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Ideal intubation position still unknown
In critically ill adults undergoing endotracheal intubation, the ramped position does not significantly improve oxygenation compared with the sniffing position, according to results of a multicenter, randomized trial of 260 patients treated in an intensive care unit.
Moreover, “[ramped] position appeared to worsen glottic view and increase the number of attempts required for successful intubation,” wrote Matthew W. Semler, MD, of Vanderbilt University Medical Center, Nashville, Tenn., and his coauthors (Chest. 2017 Oct. doi: 10.1016/j.chest.2017.03.061).
The ramped and sniffing positions are the two most common patient positions used during emergent intubation, according to investigators. The sniffing position is characterized by supine torso, neck flexed forward, and head extended, while ramped position involves elevating the torso and head.
Some believe the ramped position may offer superior anatomic alignment of the upper airway; however, only a few observational studies suggest it is associated with fewer complications than the sniffing position, the authors wrote.
Accordingly, they conducted a multicenter randomized trial with a primary endpoint of lowest arterial oxygen saturation, hypothesizing that the endpoint would be higher for the ramped position: “Our primary outcome of lowest arterial oxygen saturation is an established endpoint in ICU intubation trials, and is linked to periprocedural cardiac arrest and death,” they wrote.
The investigators instead found that median lowest arterial oxygen saturation was not statistically different between groups, at 93% for the ramped position, and 92% for the sniffing position (P = 0.27), published data show.
Further results showed that the ramped position appeared to be associated with poor glottic view and more difficult intubation. The incidence of grade III (only epiglottis) or grade IV (no visible glottis structures) views were 25.4% for ramped vs. 11.5% for sniffing (P = .01), while the rate of first-attempt intubation was 76.2% for ramped vs 85.4% for sniffing (P = .02).
While the findings are compelling, the authors were forthcoming about the potential limitations of the study and differences compared with earlier investigations. Notably, they said, all prior controlled trials of patient positioning during endotracheal intubation were conducted in the operating room, rather than in the ICU.
Also, the operators’ skill levels may further explain differences in this study’s outcomes from those of similar studies, the researchers noted. Earlier studies included patients intubated by one or two senior anesthesiologists from one center, while this trial involved 30 operators across multiple centers, with the average operator having performed 60 previous intubations. “Thus, our findings may generalize to settings in which airway management is performed by trainees, but whether results would be similar among expert operators remains unknown,” the investigators noted.
The authors reported no potential conflicts of interest. One coauthor reported serving on an advisory board for Avisa Pharma.
Editorialists praised the multicenter, randomized design of this study, and its total recruitment of 260 patients. They also noted several limitations of the study that “could shed some light” on the group’s conclusions (Chest. 2017 Oct. doi: 10.1016/j.chest.2017.06.002).
“The results diverge from [operating room] literature of the past 15 years that suggest that the ramped position is the preferred intubation position for obese patients or those with an anticipated difficult airway.” This may have been caused by shortcomings of this study’s design and differences between it and other research exploring the topic of patient positioning during endotracheal intubation, they wrote.
The study lacked a prespecified algorithm for preoxygenation and the operators had relatively low amounts of experience with intubations. Finally, the beds used in this study could contribute to the divergences between this intensive care unit experience and the operating room literature. The operating room table is narrower, firmer, and more stable, while by contrast, the ICU bed is wider and softer, they noted. This “may make initial positioning, maintenance of positioning, and accessing the patient’s head more difficult.”
Nevertheless, “[this] important study provides ideas for further study of optimal positioning in the ICU and adds valuable data to the sparse literature on the subject in the ICU setting,” they concluded.
James Aaron Scott, DO, Jens Matthias Walz, MD, FCCP, and Stephen O. Heard, MD, FCCP, are in the department of anesthesiology and perioperative medicine, UMass Memorial Medical Center, Worcester, Mass. The authors reported no conflicts of interest. These comments are based on their editorial.
Editorialists praised the multicenter, randomized design of this study, and its total recruitment of 260 patients. They also noted several limitations of the study that “could shed some light” on the group’s conclusions (Chest. 2017 Oct. doi: 10.1016/j.chest.2017.06.002).
“The results diverge from [operating room] literature of the past 15 years that suggest that the ramped position is the preferred intubation position for obese patients or those with an anticipated difficult airway.” This may have been caused by shortcomings of this study’s design and differences between it and other research exploring the topic of patient positioning during endotracheal intubation, they wrote.
