Pediatric SuperSite - Blog

Happy New Year

Posted by Federico Laham, MD  on January 4, 2010 08:52 AM

With a decade gone, I can't help feeling a bit nostalgic. I completed my training, got married, had a baby girl, adopted two cats and lived in three states. I've lost loved ones, made a lot of new friends and said goodbye to many others.

To all of that, cheers.

But while cleaning the ID desktop for 2010, it would be worthwhile to point out a couple of things and leave some questions in the air:

• Universal healthcare — perhaps no other action will have consequences so profound for the way medical care is rendered in this country. Will it pass?
• The swine flu pandemic — as we were bracing for the H5N1 avian influenza, a triple reassortant emerged to cause the first pandemic of the millennium. And we saw an abundance of influenza activity during May and June. What will happen next? What if the neuraminidase inhibitors become useless? It took eight months to have a monovalent vaccine developed, tested and on the shelves, but we are still 60,000,000 shy of the 160 million doses recommended to target the at-risk groups. What can we learn from all of this?
• There's not a whole lot in the antimicrobial pipeline. We had a blast with new antifungals, but we're still determining the optimal dosing for our preemies. A fifth generation cephalosporin (ceftobiprole) and new lypoglycopeptides (such as telavancin) are being studied to treat MRSA infections, but it seems that it is going to be a while before we can use these in children. We continue to debate how best to use vancomycin, while others alert that "heteroresistant" populations may emerge during therapy and cause clinical failures.
• On the vaccine horizon…
  • When will we move to version 3.0 of pneumococcal vaccines? Invasive pneumococcal disease remains at historical low rates, but some serotypes like 19A are surfacing as trouble-makers.
  • In 2010 will we have a trivalent or a quadrivalent flu vaccine? More importantly, are we ready for tissue-culture based vaccine manufacturing? Any promise with influenza vaccines against conserved epitopes?
  • Another year without a respiratory syncytial virus vaccine, and the American Academy of Pediatric’s Committee on Infectious Diseases has recently trimmed both the number of doses and the target population for palivizumab on a cost-benefit basis. Will motabizumab, which is 40 times more potent against RSV than palivizumab in vitro, translate into clinical benefits and reduce the burden of RSV among high-risk patients?
  • Looks like we continue to move forward with vaccines for malaria and HIV, but how far we are from immunizing to prevent these voracious killers?
• Interferon-gamma assays (cool and trendy) will soon replace the tuberculin skin test (uncool and old-fashioned).
• Water in airplanes will be safer for passengers and the crew. After 15% of 327 tested airplanes had water with more coliforms than you should be comfortable fighting, the Environmental Protection Agency has passed new standards. Now, the five-billion dollar cost implies that you either won't get the peanuts, or that you will have to spend a quarter to use the restroom. Shame on all of you who drink airplane tap water!
• We have a new 2009 Red Book with a new font size! I hope the 2012 edition will not be printed in Garamond 8. What are we waiting for? Bible paper pages and bibliographic references?
• The iDoc is envisioned to facilitate our job as physicians. Wait… 2039 is still far away.
• No better place to advertise this great subspecialty than on the TV! I suggest the following topics for Mike Rowe, the host from Dirty Jobs:
  • Fecal transplantation for recurrent C. difficile colitis.
  • New tampons with glycerol monolaurate that inhibit staphlyococcal toxin synthesis.
  • And the award-winner, "Recovery of Campylobacter jejuni in feces and semen of caged broiler breeder roosters following three routes of inoculation.”

Happy New Year and best of luck in 2010!

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Food Safety for the Holidays

Posted by Federico Laham, MD  on December 30, 2009 02:51 PM

Feasts of apocalyptic magnitude take place in most American homes towards the end of the year. After a Thanksgiving kick-off, the season culminates with a two-dose booster — Christmas and New Year's Eve. With so much food around, I thought it would be good to remind you of some safety points to make sure that you spend time with your loved ones instead of your health care providers (unless, of course, you have a non-medical pre-existing relationship).

The undesired fauna you could get are diverse:

• Staphylococcus aureus
• Group A streptococcus
• Campylobacter jejunii
• Clostridium perfringens and Clostridium botulinum
• Bacillus cereus
• Yersinia enterocolitica
• Salmonella
• Shigella
• Escherichia coli (enterohaemorrhagic or entertoxigenic)
• And why not Brucella, Listeria, Trichinella or Toxoplasma too?

Besides common sense and a little knowledge, you will need a cooking thermometer. As a cooking aficionado, I bought this one 6 years ago; they are convenient, inexpensive and necessary. They come with a probe and an alarm that tells you when the desired temperature is reached.

If you have a type A personality you will enjoy the categorized exposures and risks below. If you are type B, just read the following paragraphs as you please.

