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    <recommendedItem id="20100101_19_410"
                     title="Most Adults Are Not Getting Necessary Vaccinations"
                     score="0.011"
                     href="http://www.medpagetoday.com/InfectiousDisease/Pneumonia/tb/18317?impressionId=1265764453155"
                     
      &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_218"
                     title="Even Mild COPD Affects the Heart (CME/CE)"
                     score="-0.003"
                     href="http://www.medpagetoday.com/Pulmonology/SmokingCOPD/tb/18070?impressionId=1265764453155"
                     
      Chronic lung disease begins to affect cardiac function at even mild levels of emphysema, data from a large prospective cohort study showed.&lt;br&gt;
&lt;br&gt;A 10-point increase in percent emphysema by lung CT had a linear inverse relationship with left ventricular end-diastolic volume (LVEDV), stroke volume, and cardiac output (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001 for all parameters), researchers reported in the Jan. 21 issue of the &lt;em&gt;New England Journal of Medicine&lt;/em&gt;.&lt;br&gt;
&lt;br&gt;Current smoking status increased the magnitude of the association compared with former smokers and nonsmokers, the researchers found.&lt;br&gt;
&lt;br&gt;Left ventricular ejection fraction did not change with increasing percent of emphysema and airflow obstruction.&lt;br&gt;
&lt;br&gt;&quot;Previously, it has been well known that in very severe lung disease, the damage to the lungs affects heart function,&quot; lead author R. Graham Barr, MD, of Columbia University in New York, said in an interview.&lt;p&gt;&lt;/p&gt;
&lt;p&gt;&quot;What we have shown is that a similar physiology, a similar relationship, would appear to extend up and down the spectrum of lung disease from mild, subclinical COPD and emphysema, all the way to moderately severe lung disease.&quot;&lt;/p&gt;
&lt;p&gt;Severe COPD can lead to cor pulmonale, characterized by increased vascular resistance and right heart failure, accompanied by reduced left ventricular filling, left ventricular stroke volume, and cardiac output.&lt;/p&gt;
&lt;p&gt;However, left ventricular ejection fraction (LVEF) usually is preserved. Whether similar changes occurred with less severe COPD had not been determined, and examining that question was the principal objective of the study by Barr and colleagues.&lt;/p&gt;
&lt;p&gt;The study population comprised a subgroup of patients enrolled in the Multi-Ethnic Study of Atherosclerosis (MESA), which is exploring the prevalence, correlates, and progression of subclinical cardiovascular disease. The MESA Lung Study comprised 2,816 MESA participants who underwent cardiac MRI assessment of left ventricular structure and function.&lt;/p&gt;
&lt;p&gt;Investigators in the lung study excluded patients who had a restrictive pattern on spirometry, defined as a forced vital capacity (FVC) below the lower limit of normal and an FEV&lt;sub&gt;1&lt;/sub&gt;:FVC ratio &amp;gt;0.7.&lt;/p&gt;
&lt;p&gt;Information collected for the lung study included patient demographics, smoking history, medical history, level of physical activity, height, weight, resting blood pressure, serum glucose, C-reactive protein, and fibrinogen levels.&lt;/p&gt;
&lt;p&gt;Extent of emphysema was calculated from lung fields of cardiac CT scans, which included 70% of the lung volume from the carina to the base. Investigators defined extent of emphysema as the percentage of voxels below -910 Hounsfield units in the lung windows of cardiac CT scans.&lt;/p&gt;
&lt;p&gt;Participants who smoked at least one cigarette in the 30 days before CT or who had urinary cotinine levels &amp;gt;100 ng/mL were classified as current smokers.&lt;/p&gt;
&lt;p&gt;The mean age of the lung population was 61, and 51% were women. Current smokers accounted for 13% of the participants, former smokers for 38%, and nonsmokers for 49%. LVEF averaged about 70%.&lt;/p&gt;
&lt;p&gt;Mean spirometric measures were normal, as were measures of left ventricular structure and function. Median percent emphysema was 15%. Comparison of percent emphysema with left ventricular measures showed that a 10-point increase in percent emphysema was associated with a: &lt;ul&gt; &lt;li&gt;4.1 mL decrement in LVEDV&lt;/li&gt; &lt;li&gt;2.7 mL decrement in stroke volume&lt;/li&gt; &lt;li&gt;0.19 L/min decrement in cardiac output&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;The investigators observed no evidence of an association between percent emphysema and LVEF, reflected in a 0.02-point mean increase with each 10-point increase in extent of emphysema.&lt;/p&gt;
&lt;p&gt;Smoking status significantly influenced associations of percent emphysema with LVEDV (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001 for interaction) and stroke volume (&lt;em&gt;P&lt;/em&gt;=0.008 for interaction).&lt;/p&gt;
&lt;p&gt;The magnitude of the association was greater among smokers than former smokers, and greater among former smokers than nonsmokers. However, the associations were evident in smokers and nonsmokers alike.&lt;/p&gt;
&lt;p&gt;&quot;The apparent effect of emphysema on left ventricular end-diastolic volume and cardiac output was similar to that of traditional cardiac risk factors previously reported in MESA and, among smokers, was greater than that of traditional cardiac risk factors,&quot; the authors wrote.&lt;/p&gt;
&lt;p&gt;The linearity of associations across the study population &quot;suggests that even early-stage COPD influences stroke volume and left ventricular size,&quot; Anton Vonk-Noordegraaf, MD, of Vrije University Medical Center in Amsterdam, wrote in an accompanying editorial.&lt;/p&gt;
&lt;p&gt;&quot;Since oxygen delivery is directly related to cardiac output, a lower cardiac output in patients with COPD leads to impaired oxygen delivery,&quot; Vonk-Noordegraaf continued.&lt;/p&gt;
&lt;p&gt;&quot;Although the effects on cardiac output were small in this study population, they may be more pronounced in severe cases of emphysema and during exercise, as has been shown previously. The question is whether the striking clinical resemblance between COPD and chronic heart failure can be explained in part by a factor both diseases have in common: decreased cardiac output.&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;Co-author Paul L. Enright disclosed relationships with Pfizer and Gilead.&lt;/p&gt;&lt;p&gt;Coauthor Eric A. Hoffman disclosed relationships with VIDA Diagnostics, sanofi-aventis, AstraZeneca, and Chiesi Pharmaceuticals.&lt;/p&gt;&lt;p&gt;Coauthor Kawut disclosed a relationship with Pfizer.&lt;/p&gt;&lt;p&gt;Co-author Jo&amp;#227;o A. C. Lima disclosed relationships with Toshiba Medical Systems and General Electric.&lt;/p&gt;&lt;p&gt;Co-author Lewis J. Smith disclosed relationships with Merck and KarmelSonix.&lt;/p&gt;&lt;p&gt;Vonk-Noordegraaf had no disclosures.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_148"
                     title="SCCM: Sedating Drugs May Slow Elders&apos; Recovery (CME/CE)"
                     score="-0.006"
                     href="http://www.medpagetoday.com/MeetingCoverage/SCCM/tb/17973?impressionId=1265764453155"
                     
      &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_8_912"
                     title="OPTIONS VI: Surveillance System Monitors Flu Vaccine Efficacy in Children"
                     score="-0.006"
                     href="