The study lacked a prespecified algorithm for preoxygenation and the operators had relatively low amounts of experience with intubations. Finally, the beds used in this study could contribute to the divergences between this intensive care unit experience and the operating room literature. The operating room table is narrower, firmer, and more stable, while by contrast, the ICU bed is wider and softer, they noted. This “may make initial positioning, maintenance of positioning, and accessing the patient’s head more difficult.”
Nevertheless, “[this] important study provides ideas for further study of optimal positioning in the ICU and adds valuable data to the sparse literature on the subject in the ICU setting,” they concluded.
James Aaron Scott, DO, Jens Matthias Walz, MD, FCCP, and Stephen O. Heard, MD, FCCP, are in the department of anesthesiology and perioperative medicine, UMass Memorial Medical Center, Worcester, Mass. The authors reported no conflicts of interest. These comments are based on their editorial.
Editorialists praised the multicenter, randomized design of this study, and its total recruitment of 260 patients. They also noted several limitations of the study that “could shed some light” on the group’s conclusions (Chest. 2017 Oct. doi: 10.1016/j.chest.2017.06.002).
“The results diverge from [operating room] literature of the past 15 years that suggest that the ramped position is the preferred intubation position for obese patients or those with an anticipated difficult airway.” This may have been caused by shortcomings of this study’s design and differences between it and other research exploring the topic of patient positioning during endotracheal intubation, they wrote.
The study lacked a prespecified algorithm for preoxygenation and the operators had relatively low amounts of experience with intubations. Finally, the beds used in this study could contribute to the divergences between this intensive care unit experience and the operating room literature. The operating room table is narrower, firmer, and more stable, while by contrast, the ICU bed is wider and softer, they noted. This “may make initial positioning, maintenance of positioning, and accessing the patient’s head more difficult.”
Nevertheless, “[this] important study provides ideas for further study of optimal positioning in the ICU and adds valuable data to the sparse literature on the subject in the ICU setting,” they concluded.
James Aaron Scott, DO, Jens Matthias Walz, MD, FCCP, and Stephen O. Heard, MD, FCCP, are in the department of anesthesiology and perioperative medicine, UMass Memorial Medical Center, Worcester, Mass. The authors reported no conflicts of interest. These comments are based on their editorial.
In critically ill adults undergoing endotracheal intubation, the ramped position does not significantly improve oxygenation compared with the sniffing position, according to results of a multicenter, randomized trial of 260 patients treated in an intensive care unit.
Moreover, “[ramped] position appeared to worsen glottic view and increase the number of attempts required for successful intubation,” wrote Matthew W. Semler, MD, of Vanderbilt University Medical Center, Nashville, Tenn., and his coauthors (Chest. 2017 Oct. doi: 10.1016/j.chest.2017.03.061).
The ramped and sniffing positions are the two most common patient positions used during emergent intubation, according to investigators. The sniffing position is characterized by supine torso, neck flexed forward, and head extended, while ramped position involves elevating the torso and head.
Some believe the ramped position may offer superior anatomic alignment of the upper airway; however, only a few observational studies suggest it is associated with fewer complications than the sniffing position, the authors wrote.
Accordingly, they conducted a multicenter randomized trial with a primary endpoint of lowest arterial oxygen saturation, hypothesizing that the endpoint would be higher for the ramped position: “Our primary outcome of lowest arterial oxygen saturation is an established endpoint in ICU intubation trials, and is linked to periprocedural cardiac arrest and death,” they wrote.
The investigators instead found that median lowest arterial oxygen saturation was not statistically different between groups, at 93% for the ramped position, and 92% for the sniffing position (P = 0.27), published data show.
Further results showed that the ramped position appeared to be associated with poor glottic view and more difficult intubation. The incidence of grade III (only epiglottis) or grade IV (no visible glottis structures) views were 25.4% for ramped vs. 11.5% for sniffing (P = .01), while the rate of first-attempt intubation was 76.2% for ramped vs 85.4% for sniffing (P = .02).
While the findings are compelling, the authors were forthcoming about the potential limitations of the study and differences compared with earlier investigations. Notably, they said, all prior controlled trials of patient positioning during endotracheal intubation were conducted in the operating room, rather than in the ICU.
