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    <recommendedItem id="20100101_19_410"
                     title="Most Adults Are Not Getting Necessary Vaccinations"
                     score="0.01"
                     href="http://www.medpagetoday.com/InfectiousDisease/Pneumonia/tb/18317?impressionId=1265795613567"
                     
      &lt;p&gt;Public health experts say they&apos;re concerned about the low number of U.S. adults who receive recommended vaccinations  --  and in particular about seniors who aren&apos;t immunized against pneumonia.&lt;/p&gt;
&lt;p&gt;As of 2008, one-third of people 65 and older had not received the pneumococcal vaccine, according to a report issued by the Trust for America&apos;s Health (TFAH), the Infectious Diseases Society of America (IDSA), and the Robert Wood Johnson Foundation.&lt;/p&gt;
&lt;p&gt;In 36 states, 30% or more of their older residents had not received the vaccine.&lt;/p&gt;
&lt;p&gt;The worst coverage was in the District of Columbia, where 45.6% of seniors had not been vaccinated. Even in the best performing state, Oregon, more than a quarter (26.8%) of older people had not received the one-time shot.&lt;/p&gt;
&lt;p&gt;Among all adults, the investigators also found extremely low rates of immunization against tetanus, diphtheria, and pertussis (2.1%), shingles (&amp;lt;2%), human papillomavirus (10%), and seasonal influenza (36.1%).&lt;/p&gt;
&lt;p&gt;&quot;The vaccination efforts around the 2009 H1N1 outbreak actually showed how well our public health system can react to vaccinate millions of people in a very short amount of time,&quot; L.J. Tan, PhD, director of medicine and public health for the American Medical Association, told reporters in a conference call.&lt;/p&gt;
&lt;p&gt;&quot;But I think our response also clearly demonstrated that we do have a lack of a strategy and a system for vaccinating adults.&quot;&lt;/p&gt;
&lt;p&gt;Added Jeffrey Levi, PhD, executive director of TFAH, &quot;We need a national strategy to make vaccines a regular part of medical care and to educate Americans about the effectiveness and safety of vaccines.&quot;&lt;/p&gt;
&lt;p&gt;Doing so could avoid 40,000 to 50,000 deaths from vaccine-preventable illnesses and save about $10 billion in healthcare costs each year, he said.&lt;/p&gt;
&lt;p&gt;But, according to William Schaffner, MD, chair of IDSA&apos;s immunization working group and a co-author of the report, there are many obstacles to adult vaccination efforts.&lt;/p&gt;
&lt;p&gt;First, unlike children in school, adults lack widespread institutional access to immunizations nor is there a way to require most adults to undergo vaccination.&lt;/p&gt;
&lt;p&gt;In addition, there are limited interactions with the healthcare system because, also unlike in children, care in adults generally revolves around acute care and not well care visits.&lt;/p&gt;
&lt;p&gt;Insurance coverage also plays a major role in low vaccination rates among adults, and not just in the uninsured or underinsured.&lt;/p&gt;
&lt;p&gt;Most insurance plans do not cover routine vaccination, Schaffner said, a situation that would change under pending healthcare reform legislation in Congress. That would require insurers to pay for all vaccinations recommended by the CDC&apos;s Advisory Committee on Immunization Practices.&lt;/p&gt;
&lt;p&gt;Schaffner also cited what he called misunderstandings and misinformation regarding the safety and effectiveness of vaccines, and the limited support for research, development, and production of vaccines as reasons for low immunization rates among adults.&lt;/p&gt;
&lt;p&gt;&quot;It&apos;s a shame that we aren&apos;t focusing enough resources on the science to prevent disease and we don&apos;t have a system where we can better protect people by getting them all of the vaccines that are currently available,&quot; he said.&lt;/p&gt;
&lt;p&gt;Tan outlined several recommendations the report makes to increase adult vaccination rates, starting with the creation of a program to provide vaccine coverage to uninsured individuals.&lt;/p&gt;
&lt;p&gt;Also, he said, the CDC and local and state health departments should be given more funding to conduct public education campaigns to increase awareness about the importance of vaccination.&lt;/p&gt;
