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  • November 29, 2016 12:17 PM | Deleted user

    A probable case of local transmission of the Zika virus has been reported in Texas, state health officials announced on Monday, making it the second state, after Florida, in which the infection is thought to have been carried from person to person by mosquitoes.

    The patient is a woman who is not pregnant and lives in Brownsville, on the Gulf Coast near the Mexican border. The state’s first case of chikungunya, a virus spread by the type of mosquito that carries Zika, was confirmed this year in Brownsville.

    Medical investigators must now determine whether the infection is spreading and, if so, how many people may have become infected. Officials have begun asking the woman’s neighbors for urine samples and trapping mosquitoes to test for the virus.

    State and county health officials are working with the Centers for Disease Control and Prevention on the case. The state medical operations center has been activated to help with contact tracing, mosquito surveillance and public education.

    The C.D.C. sent a training team to Texas this year but has not yet been asked to send an emergency response team, said Dr. Thomas R. Frieden, the agency’s director.

    No travel alert suggesting that pregnant women avoid the area will be issued now, Dr. Frieden said, because a single case does not constitute evidence of continuing local transmission. “Most local cases are isolated dead ends,” he said.

    Confirmation of several cases within a roughly one-square-mile area for more than about two weeks, despite aggressive mosquito control, would prompt an alert from federal authorities.

    In Florida this year, the C.D.C. first advised pregnant women to avoid Wynwood, the neighborhood where the first cases in Miami were discovered, and later suggested they avoid all of Miami-Dade County.

    There have now been 4,444 confirmed cases of Zika infection in the continental United States, including 1,114 in pregnant women. Most of those infected had traveled to countries where the virus had been spreading, but 182 of the infections were contracted in Florida by people who had not visited such places.

    The Texas patient, who was not identified, told investigators that she had not traveled recently to anywhere the virus had been spreading. She had no other risk factors, such as having sex with someone who had visited an area with Zika transmission.

    “We knew it was only a matter of time before we saw a Zika case spread by a mosquito in Texas,” said Dr. John Hellerstedt, the state health commissioner.

    Residents of Brownsville, a city of 183,000, are concerned but not fearful, Mayor Tony Martinez said on Monday.

    “I don’t think it’s something that people need to be alarmed about, but by the same token, they need to be cautious about it and report anything that needs to be reported to our health department,” Mr. Martinez said.

    “On the coast, we kind of hoped that it wouldn’t happen,” he added, “but the likelihood was pretty high.”

    Dr. Carmen Rocco, a Brownsville pediatrician, said she had been checking her patients for Zika, but none so far had been infected. Most of her patients are poor enough to be on Medicaid, and she praised state health officials for reinstating a Medicaid benefit for mosquito repellent.

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    “Families were taking advantage of that,” she said.

    While cold weather is arriving in other parts of the country, southern Texas has had an unusually hot autumn, making it more hospitable to the Aedes aegypti mosquitoes that transmit Zika.

    Even in normal years, Aedes aegypti can persist in the Brownsville area well into December, so new cases may be confirmed in January or later.

    “I predicted last April that we would see cases along the Texas Gulf Coast this summer,” said Dr. Peter J. Hotez, the dean of the National School of Tropical Medicine at Baylor College of Medicine. “This is now the one case we know about, but we don’t know if there are dozens or hundreds.”

    “Because of the lack of funds from Congress, there has been no active surveillance along the Gulf Coast,” he added. “Those cases in Florida were found by serendipity.”

    Chris Van Deusen, a spokesman for the Department of State Health Services in Texas, said the new case was discovered because the woman fell ill and was tested for Zika infection by a local doctor, who alerted public health authorities. All such cases are investigated to see if a patient has a travel history or other risk factors that might explain the infection.

    “Pregnant women should continue to protect themselves from mosquito bites there and elsewhere in Texas,” Mr. Van Deusen said.

    Mosquito control measures will be stepped up, he said, but he did not know if they would involve aerial spraying of pesticides like Naled and larvicides like Bti.

