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    <recommendedItem id="20100101_19_410"
                     title="Most Adults Are Not Getting Necessary Vaccinations"
                     score="0.012"
                     href="http://www.medpagetoday.com/InfectiousDisease/Pneumonia/tb/18317?impressionId=1265748459314"
                     
      &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="-0.004"
                     href="http://www.medpagetoday.com/MeetingCoverage/SCCM/tb/17973?impressionId=1265748459314"
                     
      &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="20090101_19_3324"
                     title="IDF: Hypoglycemia Linked to Mortality in Hospitalized Pneumonia Patients (CME/CE)"
                     score="-0.005"
                     href="http://www.medpagetoday.com/MeetingCoverage/IDF/tb/16518?impressionId=1265748459314"
                     
      &lt;p&gt;MONTREAL  --  Patients with hypoglycemia at the time of hospitalization for community-acquired pneumonia have an increased risk of death compared with patients with normoglycemia, researchers here reported.&lt;/p&gt;
&lt;p&gt;The inhospital and 30-day mortality rates were both 20% for those with admission hypoglycemia, compared with 9% and 10%, respectively, in those with normoglycemia (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.05), according to John-Michael Gamble, MSc, of the University of Alberta School of Public Health in Edmonton, Canada.&lt;/p&gt;
&lt;p&gt;&quot;Hypoglycemia is an easy-to-measure variable on admission, and should be a red flag to alert physicians to possible high-risk pneumonia patients,&quot; Gamble said as he presented the findings at the International Diabetes Federation World Diabetes Congress.&lt;/p&gt;
&lt;p&gt;Hospital intensive care units expect an influx of community-acquired pneumonia (CAP) cases resulting from the H1N1 pandemic, making quick recognition of high risk factors particularly important, Gamble said in an interview.&lt;/p&gt;
&lt;p&gt;His prospective study included 956 pneumonia patients admitted to six Edmonton hospitals between 2000 and 2002, for whom random venous blood glucose tests measured 6.1 mmol/L or lower.&lt;/p&gt;
&lt;p&gt;Hypoglycemia was defined as a measurement below 4.0 mmol/L, and normoglycemia was defined as a measurement between 4.0 and 6.1 mmol/L.&lt;/p&gt;
&lt;p&gt;The primary outcome of the study was inhospital mortality. Secondary outcomes included 30-day, and one-year mortality. The mean age of the patients was 65 years, and 15% resided in nursing homes.&lt;/p&gt;
&lt;p&gt;Admission hypoglycemia was present in 6% (n=54) of the study sample, and among these patients, less than half (46%) were established diabetes patients.&lt;/p&gt;
&lt;p&gt;The mortality rate was significantly higher at all time points among patients with admission hypoglycemia, compared to normoglycemic patients, Gamble said.&lt;/p&gt;
&lt;p&gt;At one year, patients with admission hypoglycemia had a 35% mortality rate, compared to 25% in those with normoglycemia.&lt;/p&gt;
&lt;p&gt;In addition to adjusting for age, sex, comorbidities, medication, and nursing home residence, the study also adjusted for pneumonia severity index (PSI), smoking status, presence of advanced directives, previous pneumococcal vaccine, and direct admission to the intensive care unit.&lt;/p&gt;
&lt;p&gt;Additional sensitivity analyses included clinical markers of physiologic stress, exclusion of patients admitted to the ICU, and exclusion of patients with diabetes.&lt;/p&gt;
&lt;p&gt;Blood glucose abnormalities in general, whether high or low, &quot;may serve as a marker for sicker patients,&quot; said Silvio Inzucchi, MD, of Yale University School of Medicine.&lt;/p&gt;
&lt;p&gt;Inzucchi, who discussed blood glucose abnormalities at a separate presentation, said that among nondiabetic patients such abnormalities may be &quot;particularly dangerous.&quot;&lt;/p&gt;
&lt;p&gt;Endocrinologists and intensivists are facing a &quot;pendulum swing&quot; regarding inpatient glucose control  --  most strikingly with publication of the results from the NICE-SUGAR trial last March.&lt;/p&gt;
&lt;p&gt;In that study, critically ill patients randomized to intensive glucose control were more likely to die during the study period than patients randomized to conventional glucose control strategies.&lt;/p&gt;
&lt;p&gt;The 90-day mortality rate in the NICE-SUGAR study was 27.9% among patients treated to glucose targets of 4.5 to 6.0 mmol per liter compared with 24.9% among patients whose glucose was managed to a target of 10.0 mmol or less per liter (&lt;em&gt;P&lt;/em&gt;=0.02).&lt;/p&gt;
&lt;p&gt;In the months since those data were reported, Inzucchi helped draft an American Association of Clinical Endocrinologists/American Diabetes Association Consensus Statement on Inpatient Glycemic Control, which recommends relaxing target blood glucose levels for critically ill patients.&lt;/p&gt;
&lt;p&gt;&quot;Specifically in the case of [community-acquired pneumonia] we need to look at the risks and benefits of treating admission hypoglycemia,&quot; Gamble said.&lt;/p&gt;
&lt;p&gt;Although Gamble&apos;s analysis did not identify the causes of admission hypoglycemia, almost half of the study subjects had diabetes, with hypoglycemia likely resulting from their medication.&lt;/p&gt;
&lt;p&gt;&quot;For the others, comorbidities that they had in addition to the pneumonia may have caused spontaneous hypoglycemia,&quot; he 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;No funding source was reported for the study.&lt;/p&gt;&lt;p&gt;Gamble said he had no conflicts of interest.&lt;/p&gt;&lt;p&gt;Inzucchi declared paid lecturing with Novo-Nordisk, an Advisory Board agreement with Medtronic, research sponsored by Eli Lilly, and CME program participation in which sanfo-aventis was a funding source.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_1_408"
                     title="RSNA: Chest X-Rays Alone Won&apos;t Fly for Bird Flu Diagnosis"
                     score="-0.006"
                     href="