&lt;p&gt;For their part, physicians should adopt practices to enable them to offer their adult patients vaccines at appropriate visits, like general physicals and cancer screenings, and to make a review of vaccination history a part of standard care.&lt;/p&gt;

    </recommendedItem>
    <recommendedItem id="20100101_19_148"
                     title="SCCM: Sedating Drugs May Slow Elders&apos; Recovery (CME/CE)"
                     score="-0.005"
                     href="http://www.medpagetoday.com/MeetingCoverage/SCCM/tb/17973?impressionId=1265795613567"
                     
      &lt;p&gt;MIAMI BEACH  --  Elderly patients sedated with morphine or haloperidol (Haldol) in surgical intensive care units were less likely to to be discharged to their homes and more likely to be discharged to a nursing facility than patients given other sedatives, often resulting in a poorer quality of life, researchers reported here.&lt;/p&gt;
&lt;p&gt;Patients who received morphine were 2.57 times more likely to be discharged to a nursing home, rehabilitation center, or a skilled nursing facility (&lt;em&gt;P&lt;/em&gt;=0.029), Carrie Miller, MS, CRNP of the Hospital of the University of Pennsylvania in Philadelphia, told attendees at the annual meeting of the Society of Critical Care Medicine.&lt;/p&gt;
&lt;p&gt;Patients who were given haloperidol were 12.46 times more likely to be discharged to one of those facilities rather than to their home.&lt;/p&gt;
&lt;p&gt;Similarly, the risk of having a significantly reduced function from baseline admission was five times greater if the patient had received haloperidol (&lt;em&gt;P&lt;/em&gt;=0.044) and 2.76 times more likely if the patient had received morphine (&lt;em&gt;P&lt;/em&gt;=0.011), Miller said.&lt;/p&gt;
&lt;p&gt;&quot;While older adults frequently require medications to treat pain, anxiety, and delirium, little is know about the effects these medication have on older adults&apos; functional ability or quality of life,&quot; Miller said.&lt;/p&gt;
&lt;p&gt;To shed some light on the question, she and her colleagues evaluated 114 patients in three surgical ICUs. Mean age was about 75, some 60% were men, and 85% were white. Overall, 37% were undergoing general surgical procedures, while 35% had undergone vascular procedures and 16% were trauma patients.&lt;/p&gt;
&lt;p&gt;Patients&apos; level of consciousness and delirium status were assessed daily and information about medication use was gleaned from the ICU flow sheet and the computerized administration record.&lt;/p&gt;
&lt;p&gt;The most frequently used narcotic in the surgical ICU was fentanyl (Duragesic), administered to 77 patients; the most frequently used sedative was midazolam (Versed); and the most frequently used antipsychotic was haloperidol.&lt;/p&gt;
&lt;p&gt;Miller and her colleagues noted that use of propofol (Diprivan) appeared to be associated with better outcomes as far as discharge to one&apos;s home was concerned.&lt;/p&gt;
&lt;p&gt;They noted that there was &quot;considerable discrepancy&quot; between medication usage and dosage recorded on the patients&apos; flow sheet and medication administration record. &quot;Researchers and clinicians should consider that administered prn medications may not always be recorded on the nursing flow sheet,&quot; they concluded.&lt;/p&gt;
&lt;p&gt;The study did not control for confounding variables such as the severity of illness or comorbidities that may have affected outcomes, Miller said.&lt;/p&gt;
&lt;p&gt;&quot;This is an interesting study,&quot; said Suzan Streichenwein, MD, a private practice geriatric psychiatrist in West Palm Beach, Fla. &quot;It would be valuable for future studies to include the severity of illness or more specific details about the type of surgery relative to the dosages of morphine used and its influence on the discharge functional outcomes.&lt;/p&gt;
&lt;p&gt;&quot;Tests diagnosing mild cognitive impairment and/or dementia preop versus postop as well as the time period under anesthesia in relation to outcomes would also be helpful,&quot; said Streichenwein, who was not involved in the study.&lt;/p&gt;