    In the Wynwood section of Miami, mosquito swarms did not decrease enough to stop disease transmission until both types of aerial spraying were used.

    Thousands of Mexicans and Americans cross bridges over the Rio Grande each day in the Brownsville area; it is possible that the virus has been spreading in Matamoros, Mexico, just across the border.

    In 2002, when there was a small outbreak of dengue in Brownsville, Dr. Hotez said, there turned out to be a much larger one in Matamoros. Both cities have poor neighborhoods where residents lack air-conditioning and window screens, he said, but many more Matamoros residents live in poverty.

    “We won’t know how widespread the virus really was until babies with microcephaly begin being born, probably in the spring,” Dr. Hotez said, referring to the Zika virus and its link to the birth defect. “And I expect it to return next year.”

    The C.D.C. regularly collaborates with Mexican health authorities, and Mexico “has quite a strong mosquito control program,” Dr. Frieden said.

    Exactly how much Zika infection there may be in nearby parts of Mexico is unknown. “We know there is transmission in the border areas,” Dr. Frieden said. “But exactly where, we don’t know.”

    A version of this article appears in print on November 29, 2016, on page A11 of the New York edition with the headline: Texas Woman Contracts Zika as Mosquitoes Spread the Virus to a Second State. 


  • November 29, 2016 8:54 AM | Deleted user

    Written by Honor Whiteman

    Published: Monday 28 November 2016

    There is insufficient evidence to suggest breast cancer screening should be stopped at a specific age. This is the conclusion of the largest study to date of mammography outcomes in the United States.

    Researchers say there is no evidence that women should stop having mammograms after a certain age.

    Study co-author Dr. Cindy Lee, assistant professor in residence at the University of California-San Francisco, and team recently presented their findings at the Radiological Society of North America (RSNA) annual meeting, held in Chicago, IL.

    After skin cancerbreast cancer is the most common form of cancer among American women.

    According to the American Cancer Society, around 246,660 new cases of invasive breast cancer will be diagnosed in the U.S. this year, and more than 40,000 women will die from the disease.

    Despite these grim statistics, breast cancer death rates have been falling in the U.S. since the late 1980s - a trend that has been partly attributed to earlier detection as a result of screening.

    Mammography is considered the gold standard of breast cancer screening. The technique involves the use of X-rays to identify early signs of breast cancer, such as calcifications or tumors in breast tissue.

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    Guidelines issued by the U.S. Preventive Services Task Force (USPSTF) in 2009 recommend that women aged 40-49 at average risk of breast cancer should make an individual, informed decision as to whether they undergo mammography, while women aged 50-74 should undergo mammography every 2 years.

    For women aged 75 and older, however, the USPSTF state that there is insufficient evidence to "assess the balance of benefits and harms of screening mammography."

    Such guidelines are at odds with those from the American Cancer Society, which recommend that women aged 55 and older should undergo mammography every 2 years, and "screening should continue as long as a woman is in good health and is expected to live 10 more years or longer."

    Assessing the mammography outcomes of more than 2.5 million women

    Dr. Lee notes that the conflicting guidelines surrounding the age at which mammography should be stopped have led to much confusion.

    "There has been a lot of controversy, debate and conversation regarding the different breast cancer screening guidelines, even among major national organizations, over the past few years," she adds.

    Dr. Lee points out that previous randomized, controlled trials assessing mammography outcomes have excluded women aged 75 and older, meaning the available data have been based on results of small, observational studies.

    With this in mind, Dr. Lee and team analyzed data from the National Mammography Database. The researchers assessed more than 5.6 million screening programs that took place at 150 facilities across 31 U.S. states between January 2008 and December 2014.

    All in all, the team gathered data from more than 2.5 million women aged 40 and older. The women were divided into age groups by 5-year intervals up to the age of 90 - aged 40-44, 45-49, 50-54, 55-59, and so on.

    'No evidence for age-based mammography cessation'

    In order to determine mammography outcomes for the women in each age group, the researchers applied four standard performance measures: cancer detection rate, recall rate - the percentage of mammograms that require follow-up testing - and positive predictive value for biopsy recommended (PPV2) and biopsy performed (PPV3).