Also, the operators’ skill levels may further explain differences in this study’s outcomes from those of similar studies, the researchers noted. Earlier studies included patients intubated by one or two senior anesthesiologists from one center, while this trial involved 30 operators across multiple centers, with the average operator having performed 60 previous intubations. “Thus, our findings may generalize to settings in which airway management is performed by trainees, but whether results would be similar among expert operators remains unknown,” the investigators noted.
The authors reported no potential conflicts of interest. One coauthor reported serving on an advisory board for Avisa Pharma.
In critically ill adults undergoing endotracheal intubation, the ramped position does not significantly improve oxygenation compared with the sniffing position, according to results of a multicenter, randomized trial of 260 patients treated in an intensive care unit.
Moreover, “[ramped] position appeared to worsen glottic view and increase the number of attempts required for successful intubation,” wrote Matthew W. Semler, MD, of Vanderbilt University Medical Center, Nashville, Tenn., and his coauthors (Chest. 2017 Oct. doi: 10.1016/j.chest.2017.03.061).
The ramped and sniffing positions are the two most common patient positions used during emergent intubation, according to investigators. The sniffing position is characterized by supine torso, neck flexed forward, and head extended, while ramped position involves elevating the torso and head.
Some believe the ramped position may offer superior anatomic alignment of the upper airway; however, only a few observational studies suggest it is associated with fewer complications than the sniffing position, the authors wrote.
Accordingly, they conducted a multicenter randomized trial with a primary endpoint of lowest arterial oxygen saturation, hypothesizing that the endpoint would be higher for the ramped position: “Our primary outcome of lowest arterial oxygen saturation is an established endpoint in ICU intubation trials, and is linked to periprocedural cardiac arrest and death,” they wrote.
The investigators instead found that median lowest arterial oxygen saturation was not statistically different between groups, at 93% for the ramped position, and 92% for the sniffing position (P = 0.27), published data show.
Further results showed that the ramped position appeared to be associated with poor glottic view and more difficult intubation. The incidence of grade III (only epiglottis) or grade IV (no visible glottis structures) views were 25.4% for ramped vs. 11.5% for sniffing (P = .01), while the rate of first-attempt intubation was 76.2% for ramped vs 85.4% for sniffing (P = .02).
While the findings are compelling, the authors were forthcoming about the potential limitations of the study and differences compared with earlier investigations. Notably, they said, all prior controlled trials of patient positioning during endotracheal intubation were conducted in the operating room, rather than in the ICU.
Also, the operators’ skill levels may further explain differences in this study’s outcomes from those of similar studies, the researchers noted. Earlier studies included patients intubated by one or two senior anesthesiologists from one center, while this trial involved 30 operators across multiple centers, with the average operator having performed 60 previous intubations. “Thus, our findings may generalize to settings in which airway management is performed by trainees, but whether results would be similar among expert operators remains unknown,” the investigators noted.
The authors reported no potential conflicts of interest. One coauthor reported serving on an advisory board for Avisa Pharma.
FROM CHEST
Key clinical point: During endotracheal intubation of critically ill adults, use of the ramped position did not significantly improve oxygenation compared with the sniffing position, and it increased the number of attempts needed to achieve successful intubation.
Major finding: The median lowest arterial oxygen saturation was 93% for the ramped position and 92% for the sniffing position (P = .27).
Data source: Multicenter, randomized trial of 260 critically ill adults undergoing endotracheal intubation.
Disclosures: The authors reported no potential conflicts of interest. One coauthor reported serving on an advisory board for Avisa Pharma.
VA Shares Lessons Learned From Combating Opioid Crisis
The VA has boiled down its experience in dealing with the opioid epidemic to 8 best practices, which it is now sharing with others in government and the health care industry who work to balance pain management and opioid prescribing.
