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Mark Bostic

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    Mark Bostic Mark Bostic Presentation Transcript

    • Bioterrorism: Are Physician Assistants Prepared to Diagnose and Treat? Mark Bostic Spring 2006 PAS 646
    • Objectives  1) Talk about PA preparedness  2) Talk about bioterroristic diseases
    • What is bioterrorism?  Form of terrorism in which biological agents are used to inflict harm and/or fear upon a population. http://www.fbi.gov/anthrax/images.htm#1
    • Physician Assistant Training  Medical school model  Consistent with physician training  Bioterrorism?
    • Bioterrorism Training  Physician Assistant Programs’ Websites – No training specified  Accreditation Review Commission on Physician Assistant Programs (ARC-PA) – No training mandated  Liaison Committee on Medical Education (LCME) – No training mandated
    • Physician Assistant Preparedness  Studies lacking for PA’s  Physician preparedness – HHS Agency for Healthcare Research and Quality (AHRQ) survey indicates physicians unprepared  n=614 physicians, 18% trained, 93% expressed interest – Johns Hopkins University study indicates physicians unprepared  n=2407 physicians, pretest 46.8%, posttest 79%  Chickenpox vs. smallpox, botulism vs. Guillain-Barre
    • CDC top six bioterroristic agents  Anthrax  Smallpox  Plague  Viral hemorrhagic fevers  Botulism  Tularemia
    • Anthrax  Bacillus anthracis – Spore-forming bacterium  Livestock, meat products, wool sorters  Inhalational, cutaneous, gastrointestinal  Often misdiagnosed as influenza
    • Inhalational anthrax  Most deadly  Incubation period  Replication and toxin release  Phase I: nonspecific constitutional symptoms – Mild fever, malaise, myalgia, nonproductive cough, emesis, chest/abdominal pain  Phase II: more severe – Higher fever, chest/neck edema, mediastinal widening, dyspnea, cyanosis, meningoencephalitis, shock
    • Diagnosis: inhalational anthrax  Chest x-ray and chest CT – Mediastinal widening, pleural effusion, consolidation  Blood smear and gram stain/culture – Large bacilli – Left shift  Cerebrospinal Fluid – Purulence, decr. glucose, incr. protein, elevated pressure, blood
    • Inhalational anthrax www.cdc.gov
    • Cutaneous anthrax  Most prevalent form of infection  Skin barrier must be compromised  Replication and toxin release – May take up to 14 days
    • Diagnosis: cutaneous anthrax  1) pruritic papule or pustule surrounded by smaller vesicles  2) mild fever and malaise  3) papule enlarges to a circular lesion surrounded by edema – Ruptures and necroses – Characteristic “Black Eschar”
    • Cutaneous anthrax www.cdc.gov
    • Treatment: anthrax  Combination of: – Ciprofloxacin (Cipro ®) – Doxycycline (Vibramycin ®)  Combination varies depending upon: – Adult, child, immunocompromised  Amoxicillin for pregnant females
    • Smallpox (Variola)  DNA virus  Transmitted in droplet form  Respiratory tract mucosa  12-14 day incubation period  Often misdiagnosed as varicella
    • Diagnosis: smallpox  Rapid onset of nonspecific sx’s – Fever, HA, malaise, chills, myalgia, anorexia, N/V, diarrhea, abdominal pain, delirium, convulsions  Papules surrounded by rash a few days later  Centrifugal distribution  Papules  pustules  crusted lesion  Simultaneous staging of lesions  Not “dewdrops on a rose petal”
    • Smallpox www.cdc.gov
    • Treatment: smallpox  No cure  Tx is supportive  Vaccination available = Vaccinia
    • Plague  Yersinia pestis – Gram negative, pleomorphic coccobacillus – Infects by fleas carried by rodents  Bubonic, septicemic, pneumonic
    • Diagnosis: bubonic and pneumonic plague  Onset of nonspecific sx’s in 2 to 6 days – Fever, chills, weakness, malaise, myalgia, lethargy –  chest pain, dyspnea, watery/bloody expectorated sputum – Tender buboes (swollen lymph nodes) – 2 to 4 days later, lung exhibits necrosis, infiltration, hemorrhaging, effusion, abscesses  Chest x-ray  Hypotension, respiratory distress, pulmonary edema = death in 24 hours
    • Plague www.cdc.gov
    • Diagnosis: septicemic plague  Fever, chills, prostration, N/V, abdominal pain  Purpura and DIC  hypotension, shock, and death  Blood cultures (all types of plague) – Prior to tx with antibiotics  Gram stain & culture (all types of plague) – Prior to tx with antibiotics  Sputum sample
    • Treatment: plague  Streptomycin (1st line)  Gentamicin (2nd line)  Tetracylines such as chloramphenicol
    • Viral hemorrhagic fevers  RNA viruses: – Arenavirus, bunyavirus, filovirus, flavivirus  Infection via vectors: – Mosquitoes, ticks, cats, rabbits, people  History should include travel to tropical regions
    • Diagnosis: VHF  Onset of nonspecific symptoms: – Fever, HA, myalgia/arthralgia, N/V, diarrhea – Possible bradycardia, tachycardia, liver necrosis, delirium, confusion, coma  Hallmark: generalized systemic coagulopathy with profuse bleeding – Petechiae, ecchymoses, epistaxis, hematemesis – Bleeding from gingiva, vagina, any puncture sites  Definitive: immunoglobulin Antibody to specific virus
    • Viral hemorrhagic fevers http://www.gata.edu.tr/dahilibilimler/infeksiyon/resimler/VIRAL_HEMORRHAGIC_FEVER/__VIRAL_HEMORRHAGIC_FEVERS_2.JPG
    • Treatment: VHF  No FDA approved drugs  Ribavirin may be effective  Supportive treatment of shock: – Hydration, blood transfusions, etc.
