<?xml version="1.0" encoding="utf-8"?>
<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20090101_19_2998"
                     title="Immune-Based TB Assay Passes Test (CME/CE)"
                     score="-0.005"
                     href="http://www.medpagetoday.com/InfectiousDisease/Tuberculosis/tb/16089?impressionId=1265777655871"
                     
      &lt;p&gt;An immune-based assay can rapidly distinguish between latent and active TB, even in the absence of mcyobacteria in the sputum, researchers said.&lt;/p&gt;
&lt;p&gt;In a cohort of 347 patients suspected of having active TB, the enzyme-linked immunospot (ELISpot) assay performed on bronchoalveolar lavage (BAL) fluid&lt;strong&gt;, &lt;/strong&gt;correctly identified 90.9% of those with active disease, according to Christoph Lange, MD, PhD, of the Research Centre Borstel in Borstel, Germany, and colleagues.&lt;/p&gt;
&lt;p&gt;The test  --  used on mononuclear cells obtained through BAL  --  also correctly picked out 79.9% of those without the disease, Lange and colleagues reported in the Oct. 1 issue of the &lt;em&gt;American Journal of Respiratory and Critical Care Medicine&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;&quot;These findings show us that a positive result ... was highly indicative of an actual case of active TB and a negative result ... almost excludes active tuberculosis,&quot; Lange said in a statement.&lt;/p&gt;
&lt;p&gt;While the gold standard for a TB diagnosis remains a positive culture for&lt;strong&gt; &lt;/strong&gt;&lt;em&gt;Mycobacterium&lt;/em&gt; &lt;em&gt;tuberculosis&lt;/em&gt;, that process can take several weeks, so rapid tests need to be developed, the researchers noted.&lt;/p&gt;
&lt;p&gt;One technique is to look for acid-fast bacilli in a sputum smear, but such bacilli are missing in up to 90% of children and 50% of adults with active TB. Other tests fail to distinguish between active and latent TB, Lange and colleagues said.&lt;/p&gt;
&lt;p&gt;The ELISpot test, which finds two peptides specific to &lt;em&gt;M. tuberculosis&lt;/em&gt;, can be used on peripheral blood mononuclear cells, but when used that way also fails to distinguish between active and latent TB, the researchers said.&lt;/p&gt;
&lt;p&gt;For this study, the researchers enrolled 347 patients suspected of active TB whose tests for acid-fast bacilli were negative. Eventually, 71 were diagnosed with active pulmonary TB, either because &lt;em&gt;M. tuberculosis &lt;/em&gt;was found in culture or because other diseases were ruled out and treatment for TB was given.&lt;/p&gt;
&lt;p&gt;The researchers found that, on cells taken from the lavage fluid, the test had a sensitivity of 90.9% and a specificity of 79.9%. In contrast: &lt;ul&gt; &lt;li&gt;The same test on blood cells had a sensitivity of 92% but a specificity of only 48%.&lt;/li&gt; &lt;li&gt;The tuberculin skin test had a sensitivity of 65% and a specificity of 81%.&lt;/li&gt; &lt;li&gt;Detection of nucleic acids from M. tuberculosis had a sensitivity of 29% and a specificity of 97%.&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;The area under the receiver operating characteristic curve  --  a measure of how good a test is  --  was 0.85 when lavage fluid cells were tested by ELISpot, compared with 0.69. 0.76, and 0.62, respectively, for the other tests.&lt;/p&gt;
&lt;p&gt;If a test were perfectly accurate, correctly classifying all patients, the area under the curve would be 1.0.&lt;/p&gt;
&lt;p&gt;In a logistic regression analysis, the researchers found that the odds ratio for active TB, given a positive ELISpot test on lavage fluid cells, was 40.4, with a 95% confidence interval from 16.5 to 98.9, which was significant at &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001.&lt;/p&gt;
&lt;p&gt;The comparable odds ratios for a blood ELISpot, a tuberculin test, or nucleic acid detection were 10.1, 7.8, and 12.4, respectively, all significant at &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001.&lt;/p&gt;
&lt;p&gt;Lange and colleagues said the number needed to treat with the test in order to detect one case of active TB in patients without detectable acid-fast bacilli was two.&lt;/p&gt;
&lt;p&gt;The test doesn&apos;t require an extra invasive procedure, Lange said, &quot;because bronchoalveolar lavage is routinely performed in this situation for other diagnostic purposes.&quot;&lt;/p&gt;
&lt;p&gt;The study did have limitations noted by the authors, the most significant of which was that only 56.3% of the patients classified with active TB had proven disease, which might have led to some case misclassification.&lt;/p&gt;
&lt;p&gt;The fact that patients with HIV were excluded also limited the generalizability of the results, as did the absence of data from countries where TB is endemic and patients are exposed to multiple myobacterial antigens.&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;The test kits used in the study were supplied by the manufacturer, Oxford Immunotec.&lt;/p&gt;&lt;p&gt;The researchers did not report any additional support.&lt;/p&gt;&lt;p&gt;Lange reported financial links with AstraZeneca, GlaxoSmithKline, Pfizer, Oxford Immunotec, and Chiesi.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_19_2795"
                     title="Swine Flu Patient Recovers After Last-Ditch Zanamivir Shots (CME/CE)"
                     score="-0.006"
                     href="http://www.medpagetoday.com/Pulmonary/URIstheFlu/tb/15843?impressionId=1265777655871"
                     