The best practices are summed up by the acronym STOP PAIN, which stands for:
- S—Stepped Care Model, which encourages a continuum of care from onset through treatment. It also incorporates self-management through participation in groups such as Narcotics or Alcoholics Anonymous, counseling, treatment programs, primary care, and other medical specialists;
- T—Treatment alternatives/complementary care, expanding provider options beyond standard care in treating chronic pain. “Complementary health” includes evidence-based treatments, such as acupuncture, yoga, and progressive relaxation;
Related: Implementation and Evaluation of an APRN-Led Opioid Monitoring Clinic
- O—Ongoing monitoring of usage;
- P—Practice guidelines, which provide evidence-based recommendations for minimizing harm and increasing patient safety. (https://www.healthquality.va.gov/guidelines/MH/sud/ and https://www.healthquality.va.gov/guidelines/Pain/cot/);
- P—Prescription monitoring. The VA has a number of data sources to allow it to monitor opioid use to target specific education in real time. The practice patterns of providers differ, along with the case mixes: a provider with relatively high opioid prescribing may have an appropriate practice, or be someone who could benefit from education. These tools allow the VA to drill down to the patient level to evaluate use. Other tools can evaluate the treatment of patient panels and the veterans’ risk of potential abuse. Together, these allow identification of potential problems, educational targeting, and tracking of progress;
Related: Prescribing Patterns Shift After Detailing-Policy Change
- A—Academic detailing. The Academic Detailing program, a one-on-one peer education program for frontline providers, gives specific information on practice alternatives and resources, opioid safety, and can compare the practice of the provider to that of peers; (https://www.pbm.va.gov/PBM/academicdetailingservicehome.asp and
https://www.pbm.va.gov/PBM/academicdetailingservice/Pain_and_Opioid_Safety.asp)
- I—Informed consent for patients prior to long-term opioid therapy. This process includes education on the risks of opioid therapy, opioid interactions, and safe prescribing practices such as urine drug screens; and
- N—Naloxone distribution. The Opioid Overdose Education & Naloxone Distribution program focuses on educating providers (https://www.pbm.va.gov/PBM/academicdetailingservice/Opioid_Overdose_Education_and_Naloxone_Distribution.asp).
For more information, visit https://www.va.gov/painmanagement.
The VA has boiled down its experience in dealing with the opioid epidemic to 8 best practices, which it is now sharing with others in government and the health care industry who work to balance pain management and opioid prescribing.
The best practices are summed up by the acronym STOP PAIN, which stands for:
- S—Stepped Care Model, which encourages a continuum of care from onset through treatment. It also incorporates self-management through participation in groups such as Narcotics or Alcoholics Anonymous, counseling, treatment programs, primary care, and other medical specialists;
- T—Treatment alternatives/complementary care, expanding provider options beyond standard care in treating chronic pain. “Complementary health” includes evidence-based treatments, such as acupuncture, yoga, and progressive relaxation;
Related: Implementation and Evaluation of an APRN-Led Opioid Monitoring Clinic
- O—Ongoing monitoring of usage;
- P—Practice guidelines, which provide evidence-based recommendations for minimizing harm and increasing patient safety. (https://www.healthquality.va.gov/guidelines/MH/sud/ and https://www.healthquality.va.gov/guidelines/Pain/cot/);
- P—Prescription monitoring. The VA has a number of data sources to allow it to monitor opioid use to target specific education in real time. The practice patterns of providers differ, along with the case mixes: a provider with relatively high opioid prescribing may have an appropriate practice, or be someone who could benefit from education. These tools allow the VA to drill down to the patient level to evaluate use. Other tools can evaluate the treatment of patient panels and the veterans’ risk of potential abuse. Together, these allow identification of potential problems, educational targeting, and tracking of progress;
Related: Prescribing Patterns Shift After Detailing-Policy Change
- A—Academic detailing. The Academic Detailing program, a one-on-one peer education program for frontline providers, gives specific information on practice alternatives and resources, opioid safety, and can compare the practice of the provider to that of peers; (https://www.pbm.va.gov/PBM/academicdetailingservicehome.asp and
https://www.pbm.va.gov/PBM/academicdetailingservice/Pain_and_Opioid_Safety.asp)
- I—Informed consent for patients prior to long-term opioid therapy. This process includes education on the risks of opioid therapy, opioid interactions, and safe prescribing practices such as urine drug screens; and
- N—Naloxone distribution. The Opioid Overdose Education & Naloxone Distribution program focuses on educating providers (https://www.pbm.va.gov/PBM/academicdetailingservice/Opioid_Overdose_Education_and_Naloxone_Distribution.asp).
For more information, visit https://www.va.gov/painmanagement.
The VA has boiled down its experience in dealing with the opioid epidemic to 8 best practices, which it is now sharing with others in government and the health care industry who work to balance pain management and opioid prescribing.