    Positive predictive value represents the number of cancers identified through mammography that result in biopsy or recommended biopsy.

    According to the researchers, a higher cancer detection rate, higher PPV2 and PPV3, and a low recall rate reflect an optimal mammography performance.

    For every 1,000 patients, the team identified an overall mean cancer detection rate of 3.74, a 10 percent recall rate, a 20 percent PPV2 rate, and a 29 percent PPV3 rate.

    With increasing age, the researchers identified an increase in cancer detection rate, a gradual rise in PPV2 and PPV3 rates, and a fall in recall rates - meeting the criteria for ideal screening performance.

    "The continuing increase of cancer detection rate and positive predictive values in women between the ages of 75 and 90 does not provide evidence for age-based mammography cessation."

    Dr. Cindy Lee

    The researchers conclude that their findings suggest it should be a woman's individual choice - based on health status and personal preferences - as to whether she wants to cease or continue breast cancer screening at the age of 75 or older.

    While further investigation is needed, the new research indicates that the benefits of breast cancer screening after the age of 74 may outweigh the risks.

    Read how digital mammography could help predict heart disease.

    Written by Honor Whiteman


  • November 29, 2016 8:52 AM | Deleted user

    Statement by Josanne Pagel following NCCPA’s November 18th PANRE Proposal Communication

    On November 18, 2016, NCCPA announced that it had finalized its plans for modifying PA maintenance of certification requirements. It has discarded its proposal to require PAs to take a closed-book, proctored exam in a specialty area, as well as its plans to introduce either several take-home exams or other new requirements during each 10-year recertification cycle.  NCCPA also announced its intention to modify the PANRE exam to focus on “core knowledge.”

    We are grateful to the many PAs who have made and continue to make their voices heard on this issue.  On their behalf, AAPA welcomes NCCPA’s decision to abandon some of the most onerous parts of its recertification proposal. But we continue to oppose high-stakes recertification exams.

    AAPA opposes re-testing because there is no evidence that it improves patient outcomes or safety. We urge NCCPA to conduct research on the impact of PA recertification exams on patients.

    In the meantime, we will redouble our efforts to remove state laws and regulations that require current NCCPA certification for license renewal.  If we can change these provisions, at least PAs will not be at risk of losing their license if they fail NCCPA’s high stakes recertification exam.  We have already contacted the State Chapters in the 20 states where this requirement exists, and we encourage you to join your State Chapter and help us work on this issue.

    We continue to examine the feasibility of starting a new recertifying organization, and we look forward to a robust conversation on this topic with PAs at AAPA’s Leadership and Advocacy Summit (March 4-5) in Washington, D.C.

    NCCPA Revises Potential Changes to the PA Recertification Exam

    September 19, 2016

    NCCPA advised AAPA, PAEA and ARC-PA at our meeting in Atlanta on September 6 that it is considering an alternative to its previous proposal for recertification testing. NCCPA did not ask the organizations present to endorse its proposal, nor did we offer to do so. We – AAPA, PAEA and ARC-PA – agreed to give NCCPA time to make an official announcement to the PA community before reaching out to our respective stakeholders. NCCPA distributed the alternative they are currently considering by email to PAs on September 9. Over the coming weeks, AAPA’s board will evaluate the new NCCPA proposal in light of AAPA policy, the views of our constituent organizations (COs) and those of individual PAs.

    Listening to and being responsive to our membership is at the heart of AAPA. We will continue to provide transparency in our decision-making and actively seek the opinions of PAs and COs. Please continue making your voices heard by posting your views of the NCCPA alternative on our Facebook page, Twitter #PARecert or in Huddle. You can also send us your views by emailing AAPA at this address: recertificationcomments@aapa.org. We also encourage you to share your views directly with NCCPA.