Common rules

1. Two-hour Rule: Don’t leave perishables out at room temperature for more than two hours.
2. Raw vegetables and meat are potentially infectious!
   • Do not use the same utensils for handling raw and cooked vegetables or meats.
   • Wash fruits and vegetables thoroughly before consumption.
   • Clean counter surfaces after contact with raw vegetables and meats
   • It is a good idea to prepare salads separately from meats!
3. Refrigerate leftovers promptly.

Poultry

If you have serious hunger for information, you can call the USDA Meat and Poultry Hotline at 1-888-MPHotline or email them. There is no such a thing as juicy or bloody turkey.

• Internal cooking temperature: 165 ºF

Ham

I love those spiral-cut hams. Many come fully-cooked, so you just have to reheat it. Others come fresh.

• Internal cooking temperature: 160 ºF (if fresh)
• Internal cooking temperature: 140 ºF (if reheating)

Gravies

Mix fats (your turkey drippings perhaps) with starches and broth according to grandma's recipe and voilá! A gravy is born. But if you don’t bring to a boil, you may catch an infection, or even worse: the gravy will stay ignored on the table.

Eggs

Birds and reptiles are known to carry Salmonella. Even shiny grade A eggs can be contaminated with Salmonella (usually S. enteritidis). Omelets, custards or pie fillings should be cooked until yolk and white are fully solid.

• Internal cooking temperature: 160 ºF

BBQ

Keep meats refrigerated until close to cooking. My first comment about marinades, as an Argentina-trained griller, is that it masks the true flavor from your grill and doesn't reflect the amount of dexterity you have when grilling or smoking. Having said that, on occasion they are invincible.

Marinades work by flavoring and precooking your raw meats due to their acidic content. As the process is slow, marinated meats (usually in a Ziploc bag) should be placed in the refrigerator.

Poultry can be marinated up to two days. Beef, veal, pork, and lamb roasts, chops, and steaks may be marinated up to five days. Do not use marinade leftovers when serving the food unless you boil it!

Uncooked or undercooked red meat is undesirable unless you were born in France (in which case you probably already have gotten Toxoplasma). Pink meat may still pose some risks. To avoid E. coli O157:H7 in your next burger, it is preferable to use the USDA recommended internal cooking temperatures as a guide.

Safe minimum internal temperatures

• Poultry (as above): 165 ·F
• Hamburgers, beef: 160 ·F
• Sausage: 165 ·F

Beef, veal and lamb (stakes, roasts and chops):

• Medium rare: 145 ·F
• Medium: 160 ·F

All cuts of pork: 160 ·F

When smoking, temperatures should be kept at a minimum of 250 ºF.

Chitterlings — aka "chitlins"

Classically, the large intestine of swine may harbor Yersinia enterocolitica, causing Yersiniosis and many pediatric board questions. Without judging if it is worth eating, these should be boiled for five minutes before cleaning and cooking. All the utensils used during cooking should be autoclaved and buried in the back yard, three-feet under.

There are also issues with home-made preserves (botulism becomes REAL), but not many people are so defiant. I have a recipe for marinated eggplants that is killer, but I am willing to give it up.

I hope you will remember these tips and enjoy a wonderful meal with your family and acquaintances. Eat with moderation, drink responsibly, do offer help and give thanks for things received throughout our short visit to this world.

I wish you a safe 2010!

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Obstacles to obtaining the seasonal flu, H1N1 vaccines

Posted by Noelle LoConte, MD  on November 6, 2009 10:49 AM

I can't find flu shots or influenza A (H1N1) shots for my kids anywhere. As much as I want them to be vaccinated, no one within 50 miles of my home appears to have them.

My kids meet criteria on many levels — age, being in day care and having caregivers who are health care providers ... However, I have patients who meet none of the Centers for Disease Control and Prevention or Wisconsin Division of Public Health criteria to receive the H1N1 vaccine, but I presume through their persistence, they have convinced their primary care doctors to give it to them.

I have two thoughts on this: (1) I'm frustrated with people who do not meet criteria taking away vaccines from those who do, and no one (physicians, nurses, pharmacists) standing up to them and explaining why we only recommend H1N1 vaccine for those higher-risk people right now, and (2) how this vaccine fiasco has evolved is quite a blemish on our public health system. We have been talking about swine flu for more than a year! We knew this was coming; how can we not have adequate numbers of vaccines for at least the highest-risk patients?

In particular, continuing to manufacture the seasonal flu vaccine before the swine flu vaccine was likely not the right decision (see this summary of the production foibles here).

Now I am fairly sure that by the time my kids get the shot (if ever!) the peak of the infection likely may have passed. And I'm mad about it.

Dr. LoConte is an oncologist and a regular blogger for PediatricSuperSite.com's sister publication, HemOncToday.com.

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