The best practices are summed up by the acronym STOP PAIN, which stands for:
- S—Stepped Care Model, which encourages a continuum of care from onset through treatment. It also incorporates self-management through participation in groups such as Narcotics or Alcoholics Anonymous, counseling, treatment programs, primary care, and other medical specialists;
- T—Treatment alternatives/complementary care, expanding provider options beyond standard care in treating chronic pain. “Complementary health” includes evidence-based treatments, such as acupuncture, yoga, and progressive relaxation;
Related: Implementation and Evaluation of an APRN-Led Opioid Monitoring Clinic
- O—Ongoing monitoring of usage;
- P—Practice guidelines, which provide evidence-based recommendations for minimizing harm and increasing patient safety. (https://www.healthquality.va.gov/guidelines/MH/sud/ and https://www.healthquality.va.gov/guidelines/Pain/cot/);
- P—Prescription monitoring. The VA has a number of data sources to allow it to monitor opioid use to target specific education in real time. The practice patterns of providers differ, along with the case mixes: a provider with relatively high opioid prescribing may have an appropriate practice, or be someone who could benefit from education. These tools allow the VA to drill down to the patient level to evaluate use. Other tools can evaluate the treatment of patient panels and the veterans’ risk of potential abuse. Together, these allow identification of potential problems, educational targeting, and tracking of progress;
Related: Prescribing Patterns Shift After Detailing-Policy Change
- A—Academic detailing. The Academic Detailing program, a one-on-one peer education program for frontline providers, gives specific information on practice alternatives and resources, opioid safety, and can compare the practice of the provider to that of peers; (https://www.pbm.va.gov/PBM/academicdetailingservicehome.asp and
https://www.pbm.va.gov/PBM/academicdetailingservice/Pain_and_Opioid_Safety.asp)
- I—Informed consent for patients prior to long-term opioid therapy. This process includes education on the risks of opioid therapy, opioid interactions, and safe prescribing practices such as urine drug screens; and
- N—Naloxone distribution. The Opioid Overdose Education & Naloxone Distribution program focuses on educating providers (https://www.pbm.va.gov/PBM/academicdetailingservice/Opioid_Overdose_Education_and_Naloxone_Distribution.asp).
For more information, visit https://www.va.gov/painmanagement.
Eye Hemorrhage Signals Myeloid Leukemia
A 40-year-old man suddenly began to lose vision in his left eye. The retinal exam was normal for the right eye. But the left showed isolated subinternal limited membrane hemorrhage at the fovea along with a white-centered hemorrhage above the fovea.
The patient had no history of trauma or Valsalva retinopathy. His blood pressure was normal as was his blood glucose. However, when bloodwork showed a high total count, increased platelet count, and the peripheral smear indicated myeloid hyperplasia, clinicians at LV Prasad Eye Institute in Hyderabad, India, diagnosed the patient with underlying chronic myeloid leukemia (CML).
A physical examination revealed a palpable spleenomegaly—underscoring the fact, the clinicians note, that when an ophthalmologic finding suggests a systemic disease, a general physical examination will reveal more clinical clues. The patient was referred to an oncologist and started on imatinib for CML.
White-centered or pale-centered hemorrhages are believed to represent an accumulation of leukemic cells or platelet fibrin aggregates, the clinicians say. Blood dyscrasias, such as anemias, leukemia, multiple myeloma, and other platelet disorders may present with similar features. Such hemorrhages are known to resolve spontaneously when the patient is treated for the underlying condition, and the hematologic status improves, the clinicians say. This patient’s hemorrhage gradually resolved over the next month, and his visual acuity improved to 20/20.
Ocular manifestations as a presenting sign of leukemia, especially chronic, are rare, the clinicians say. They note that retinal hemorrhages are one of the “most striking findings” in leukemia, and because they can be directly observed, they provide a “subtle but important clue toward an otherwise asymptomatic disease.” If diagnosed early and treated promptly, patients with CML have a good survival rate.
Source:
Tyagi M, Agarwal K, Paulose RM, Rani PK. BMJ Case Rep. 2017;2017: pii: bcr-2017-21974.
doi: 10.1136/bcr-2017-219741.
A 40-year-old man suddenly began to lose vision in his left eye. The retinal exam was normal for the right eye. But the left showed isolated subinternal limited membrane hemorrhage at the fovea along with a white-centered hemorrhage above the fovea.
The patient had no history of trauma or Valsalva retinopathy. His blood pressure was normal as was his blood glucose. However, when bloodwork showed a high total count, increased platelet count, and the peripheral smear indicated myeloid hyperplasia, clinicians at LV Prasad Eye Institute in Hyderabad, India, diagnosed the patient with underlying chronic myeloid leukemia (CML).