      &lt;p&gt;A 22-year-old woman critically ill with H1N1 pandemic influenza survived after her doctors resorted to a last-ditch and unlicensed treatment  --  intravenous zanamivir (Relenza).&lt;/p&gt;
&lt;p&gt;After 16 days in intensive care  --  including 13 days of mechanical ventilation as standard antiviral regimens failed  --  the woman was given intravenous zanamivir at 600 milligrams twice a day, according to Michael Kidd, FRCPath, and colleagues from the University College London Hospitals NHS Foundation Trust.&lt;/p&gt;
&lt;p&gt;Within 48 hours, the patient&apos;s condition improved, and she was able to come off mechanical ventilation five days later. She was discharged to a general ward eight days later, Kidd and colleagues wrote in a case report online in &lt;em&gt;The Lancet&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;The physicians cautioned that in a single case report &quot;direct cause and effect cannot be confirmed.&quot;&lt;/p&gt;
&lt;p&gt;But, they added, &quot;the improvement in clinical status following intravenous zanamivir encourages prompt further investigation.&quot;&lt;/p&gt;
&lt;p&gt;The woman, who was neutropenic after chemotherapy for Hodgkin&apos;s disease, was admitted to the intensive care unit on July 8th. She had increasing shortness of breath, bilateral chest infiltrates, and laboratory-confirmed pandemic H1N1 flu.&lt;/p&gt;
&lt;p&gt;The viral infection was not responding to oseltamivir (Tamiflu) at 75 milligrams twice daily, combined with the broad-spectrum anti-microbials meropenem (Merrem), teicoplanin (Targocid), and caspofungin (Cancidas).&lt;/p&gt;
&lt;p&gt;Her condition worsened, and she needed mechanical ventilation starting on the third day in intensive care. Hydrocortisone was also started, but was gradually reduced and stopped by day 13.&lt;/p&gt;
&lt;p&gt;The patient remained in single organ failure and needed high levels of inspired oxygen, as well as protective lung ventilation (with tidal volumes no more than 6-8 mL/kg), and a neutral fluid balance.&lt;/p&gt;
&lt;p&gt;On the 10th day in intensive care, polymerase chain reaction (PCR) testing of bronchoalveolar lavage fluid detected high H1N1 RNA (with a cycle threshold of 21), despite six days of oseltamivir given nasogastrically.&lt;/p&gt;
&lt;p&gt;The physicians changed that treatment to nebulized zanamivir on days six through 13, because of a high volume of gastric aspirates indicating impaired bowel function that decreased absorption of the drug. Over the following three days, the treatment was escalated with the addition of 150 milligrams of oseltamivir twice a day.&lt;/p&gt;
&lt;p&gt;However the more intense treatment &quot;delivered neither clinical nor virological response&quot; and the physicians opted for injected zanamivir twice a day, combined with methylprednisolone.&lt;/p&gt;
&lt;p&gt;The treatment, they noted, used an unlicensed route of administration and an unlicensed preparation of the drug, but the attempt had the approval of the hospital formulary committee and the patient&apos;s next of kin.&lt;/p&gt;
&lt;p&gt;The medication was provided by GlaxoSmithKline, the maker of zanamivir.&lt;/p&gt;
&lt;p&gt;The mechanical ventilation was stopped on day 21, five days after the intravenous zanamivir was started. On the same day, her viral load detected by PCR in bronchoalveolar lavage fluid began to fall, with a cycle threshold of 30.&lt;/p&gt;
&lt;p&gt;A higher cycle threshold on PCR reflects a lower level of the virus. The fall from 23 to 30 after 5 days of zanamivir reflects about a 128-fold fall in viral load, the physicians said.&lt;/p&gt;
&lt;p&gt;The patient was discharged to a general ward after 24 days in intensive care, and the antiviral and steroid were stopped on days 26 and 28, respectively.&lt;/p&gt;
&lt;p&gt;The standard treatment in such cases, Kidd and colleagues said, depends on effective absorption in the gut, if oseltamivir is used, or uninhibited access to the infected respiratory tissue, if zanamivir is used.&lt;/p&gt;
&lt;p&gt;&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;
&lt;p&gt;&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;
&lt;p&gt;On the other hand, the patient&apos;s lungs  --  inflamed and atelectatic -- &quot;were probably impeding adequate drug absorption&quot; of the nebulized zanamivir, they added.&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;The work was supported by the United Kingdom Department of Health. The researchers did not report any conflicts.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_19_3533"
                     title="Older H1N1 Patients Most Likely to Die (CME/CE)"
                     score="-0.006"
                     href="http://www.medpagetoday.com/InfectiousDisease/URItheFlu/tb/16786?impressionId=1265777655871"
                     
