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RPS Newsletter September 2010
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In This Issue:
Preventive Medicine Funding Escapes Cut
Study Links Nighttime Sleep in Children to Obesity
Bed Bugs Bite Back
Safety Groups Call for Federal Regulation of Resident Hours
Case Study:...Altered Mental Status
Sign up for ACPM Advocacy Day!
Preventive Medicine Funding Escapes Cut
ByAshley Maltz and Samuel Peik

On September 14, an effort in the U.S. Senate to raid the $15 billion Prevention and Public Health Fund was successfully voted down. Sen. Mike Johanns (R-NE) had introduced an amendment to the Small Business Jobs and Credit Act, which would have cut the Prevention and Public Health Fund to pay for a provision that would ameliorate tax reporting requirements for small businesses. An alternative to the Johanns Amendment was the Nelson Amendment, authored by Sen. Bill Nelson (D-FL). This amendment aimed to provide similar relief to small businesses by repealing a tax deduction for large oil companies. This amendment was also rejected, and a subsequent vote approved the larger bill with neither amendment attached.

The Prevention and Public Health Fund was created as part of the Affordable Care Act (ACA) with the strong support from ACPM and the entire public health community, and provides funding for Preventive Medicine residency programs and other public health education programs.It is designed to foster an environment where prevention and public health programs can flourish and reach their maximum potential without the unique burden of obtaining outside revenue streams.

Although the amendment was defeated, it does raise concern that it may set the tone for future attacks on this fund. ACPM has added this issue to its Legislative Action Alert to aid its members in case of any future attempts to raid this fund. Stay tuned for any future announcements on this issue.

Study Links Nighttime Sleep in Children to Obesity
By Clarence Lam

A study recently published in theArchives of Pediatrics and Adolescent Medicinefound an association between nighttime sleep duration in young children and subsequent childhood obesity. This study is one of very few that have examined the prospective association between sleep and obesity.

The prospective cohort study used sleep duration data gathered from time diaries completed by the caregivers of 1930 children aged 13 years and younger. Body mass index (BMI) was subsequently measured at 5 years later in order to determine likelihood for obesity.

It found in that in children of age 0 to 4 years, a short duration of nighttime sleep was significantly associated with increased odds of overweight or obesity (OR=1.80, 95% CI, 1.16-2.80). In older children of age 5 to 13 years, it found no statistically significant association between duration of nighttime sleep and BMI status at time of follow-up. Covariates such as socioeconomic status, parents' BMI, and BMI at baseline were accounted for in the determinations of the study.

The relationship between sleep duration and obesity is unknown. Possible hypotheses include decreased physical activity because of tiredness, increased opportunity to eat as less time is spent sleeping, and hypothalamic imbalances in key metabolic hormones such as leptin and ghrelin.

According to the study, data from 2003 to 2004 has shown that 17% of children and adolescents were obese and 34% were overweight. In the preceding three decades, rates of obesity have doubled in children aged 2 to 5 years and adolescents aged 12 to 19 years and tripled in children aged 6 to 11 years.

Bed Bugs Bite Back
bySamuel Peik

Bed bugs, once nearly eradicated from the developed world in the mid-20th century, are making a strong comeback on the pest scene. While signs have pointed to an increase in infestations for over a decade, news stories on the small parasitic insects have begun popping up over the last several years, and concern has risen dramatically in recent months. According to the National Pest Management Association (NPMA), reports of bed bugs have increased 71% in the past 5 years, and this likely under represents the true problem. According to the CDC, bed bugs can have significant impact on public health including physical and mental health, economic consequences, and public concern.

The insects belong to the family Cimicidae, with Cimex lectularius the most common species seen in human environments.Adults are reddish-brown in color, grow to 4-5 mm in length, and feed exclusively on the blood of animals. Bed bugs get their name for their tendency to appear in and around households and sleeping areas as well as a propensity to feed at night, while you blissfully slumber. The ban of pesticides such as DDT, increased international travel, and greater pesticide resistance have likely hastened the resurgence, but scientists still have no conclusive evidence for the timing of the current revival.

Although not all bites have visible signs, they can cause skin irritation and itching, and treatment with topical corticosteroids and washing with hot water may relieve symptoms. Apprehension and stress over infestations can also cause significant anxiety and social stigma, with delusional parasitosis being an extreme consequence. Surprisingly, although bed bugs seem to be biologically suited for passing disease, to date there are no known cases of transmission to humans. However, this also puts the issue low on the research agenda for the government and scientists, and there is a general dearth of information outside of the pesticide industry.

Prevention remains the best way to control infestations.Bed bugs are commonly spread on clothing or luggage, so care should be taken when traveling to avoid contact.The prudent traveler should also wash all clothing on return and check luggage for any signs of the bugs. Resolving existing infestations can be a complicated process and requires integrated pest management, to include an experienced pest control company, vacuuming, sealing cracks, and heat or pesticide treatment.Like the pests themselves, the old saying "Goodnight, sleep tight, don't let the bedbugs bite," may be also making a return to the social stage.