&lt;p&gt;Streichenwein told &lt;em&gt;MedPage Today&lt;/em&gt; that other possible confounding factors require further studies in this area.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;None of the clinicians had relevant financial disclosures.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_116"
                     title="SCCM: Toddler Found Frozen in Creek Revives (CME/CE)"
                     score="-0.005"
                     href="http://www.medpagetoday.com/MeetingCoverage/SCCM/tb/17927?impressionId=1265795613567"
                     
      &lt;p&gt;MIAMI BEACH  --  When Scott Magley, MD, of Conemaugh Memorial Medical Center in Johnstown, Pa., arrived at the scene in December 2008, the 23-month old toddler was literally a block of ice.&lt;/p&gt;
&lt;p&gt;After going missing for at least three hours, she had been found face down in a creek. She had no heartbeat, no response. Her initial core temperature was below the reading limits of Magley&apos;s field thermometer. Ice crystals had formed in her mouth.&lt;/p&gt;
&lt;p&gt;&quot;We have learned that we can&apos;t just give up on these patients,&quot; said Ricardo Patton Po, MD, chief trauma and surgical resident at Conemaugh, who presented the girl&apos;s remarkable case study at the annual meeting of the Society of Critical Care Medicine here. &quot;We believe this was the youngest child to be revived without extracorporeal warming.&quot;&lt;/p&gt;
&lt;p&gt;Magley, another critical care specialist who lives in the countryside near the spot where the Amish child was found, managed to perform endotracheal intubation. He began advanced life support and transported her to the hospital, with multiple doses of epinephrine and atropine administered en route.&lt;/p&gt;
&lt;p&gt;&quot;On arrival the girl was unresponsive, with fixed and dilated pupils, no palpable pulse and no appreciable cardiac wall movement on ultrasound,&quot; Po recalled. &quot;Cardiac rhythm showed asystole.&quot;&lt;/p&gt;
&lt;p&gt;Over the course of the next two hours, the cardiopulmonary resuscitation Magley had begun in the field continued at the hospital. Passive warming was initiated, but the staff could not do an extracorporeal bypass because the appropriate-sized catheters weren&apos;t available. Active warming was performed using the Arctic Sun Management System.&lt;/p&gt;
&lt;p&gt;&quot;We continued working because we were encouraged that her body temperature appeared to be rising  --  from a low of 19 degrees Celsius (66.8 degrees F),&quot; Po said.&lt;/p&gt;
&lt;p&gt;The girl occasionally opened her eyes and made nonpurposeful arm movements during cardiac compressions.&lt;/p&gt;
&lt;p&gt;When her core temperature rose to 26 degrees C (79 degrees F), doctors detected ventricular fibrillation. They administered one electric shock, and regular sinus rhythm returned. That resulted in a palpable pulse and eventually a discernible blood pressure.&lt;/p&gt;
&lt;p&gt;&quot;She then began to exhibit purposeful movements and appeared to recognize her parents, who had since arrived at the hospital,&quot; Po told &lt;em&gt;MedPage Today&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;She was transferred to Children&apos;s Hospital of Pittsburgh when her internal temperature rose to 31-33 degrees C (88-91 degrees F).&lt;/p&gt;
&lt;p&gt;Po said the transfer created a problem because her parents insisted that she not be transported by powered vehicles  --  and most certainly not by an aircraft, as doctors first proposed.&lt;/p&gt;
&lt;p&gt;He said they finally compromised on an ambulance transfer.&lt;/p&gt;
&lt;p&gt;She was extubated on day one at the hospital and was discharged home on day five, with apparently normal neurological status.&lt;/p&gt;
&lt;p&gt;Po said that on follow-up, her parents thought she was having some difficulty in picking up items with either hand, but otherwise did not appear to have any lasting ill-effects.&lt;/p&gt;
&lt;p&gt;&quot;This case serves as an opportunity to review important concepts in the resuscitation of the profoundly hypothermic patient and to emphasize the resiliency of quickly cooled tissue, deprived of perfusion but before hypoxia damages cellular mechanisms involved in recovery,&quot; Po said.&lt;/p&gt;