A physical examination revealed a palpable spleenomegaly—underscoring the fact, the clinicians note, that when an ophthalmologic finding suggests a systemic disease, a general physical examination will reveal more clinical clues. The patient was referred to an oncologist and started on imatinib for CML.
White-centered or pale-centered hemorrhages are believed to represent an accumulation of leukemic cells or platelet fibrin aggregates, the clinicians say. Blood dyscrasias, such as anemias, leukemia, multiple myeloma, and other platelet disorders may present with similar features. Such hemorrhages are known to resolve spontaneously when the patient is treated for the underlying condition, and the hematologic status improves, the clinicians say. This patient’s hemorrhage gradually resolved over the next month, and his visual acuity improved to 20/20.
Ocular manifestations as a presenting sign of leukemia, especially chronic, are rare, the clinicians say. They note that retinal hemorrhages are one of the “most striking findings” in leukemia, and because they can be directly observed, they provide a “subtle but important clue toward an otherwise asymptomatic disease.” If diagnosed early and treated promptly, patients with CML have a good survival rate.
Source:
Tyagi M, Agarwal K, Paulose RM, Rani PK. BMJ Case Rep. 2017;2017: pii: bcr-2017-21974.
doi: 10.1136/bcr-2017-219741.
A 40-year-old man suddenly began to lose vision in his left eye. The retinal exam was normal for the right eye. But the left showed isolated subinternal limited membrane hemorrhage at the fovea along with a white-centered hemorrhage above the fovea.
The patient had no history of trauma or Valsalva retinopathy. His blood pressure was normal as was his blood glucose. However, when bloodwork showed a high total count, increased platelet count, and the peripheral smear indicated myeloid hyperplasia, clinicians at LV Prasad Eye Institute in Hyderabad, India, diagnosed the patient with underlying chronic myeloid leukemia (CML).
A physical examination revealed a palpable spleenomegaly—underscoring the fact, the clinicians note, that when an ophthalmologic finding suggests a systemic disease, a general physical examination will reveal more clinical clues. The patient was referred to an oncologist and started on imatinib for CML.
White-centered or pale-centered hemorrhages are believed to represent an accumulation of leukemic cells or platelet fibrin aggregates, the clinicians say. Blood dyscrasias, such as anemias, leukemia, multiple myeloma, and other platelet disorders may present with similar features. Such hemorrhages are known to resolve spontaneously when the patient is treated for the underlying condition, and the hematologic status improves, the clinicians say. This patient’s hemorrhage gradually resolved over the next month, and his visual acuity improved to 20/20.
Ocular manifestations as a presenting sign of leukemia, especially chronic, are rare, the clinicians say. They note that retinal hemorrhages are one of the “most striking findings” in leukemia, and because they can be directly observed, they provide a “subtle but important clue toward an otherwise asymptomatic disease.” If diagnosed early and treated promptly, patients with CML have a good survival rate.
Source:
Tyagi M, Agarwal K, Paulose RM, Rani PK. BMJ Case Rep. 2017;2017: pii: bcr-2017-21974.
doi: 10.1136/bcr-2017-219741.
CDC data show decline in some hospital-acquired infections
SAN DIEGO – There was an encouraging 22% reduction in hospital-acquired infections (HAIs) after adjustment for clinical variables when 2015 and 2011 data from national Centers for Disease Control and Prevention hospital surveys were compared.
“The data suggest that national efforts toward preventing HAIs are succeeding,” reported Shelley S. Magill, MD, PhD, a medical epidemiologist in the Division of Healthcare Quality Promotion at the CDC who summarized the data at an annual scientific meeting on infectious diseases .
The comparative data were drawn from point prevalence surveys conducted in 2011 and 2015 as part of the CDC’s Emerging Infections Program. In this type of survey, the data are collected over 1 day, providing a snapshot in time among selected hospitals. The analysis presented by Dr. Magill was restricted to the 148 hospitals that participated in both the 2011 and 2015 surveys, although the 2015 survey included a total of 199 hospitals, of which other data analyses are planned.
Due to the change in incidence, the rank order of HAIs was different in 2015 relative to 2011. While surgical site infections (SSIs) represented the most frequent HAI in 2011, they fell to the third most frequent HAI in 2015; pneumonia and gastrointestinal (GI) infections assumed the first and second spots, respectively. The GI HAI infection category includes Clostridium difficile infection.