      Although the pandemic H1N1 flu tends to strike younger people, it can be life-threatening when older people are infected, California researchers said.&lt;br&gt;
&lt;br&gt;In the first four months of the pandemic, 1,088 people in the state needed inpatient care or died of the pandemic flu strain, according to Janice Louie, MD, of the California Department of Public Health and colleagues.&lt;br&gt;
&lt;br&gt;The median age of the victims was 27  --  younger than is usually seen with the seasonal flu  --  but the highest case fatality rate was seen among those 50 and older, Louie and colleagues reported in the Nov. 4 issue of the &lt;em&gt;Journal of the American Medical Association&lt;/em&gt;.&lt;p&gt;&lt;/p&gt;
&lt;p&gt;Those findings are based on statewide enhanced public health surveillance between April 23 and Aug. 11, the researchers said. The first cases of the pandemic flu in the U.S. were reported in Southern California on April 17.&lt;/p&gt;
&lt;p&gt;For this analysis, the researchers defined a case as anyone who needed inpatient care or died with a laboratory finding of confirmed or probable H1N1 influenza.&lt;/p&gt;
&lt;p&gt;Of the 1,088 patients who met the outlined criteria, Louie and her colleagues found that:

&lt;ul&gt; 
&lt;li&gt;The median age of the patients was 27, with 32% under 18, although the oldest victim was 92.&lt;/li&gt; 

&lt;li&gt;Overall, 11% died but the case-fatality rate was highest in people 50 or older, at between 18% and 20%.&lt;/li&gt;
&lt;li&gt;31% required intensive care and 25% needed mechanical ventilation.&lt;/li&gt; 

&lt;li&gt;The overall rate of hospitalization and/or fatality per 100,000 population for all age groups was 2.8, but it ranged from 11.9 in infants younger than a year to 1.5 in those 70 or older.&lt;/li&gt;
 
&lt;li&gt;68% of the patients had risk factors for seasonal influenza complications. &lt;/li&gt; 

&lt;li&gt;Of the 833 patients who had chest x-rays on admission, 66% had infiltrates suggesting pneumonia or acute respiratory distress syndrome. &lt;/li&gt; 


&lt;li&gt;Only 4% had a secondary bacterial infection.&lt;/li&gt; &lt;li&gt;21% were not treated with antiviral medication.&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;About 57% of the patients were tested for flu using a rapid antigen test, but physicians got a false negative 34% of the time, Louie and colleagues said.&lt;/p&gt;
&lt;p&gt;&quot;We found many physicians delayed treatment of their patients because they were falsely reassured by the rapid test,&quot; she said.&lt;/p&gt;
&lt;p&gt;The findings about older victims are consistent with what&apos;s already known about the pandemic flu, according to Thomas Frieden, MD, director of the CDC.&lt;/p&gt;
&lt;p&gt;In a telephone news briefing, he said the H1N1 strain tends to strike younger people, rather than the old. For that reason, the CDC recommends the young get priority for vaccine, and there are no plans to change that recommendation, he said.&lt;/p&gt;
&lt;p&gt;But, Frieden said, if older people get the H1N1 strain, &quot;it can be every bit as serious as the seasonal flu.&quot;&lt;/p&gt;
&lt;p&gt;Louie and colleagues acknowledged that the study had design limitations: Data were extracted from nonstandardized medical records and case ascertainment was based on passive reporting, which may have led to under-reporting.&lt;/p&gt;
&lt;p&gt;They added that laboratory testing to confirm cases had limited availability, which may have also led to under-reporting.&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;The study was supported by the California Department of Public Health. The researchers made no disclosures.&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="-0.007"
                     href="http://www.medpagetoday.com/MeetingCoverage/SCCM/tb/17934?impressionId=1265777655871"
                     
      &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_116"
                     title="SCCM: Toddler Found Frozen in Creek Revives (CME/CE)"
                     score="-0.007"
                     href="http://www.medpagetoday.com/MeetingCoverage/SCCM/tb/17927?impressionId=1265777655871"
                     
      &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>
</recommendedContent>