&lt;p&gt;&quot;The abundant case reports in the literature, both children and adults, speak to the ability of prolonged and vigorous resuscitation to achieve favorable outcomes,&quot; he said.&lt;/p&gt;
&lt;p&gt;Dominic Cave, MD, a fellow in pediatric intensive care at Stollery Children&apos;s Hospital/University of Alberta in Edmonton, said he&apos;s seen similar episodes.&lt;/p&gt;
&lt;p&gt;&quot;This is another one of those amazing cases that seem to follow the rule that a person isn&apos;t dead until he or she is warm and dead,&quot; he told &lt;em&gt;MedPage Today&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;&quot;The survival of this child without apparent brain damage is also gratifying,&quot; he added. &quot;You never know if the person you are reviving is going to make such an amazing recovery.&quot;&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;None of the doctors disclosed any relevant financial relationships.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_121"
                     title="SCCM: Teamwork Cuts ICU Pneumonia (CME/CE)"
                     score="-0.006"
                     href="http://www.medpagetoday.com/MeetingCoverage/SCCM/tb/17934?impressionId=1265795613567"
                     
      &lt;p&gt;MIAMI BEACH  --  A coordinated effort among physicians, nurses, therapists, and other intensive care staff produced a dramatic reduction in the incidence of ventilator-associated pneumonia at a Tennessee hospital, according to a study reported here.&lt;/p&gt;
&lt;p&gt;Researchers told attendees at the annual meeting of the Society of Critical Care Medicine that nosocomial pneumonia cases decreased from 34 episodes in one 12-month period to four in the most recent year  --  including a 10-month period when no cases of ventilator-associated pneumonia were reported.&lt;/p&gt;
&lt;p&gt;&quot;The use of a collaborative team approach, daily multidisciplinary rounds, and implementation of a ventilator-acquired pneumonia protocol has led to ventilator-acquired pneumonia reductions while improving patient care and outcomes,&quot; said Lisa Boghozian, MSN, RN, a clinical nurse specialist at Johnson City Medical Center.&lt;/p&gt;
&lt;p&gt;&quot;We learned to work together,&quot; she said at a poster presentation. &quot;We learned to share jobs and to make sure the patients received the protocol-required treatment. But the success of these programs may have to be nurse-driven.&quot;&lt;/p&gt;
&lt;p&gt;By cutting the incidence of ventilator-associated pneumonia by 88%, the effort reduced ICU intensive care unit expenses by $2.2 million and overall hospital expenses by $9 million, according to Pamela Ditto, MBA, RRT, a respiratory therapist and the team&apos;s record keeper.&lt;/p&gt;
&lt;p&gt;She said that the reduction in ventilator-associated pneumonia cases resulted in avoiding 2,470 days in the intensive care unit and 207 days on ventilation.&lt;/p&gt;
&lt;p&gt;&quot;We educated our staff that the six components of ventilator-acquired pneumonia prevention had to be performed every day on every shift,&quot; she said.&lt;/p&gt;
&lt;p&gt;The protocol requires: &lt;ul&gt; &lt;li&gt;Keeping the patient&apos;s head raised 30&amp;#176;&lt;/li&gt; 
&lt;li&gt;Performing oral hygiene&lt;/li&gt; 
&lt;li&gt;Performing deep vein thrombosis prophylaxis&lt;/li&gt; 
&lt;li&gt;Performing gastrointestinal prophylaxis to prevent reflux&lt;/li&gt; 
&lt;li&gt;Regularly assessing the ability to wean patients from the ventilator&lt;/li&gt; 
&lt;li&gt;Giving adequately sedated patients vacations from sedation&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;In the year before the study period  --  when the hospital counted 34 cases of ventilator-associated pneumonia  --  Boghozian said it seemed that the staff simply accepted that there would be cases and there wasn&apos;t a concentrated effort to control the occurrence.&lt;/p&gt;
&lt;p&gt;The four cases of ventilator-associated pneumonia in the year ending in June 2009 all occurred in April  --  after 10 consecutive months without a single case. &quot;We might have become complacent,&quot; she speculated, but she also noted that during that period the hospital cared for several trauma cases that included patients with facial injuries that might have prevented careful oral hygiene known to be a major factor in ventilator-associated pneumonia.&lt;/p&gt;