    • Botulism  Spore-forming anaerobic bacterium Clostridium botulinum  Toxin is most lethal of all toxins – 100,000x sarin gas – 15,000x nerve gas  Iraq: enough to kill every human 3 times  Bacterium or toxin may be aerosolized, placed in food supplies  Blocks ACh release
    • Diagnosis: botulism  Descending paralysis  Ptosis, diplopia, blurred vision, and dilated, sluggish pupils  Difficulty speaking, chewing, swallowing  Paralytic asphyxiation or flaccid airway collapse  Culture serum, stool, gastric contents, suspected food
    • Treatment: botulism (cont.)  Equine botulinum antiserum  Antibiotic therapy experimental – Metronidazole – PCN  Supportive: ventilation and tube feeding
    • Tularemia  Nonmotile, aerobic gram negative coccobacillus Francisella tularensis – 2 subspecies: biovar tularensis & biovar palaeartica  Bite of tick, mosquito, handling infected carcass  Aerosolization possible  Incubates, then moves to LN and multiplies  Pathology at all sites where bacillus spreads
    • Diagnosis: tularemia  Site of inoculation: papule-pustule-ulcer pattern  Eye: ulceration of conjunctiva with LAD  Oral: tonsillitis or pharyngitis with cervical LAD  Lungs: bronchiolitis, pneumonitis, pleuropneumonitis with LAD  Fever, abdominal pain, diarrhea, emesis  IF, GS&C
    • Tularemia http://www.logicalimages.com/resourcesBTAgentsTularemia.htm http://phil.cdc.gov/Phil/details.asp
    • Treatment: tularemia  Ciprofloxacin or doxycycline (early)  Streptomycin or gentamicin (late)  No vaccine
    • Reporting  Written plan in every health care facility  Notify local health care officer for suspected or confirmed cases
    • Conclusion  Data suggest that physicians are unprepared to diagnose and manage diseases of a bioterroristic cause.  Studies need to be performed to determine whether or not PA’s are prepared.
    •  Thank you for your attention!
    • References  ARC-PA (2005). “Accreditation standards for physician assistant education.” Section B(1-7): 11-13.   CDC (2005). “Agents, diseases, and other threats.” Cited on World Wide Web 1 December 2005 at http://www.bt.cdc.gov/agent/.   Cosgrove, S. E., T. M. Perl, X. Song, S. D. Sisson (2005). “Ability of physicians to diagnose and manage illness due to category A bioterrorism agents.” Archives of Internal Medicine 165(17): 2002-2006.   Endy, T. P., S. J. Thomas, J. V. Lawler (2005). “History of U.S. Military Contributions To The Study of Viral Hemorragic Fevers.” Military Medicine 170(4): 77-91.   Goad, J. A., J. Nguyen (2003). “Hemorrhagic Fever Viruses.” Top Emerg Med 25(1): 66-72.   Hickner, J., F. M. Chen (2002). “Survey on Eve of Anthrax Attacks Showed Need for Bioterrorism Training.” Press release 5 September 2002. Agency for Healthcare Research and Quality, Rockville, MD. Cited on World Wide Web on 22 December 2005 at http://www.ahrq.gov/news/press/pr2002/anthraxpr.htm   Karwa, M. (2005). “Bioterrorism: Preparing for the impossible or the improbable.” Critical Care Medicine 33(1 Suppl): S75-95.
    • References  LCME (2004). “Functions and structure of a medical school.” Section II(A): 2.   Leger, M. M., R. McNellis, R. Davis, L. Larson, R. Muma, T. Quigley, S. Toth (2001). “Biological and chemical terrorism: Are we clinicians ready?” American academy of physician assistants. Cited on world wide web 3 January 2005 at http://www.aapa.org/  clinissues/BTtext.htm.   Lohenry, K. (2004). “Anthrax exposure – stay alert, act swiftly” Journal of the American Academy of Physician Assistants 17(8): 29-33.   NPR online, (2005). “History of Biological Warfare.” Cited on World Wide Web 21 November 2005 at http://www.npr.org/news/specials/response/anthrax/features/2001/  oct/011018.bioterrorism.history.html.   O’Brien, K., M. Higdon, J. Halverson (2003). “Recognition and Management of Bioterrorism Infections.” American Family Physician 67(9): 1927-34.   Straight, T. M., A. A. Lazarus, C. F. Decker (2002). “Defending Against Viruses in Biowarfare.” Postgraduate Medicine 112(2): 75-80.
    • References  Varkey, P., G. Poland, F. Cockerill, T. Smith, P. Hagen (2002). “Confronting Bioterrorism: Physicians on the Front Line.” Mayo Clinic Proceedings 77(7): 661-72.   United States Department of Health and Human Services (2002). “HHS announces $1.1 billion in funding to states for bioterrorism preparedness.” HHS press release 31 January 2002. Cited on World Wide Web 30 December 2005 at http://www.hhs.gov/news/press/  2002pres/20020131b.html.