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  • November 28, 2016 8:16 AM | Deleted user
  • November 28, 2016 8:07 AM | Deleted user

    Black Friday and Cyber Monday are here! While you’re surfing around Amazon to find the perfect gifts, please shop under ARHP’s Amazon Smile portal. ARHP’s receives automatic donations from every Amazon purchase that comes through our account—at no cost to you.

    Easy and fast sign-up is here: à http://www.arhp.org/about-us/support-arhp.

    Please send to your family and friends as well. We actually DO receive a small but helpful check each year from Amazon through the SMILE program. Let’s make this year’s bigger than ever. 


  • November 22, 2016 8:51 AM | Deleted user

    Sexual Health and Your Patients: A Provider’s Guide can help healthcare providers better integrate sexual health conversations and recommended preventive services into routine visits with adolescents and adults. By using this guide, providers can:

    • Streamline their sexual history taking
    • Increase their delivery of recommended preventive sexual health services by using “at a glance” tables

    • Improve their care for LGBT patients 

    • Be better prepared to discuss sexual health topics and answer patient questions 

    • Become more knowledgeable about sexual health

    Explore the guide's sections by clicking on the links below, or download the entire guide by clicking in the box.

    How to Discuss Sexual Health
    Sex can be difficult to discuss, but many patients want to talk about it with you. Get tips for ensuring a productive sexual health conversation with your patients.

    Asking Essential Sexual Health Questions
    Find the essential sexual health questions to ask adults and adolescents at least annually, plus additional questions you can ask to get more information.

    Delivering Recommended Preventive Sexual Health Services
    Preventive services are a key element to improving and protecting sexual health. Find out which your patients should be getting, and which they shouldn't be.

    Responding to Your Patients' Questions
    Not always ready to answer questions about sexual health? See sample responses to common questions so you can include all the important elements in your answers.

    Information About Recommended Screening Tests
    See here for general information about recommended screening tests, including their sensitivity and specificity. 

    Where to Learn More
    Want to learn more about a particular sexual health topic? Visit this list of clinical education and resources.


  • November 21, 2016 2:07 PM | Deleted user

    A new clinical research study seeks to determine whether a rapid molecular diagnostic test can reliably identify gonorrhea infections that may be successfully treated with a single dose of an older antibiotic, ciprofloxacin. The study will enroll up to 381 men and women diagnosed with untreated Neisseria gonorrhoeae. It is sponsored by the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health. The study is being conducted by the NIAID-funded Sexually Transmitted Infections Clinical Trials Group at four sites: one each in San Francisco, and Philadelphia, and two in Los Angeles.

    The Centers for Disease Control and Prevention estimates that more than 800,000 new gonococcal infections occur in the United States each year. Fewer than half of these infections are detected, and antibiotic-resistant infections are a growing problem. People treated for gonorrhea must now receive two drugs--one orally (azithromycin) and another as an injection (ceftriaxone)--to hedge against the possibility that they may harbor a strain resistant to one of the two drugs. The availability of a greater variety of treatments for gonorrhea--and a tool to pinpoint the best treatment option for each individual--would benefit patients and also potentially help slow the development of drug resistance, say the study authors.

    In this new trial, scientists will employ a rapid molecular assay using swabbed samples from participants' infection sites to determine whether they are infected with gonorrhea of a specific genetic profile (genotype), gyrA serine 91. Participants with that strain who agree to take part in the study will receive one dose of oral ciprofloxacin (500 mg), and will return for clinical and laboratory assessments within 5 to 9 days to determine if they are cured. Participants who remain infected will be referred for standard treatment.

    If the gyrA serine 91 genotype proves to be a reliable marker of vulnerability to ciprofloxacin, healthcare providers may be able to reintroduce ciprofloxacin as a viable treatment for gonorrhea in some cases.

    Source:

    NIH/National Institute of Allergy and Infectious Diseases


  • November 18, 2016 9:32 AM | Deleted user

    Teaching a "Martian" how to make a peanut butter and jelly sandwich is part of new curriculum at Northwestern Medicine that aims to eliminate medical errors. Credit: Northwestern University

    Why do physicians accidentally jab themselves in the hand with an EpiPen (epinephrine injection) when they are trying to give another person an injection while holding their breath? 