&lt;p&gt;&quot;Prevention of ventilator-acquired pneumonia and other nosocomial infections are the types of things that healthcare providers will be looking at to improve conditions for patients and to cut costs,&quot; Ditto said.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;Neither Boghozian nor Ditto had relevant financial disclosures.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_91"
                     title="SCCM: Old Blood Bad for Young Bodies (CME/CE)"
                     score="-0.006"
                     href="http://www.medpagetoday.com/MeetingCoverage/SCCM/tb/17893?impressionId=1265795613567"
                     
      &lt;p&gt;MIAMI BEACH  --  If blood used for transfusions is more than 14 days old, it appears to significantly increase the risk that critically ill pediatric patients will suffer multiple organ dysfunction syndrome, researchers said here.&lt;/p&gt;
&lt;p&gt;&quot;While other investigators have found this problem among adults, no one has reported this before in children,&quot; Philip Spinella, MD, of Connecticut Children&apos;s Medical Center in Hartford told attendees at the Society of Critical Care Medicine meeting.&lt;/p&gt;
&lt;p&gt;Spinella and colleagues accessed two data sets and found similar relationships among critically ill children who required blood transfusions. In one study of 455 children, the risk of suffering multiple organ dysfunction syndrome more than doubled (adjusted odds ratio 2.23; 95% CI 1.20 to 4.15, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.05) if children were transfused with red blood cells that were 14 days old or older.&lt;/p&gt;
&lt;p&gt;The risk nearly tripled if the blood was 21 days or older (adjusted odds ratio 2.99; 95%CI 1.63 to 5.48, &lt;em&gt;P&lt;/em&gt;&amp;gt;0.05).&lt;/p&gt;
&lt;p&gt;&quot;Stable critically ill children receiving red blood cell units with increased storage time may be at greater risk of developing new or progressive multiple organ dysfunction syndrome,&quot; said co-author Marisa Tucci, MD, of Sainte-Justine University Hospital, Montreal.&lt;/p&gt;
&lt;p&gt;However, Tucci noted, their work comes with a caveat. &quot;Definitive conclusions about a cause and effect relationship cannot be drawn from this secondary analysis of a prospective study,&quot; she said at her poster presentations. &quot;These data justify undertaking a randomized controlled trial to address this question.&quot;&lt;/p&gt;
&lt;p&gt;The researchers analyzed the results of the TRIPICU (Transfusion Requirements in Pediatric Intensive Care Units) study, which was conducted in 19 centers in the U.S. and Canada. That study analyzed strategies for transfusion. Age of the blood used in transfusion was a secondary outcome, Tucci explained.&lt;/p&gt;
&lt;p&gt;In another study, 930 children were enrolled to analyze the rates of new or progressive multiple organ dysfunction syndrome, while a secondary analysis looked at whether the age of red blood cell transfusion played a role in hospital length of stay.&lt;/p&gt;
&lt;p&gt;&quot;We found that in critically ill children, transfusion of red blood cell units stored for longer than 14 days is independently associated with an increased occurrence of multiple organ dysfunction syndrome and prolonged stay in the pediatric intensive care unit,&quot; Spinella said&lt;/p&gt;
&lt;p&gt;Nearly half of the children (447) were transfused; time of storage was known in 298 of the cases. &quot;About half the children in these studies were infused with blood older than 14 days,&quot; Tucci said.&lt;/p&gt;
&lt;p&gt;For patients receiving blood stored longer than 14 days, the adjusted odds ratio for an increased incidence of multiple organ failure was 1.87 (95% CI 1.06 to 3.31, &lt;em&gt;P&lt;/em&gt;=0.03), she said.&lt;/p&gt;
&lt;p&gt;&quot;There was also a significant difference (&amp;lt;0.001) in the total length of pediatric intensive care unit stay of 3.7 days,&quot; she said.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;Niether Tucci nor Spinella had any relevant disclosures.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
</recommendedContent>