To read the CDC/EPA joint statement on bed bugs, visithttp://www.cdc.gov/nceh/ehs/publications/Bed_Bugs_CDC-EPA_Statement.htm
.
For information provided by the NYDOMH, visit
http://www.nyc.gov/html/doh/html/vector/vector-faq1.shtml.
And for those concerned about specific locations, visit the Bed Bug Registry at
http://bedbugregistry.com/.

Safety Groups Call on Federal Government to Restrict Excessive Resident Work Hours
byCharlie Preston


On September 2nd, the consumer interest group Public Citizen and a coalition of other health and safety advocates submitted a petitionhttp://www.citizen.org/hrg1917to the Occupational Safety and Health Administration (OSHA) to take over the regulation of resident work hours from the current entity, the Accreditation Council for Graduate Medical Education (ACGME).

The groups submitted the petition because they felt ACGME's 2011 proposal did not go far enough to protect patients and residents from the detrimental effects of chronic sleep loss. ACGME first issued rules in 2003, when they introduced the 80-hour workweek and the 30 hour call shift. Since then, there's been a vast amount of research showing that sleep deprived residents are a danger to patients and a danger to themselves. One randomized controlled trial showed that interns who worked on-call shifts made roughly 36% more medical errors than interns who did not. Other research demonstrated that residents who worked such long hours suffered higher rates of motor vehicle crashes, needlestick exposures, pregnancy complications (high blood pressure, low birth weight, pre-term labor, pre-term delivery), and depression.

In 2009, the Institute of Medicine weighed in on the topic, and concluded that it was unsafe for residents to work more than 16 hour shifts without sleep. They recommended a protected sleep period after 16 hours of work.The ACGME, in its 2011 proposal, did not heed this recommendation. They suggested that interns' shifts be capped at 16 hours, but that upper-year residents still be allowed to work shifts of up to 28 continuous hours. There were other places where the ACGME's recommendations fell short of the IOM's. For a comparison of recommendations, see:http://www.nejm.org/doi/full/10.1056/NEJMsb1005800.

Specifically, the petition calls for:

  1. A limit of 80 hours of work in each and every week, without averaging;
  2. A limit of 16 consecutive hours worked in one shift for all resident physicians and subspecialty resident physicians;
  3. At least one 24-hour period of time off work per week and one 48-hour period of time off work per month, for a total of five days off work per month, without averaging;
  4. In-hospital on-call frequency no more than once every three nights, no averaging;
  5. A minimum of at least 10 hours off work after a day shift, and a minimum of 12 hours off after a night shift;
  6. A maximum of four consecutive night shifts with a minimum of 48 hours off after a sequence of three or four night shifts;

The rationale for the petition is two-fold. First, the US government has a long history of regulating the trucking, aviation, railroad, and maritime industries because of potential danger to the public's health. Second, the petition argues that ACGME has not done a good job of enforcing its own rules. In a 2006 JAMA study, for example, 83.6% of interns reported work hour violations during one or more months.

OSHA is the best entity to regulate resident work hours, the coalition says, because it is tasked with providing for a healthy and safe workplace, and residents are clearly workers since they collect paychecks, pay taxes, and do not pay tuition or other student fees.

In response to the petition, OSHA's administrator, Dr. David Michaels, said, "We are very concerned about medical residents working extremely long hours, and we know of evidence linking sleep deprivation with an increased risk of needle sticks, puncture wounds, lacerations, medical errors and motor vehicle accidents. We will review and consider the petition on this subject submitted by Public Citizen and others. . . Hospitals and medical training programs are not exempt from ensuring that their employees' health and safety are protected. . . No worker, whether low-skilled and low-wage, or highly trained, should be injured, or lose his or her life for a paycheck".

The other signatories to Public Citizen's petition were the American Medical Student Association, the Committee on Interns and Residents/ SEIU Healthcare, Dr. Charles Czeisler and Dr. Christopher Landrigan of Harvard Medical School and the Harvard Work Hours Health and Safety Group, and Dr. Bertrand Bell, the grandfather of resident work hour regulation and author of the Bell Commission, the report that started the process of regulating resident work hours in the United States.

Case Study: Altered Mental Status
by Jordana Rothschild

A 35 year old computer programmer is brought in by his coworker at noon. He seemed fine when he came in to work at 9am, but when everyone got up for lunch he was found slumping in his chair, minimally responsive.
Past medical history: chronic back pain, recent disciplinary problems at work.

Vital signs:
T 99.5 HR 96 RR 16SaO2 85%RA

Physical Exam:
Responds to pain, opens eyes, breathing spontaneously, controlling secretions
Pupils: dilated, reactive to light but not accommodation
Skin: warm, dry mucous membranes
Heart: sinus tachycardia
Lungs: clear to auscultation
Abdomen: soft, decreased bowel sounds

ECG:
Prolonged QRS, PR, and QT intervals

What is the diagnosis?
How would you manage and treat this patient?
(Explanation to follow next month.)

Sign up for ACPM Advocacy Day!

In conjunction with ACPM's upcoming board meeting, the college will be hosting an Advocacy Day on Capitol Hill on September 28th from 12-5 pm.If you are in the area and are interested in promoting the interests of the college, please sign up to participate!Contact Ashley Maltz, the current ACPM Pfizer Health Policy resident, atamaltz@acpm.orgfor more information.This is a great opportunity to get involved with ACPM and hone your advocacy skills!


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