    How does directing a "Martian" to make a peanut butter and jelly sandwich improve health care communications?  

    The answers are part of the curriculum for the first Ph.D. in health care quality and patient safety program in the country—at Northwestern Medicine — which aims to prevent the annual 440,000 deaths from medical errors in the United States. 

    "You can't stress enough how crazy it is that the third-leading cause of death is medical errors," said Donna Woods, director of the graduate programs in health care quality and patient safety at Northwestern University Feinberg School of Medicine. "How will this ever get fixed if we don't train a work force to do it? We need an army of experts who need to know how to address this. The medical field does not have the skills to do it."

    The first Ph.D. student in health care quality and patient safety graduated this fall with others in the pipeline.

    Senior and mid-career clinicians (physicians, nurses, pharmacists) and health care professionals are trained by engineers, cognitive psychologists and risk assessment and change management specialists, who bring a critical fresh eye to the medical world. The "outsiders" teach students how to spot the vulnerable chinks in the system and figure out how to fix them. The students learn to do research, so they can design fixes based on scientific evidence.

    To build a national health care safety army, Northwestern has provided a template from its master's level health care quality and patient safety program—also the first in the country—to other medical schools to launch their own master's programs. These include George Washington University, Thomas Jefferson University's College of Population Health, University of Illinois and Cornell University. 

    Doctors, nurses and pharmacists are working in a system that has not been designed for safety, and they never got the skills or perspective to help them redesign health care to make it safer. Thus, the problem can't be fixed by insiders without training in health care quality and patient safety, Woods said.

    "Under the current model, when medical students and residents walk into an Emergency Department, their challenge is to survive and adapt to a crazy system, not figure out how to fix it," Woods said. "When they become attending physicians, they are inured to the problems and no longer see the risks. We have to reintroduce them to these risks. If they don't see them, they won't ever do anything to fix them."

    The Ph.D. students learn about physical and cognitive ergonomics, which is the study of predictable errors your mind can make and how to consider these in health care design to make the delivery of health care more reliable.

    In one class session for Ph.D. and graduate students, a faculty member who is a physician and an engineer, brought EpiPen trainers to class. He asked students—most of whom had medical degrees—to hold their breath (to create a sense of urgency) while reading the directions and give another person the injection. In the scenario, the person was having a life-threatening anaphylactic reaction. Every time this session is held, at least one student accidentally sticks himself or herself in the hand with the injector, wasting the life-saving medicine. Students had to figure out why the device's design led to that problem.

    The lesson learned: it's hard to make your eyes focus when you are in a crisis situation.

    The faculty member who taught the EpiPen class subsequently worked with the manufacturer to develop a new design in which the injector gives spoken instructions.

    In another class, students are instructed to write a protocol for a "Martian," who has no earthly cultural knowledge, to make a peanut butter and jelly sandwich. When the instructor attempts to literally follow students' directions, sandwich-making chaos ensues. It illustrates when a person writes a protocol for a health care procedure, they make a lot of cultural assumptions that not everyone shares or understands across medical departments, services and professions. That can lead to errors. 

    Students also learn one of the riskiest moves for a patient is from an intensive care unit (ICU) to the regular-care hospital floor. In the ICU, each nurse cares for two patients and checks them constantly. On the regular floor, a nurse may have seven or eight patients and visits them every four to six hours.

    "In four hours, a patient just transferred from the ICU can quickly deteriorate to the point of death," Woods said. "One opportunity for change is not just recognizing this to be a potentially risky transition but to develop a system of additional monitoring and checking on these patients. Many hospitals have a rapid response system after a patient has deteriorated. Possibly, a system of rapid-response rounding can provide a system so a nurse comes around more frequently. This is the type of intervention our students will develop."

    Woods has a personal interest in this solution; several years ago her mother died within a day after being moved from the ICU to a regular floor.

