, readings were recorded for 2 min while ventilation rate was maintained at 10/min, then for 2 min at 24/min. COx readings were recorded by the oximeter and manually by the investigator. Statistical analyses were done using a paired t-test. Sixteen subjects were enrolled, four had return of pulses. COx reliably detected cortical oxygenation in only one subject during cardiac arrest. None of 16 patients exhibited consistently detectable levels of oxygen during cardiac arrest. In three subjects with ROSC, readings increased with return of pulses and with increasing blood pressure. In a fourth subject the protocol was completed and the device removed, subsequently ROSC was noted and the device re-applied. No patient exhibited any change in oxygen levels with variation of ventilation rates during CPR. The use of cerebral oximetry during OOHCA is feasible. In our sample of OOHCA patients, cerebral perfusion is rarely detectable using an oximeter during CPR. Ventilation rate does not alter the oximeter readings. It is possible that the current standard mechanical method of cardiopulmonary resuscitation provides little or no cerebral oxygenation during OOHCA.

Acute abdominal emergencies. Assessing & treating patients with severe abdominal pain.

A focused approach to the patient with abdominal pain includes a working knowledge of relevant anatomy, a basic understanding of physiology and the ability to take a careful history. Creating a differential diagnosis, resuscitating patients in shock and appropriately treating a patient's pain will allow EMS crews to greatly impact patient care.

World Cup 2010 planning: an integration of public health and medical systems.

OBJECTIVES: To present crucial stages of planning and the resources involved in the medical and health care that will address issues affecting the health and safety of all participants in the 2010 World Cup. DESIGN: Relevant literature reviews of mass gathering medical care supplemented experience of the authors in planning for previous similar events. Attention is focused on issues wherein effective planning requires the integration of public health practices with those of clinical emergency medical services. The tables that are included serve to illustrate the depth and breadth of planning as well as the organizational relationships required to execute care of a universally acceptable standard. CONCLUSIONS: This article offers guidance in planning for the 2010 World Cup health and emergency medical care, emphasizing the need for integration of public health and medical practices. It depicts the span of planning envisioned, the organizational relationships crucial to it, and emphasizes the necessity of an early start.