    The curriculum also targets how to improve teamwork and communication in health care—often disjointed and risky—as a patient moves through the system. A patient's primary care doctor and specialists don't always communicate or know about changes in drugs, which could lead to dangerous interactions or overdoses. Students are tasked with making electronic health records more reliable, including more accurate processes for including all of a patient's current medications. Unreliable information is frequently the cause of medical errors. 
    The first Ph.D. student who graduated in September, Cindy Barnard, is non-traditional in that she is already an executive in the health care world as vice president of quality for Northwestern Memorial Healthcare. In her research, she asks patients how they define quality health care.

    "As surprising as it may seem, nobody has asked them," Barnard said. "We discovered patients have thoughtful and distinctive views of what health care quality should be, and what they want us to improve. Now we need to figure out how we can use their perspective to change what we measure in order to provide what's important to them."

    The medical field thinks patients care most about emotional support and the hotel aspects of the hospital (food quality, cleanliness and parking). But what they really value is a timely, accurate diagnosis and evidence-based care, Barnard said. They also are concerned about medical errors and recognize the most vulnerable time in their care is when they are transitioning from one nurse or doctor to another. Many said they want to make sure all of their doctors are on the same computer system.

    "We've learned the health care industry needs to do a better job of creating quality measures to determine if the patient received a prompt and accurate diagnosis," Barnard said. "There's no way to say this hospital or doctor did or did not do a great job."

    Gayle Kricke, a geriatric social worker who will get her Ph.D. next year, is researching quality end-of-life care for older adults with multiple chronic conditions. They account for two-thirds of the older adult population more than 65 years old, a number on the rise.  

    "These patients tend to be on a roller coaster of sickness and relative health, so you don't really know when they are approaching the end of their lives," Kricke said. She's investigating how to improve care for them, moving them into palliative care sooner and hospice at the appropriate time. Many spend only a few days in hospice care, which means they aren't getting the full benefit, including a focus on comfort and holistic care to meet the spiritual and emotional needs of the patient and family.

    "These students are the future of safer and higher quality medical care," said Neil Jordan, director of Northwestern's Health Sciences Integrated Ph.D. Program, which includes the Ph.D. degree in health care quality and patient safety.


  • November 17, 2016 9:22 AM | Deleted user

    Be the change. The nccPA Health Foundation challenges PAs to take responsibility for making a change to improve health and offers a funding opportunity to support PA efforts. This grant is for PAs to lead, design, and execute activities that expand access to care as a strategy for promoting more equitable care. These grants are intended to encourage, facilitate, and support volunteerism and service-learning, mechanisms that allow PAs to leverage their unique skills and training to support patient education and care in their communities. 

    This program is for certified PAs, PA organizations (educational programs or constituent organizations), and PA students. Grants are considered on a rolling basis and awarded based on merit, in amounts up to $1,000 until all funds are expended. Applicants should be a certified PA or PA student (working with a PA faculty member at an accredited PA program). (Co-applicants may be interprofessional colleagues.) Funds are generally disbursed to the organization sponsoring the project. Individuals coordinating outreach activities are also welcome to apply.

    For more information and to apply, click here

  • November 17, 2016 9:00 AM | Deleted user

    The Food and Drug Administration (FDA) has approved Bonjesta (doxylamine succinate and pyridoxine HCl extended-release tablets; Duchesnay), a fixed-dose combination drug product for the treatment of nausea and vomiting of pregnancy in women who do not respond to conservative management. This product has not been studied in women with hyperemesis gravidarum.

    Each tablet of Bonjesta contains 20mg of doxylamine succinate, an antihistamine, and 20mg of pyridoxine HCl, a vitamin B6 analog. The combination of doxylamine succinate and pyridoxine HCl has been the subject of many epidemiological studies designed to detect possible teratogenicity. No increased risk for congenital malformations has been reported based on these studies.

    Bonjesta will be available in extended-release tablets in 100-count bottles. The tablet should be taken on an empty stomach as food may delay the onset of action.

    Duchesnay also markets Diclegis, which contains doxylamine succinate 10mg and pyridoxine HCl 10mg, for a similar indication.

    For more information visit Duchesnay.com.


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