The incidence of SSI HAI among all hospitalized patients in the survey fell by 41% between 2011 and 2015 (from 1.00% to 0.59%; P = .001). The other big contributor to the overall reduction in HAIs was the fall in the incidence of urinary tract infections, which fell 36% (from 0.55% to 0.35%; P = .04). The decrease in pneumonia (from 0.97% to 0.89%) was not significant, nor was the even more modest reduction in bloodstream HAI (from 0.45% to 0.43%). There was a modest increase in GI/Clostridium difficile infections (from 0.56% to 0.59%).
The surveys do not permit the reduction in HAI rates to be attributed to any specific prevention practices, but Dr. Magill pointed out that the overall reductions correlate with reduced use of urinary catheters and central lines; reductions of both have been advocated as a means for improved infection control. Of several factors that might contribute to a reduction in SSI HAI, Dr. Magill speculated that better adherence to guidelines and more rigorous steps at preoperative infection control strategies might be among them.
Detailed analyses of the data collected from all of the hospitals that participated in the 2015 survey are planned, including an evaluation of which antibiotics were used to treat the HAIs found in this survey. Although the findings so far encourage speculation that infection control practices, such as prudent use of urinary catheters, are having a positive effect, Dr. Magill said that the data also point out the challenges.
“Given that pneumonia continues to represent a large proportion of HAIs in hospitals, more work is needed to identify risk factors; understand the factors that are preventable, particularly in the nonventilated patients; and develop better preventive approaches,” Dr. Magill said.
Dr. Magill reported no financial relationships relevant to this study.
SAN DIEGO – There was an encouraging 22% reduction in hospital-acquired infections (HAIs) after adjustment for clinical variables when 2015 and 2011 data from national Centers for Disease Control and Prevention hospital surveys were compared.
“The data suggest that national efforts toward preventing HAIs are succeeding,” reported Shelley S. Magill, MD, PhD, a medical epidemiologist in the Division of Healthcare Quality Promotion at the CDC who summarized the data at an annual scientific meeting on infectious diseases .
The comparative data were drawn from point prevalence surveys conducted in 2011 and 2015 as part of the CDC’s Emerging Infections Program. In this type of survey, the data are collected over 1 day, providing a snapshot in time among selected hospitals. The analysis presented by Dr. Magill was restricted to the 148 hospitals that participated in both the 2011 and 2015 surveys, although the 2015 survey included a total of 199 hospitals, of which other data analyses are planned.
Due to the change in incidence, the rank order of HAIs was different in 2015 relative to 2011. While surgical site infections (SSIs) represented the most frequent HAI in 2011, they fell to the third most frequent HAI in 2015; pneumonia and gastrointestinal (GI) infections assumed the first and second spots, respectively. The GI HAI infection category includes Clostridium difficile infection.
The incidence of SSI HAI among all hospitalized patients in the survey fell by 41% between 2011 and 2015 (from 1.00% to 0.59%; P = .001). The other big contributor to the overall reduction in HAIs was the fall in the incidence of urinary tract infections, which fell 36% (from 0.55% to 0.35%; P = .04). The decrease in pneumonia (from 0.97% to 0.89%) was not significant, nor was the even more modest reduction in bloodstream HAI (from 0.45% to 0.43%). There was a modest increase in GI/Clostridium difficile infections (from 0.56% to 0.59%).
The surveys do not permit the reduction in HAI rates to be attributed to any specific prevention practices, but Dr. Magill pointed out that the overall reductions correlate with reduced use of urinary catheters and central lines; reductions of both have been advocated as a means for improved infection control. Of several factors that might contribute to a reduction in SSI HAI, Dr. Magill speculated that better adherence to guidelines and more rigorous steps at preoperative infection control strategies might be among them.
Detailed analyses of the data collected from all of the hospitals that participated in the 2015 survey are planned, including an evaluation of which antibiotics were used to treat the HAIs found in this survey. Although the findings so far encourage speculation that infection control practices, such as prudent use of urinary catheters, are having a positive effect, Dr. Magill said that the data also point out the challenges.
“Given that pneumonia continues to represent a large proportion of HAIs in hospitals, more work is needed to identify risk factors; understand the factors that are preventable, particularly in the nonventilated patients; and develop better preventive approaches,” Dr. Magill said.
Dr. Magill reported no financial relationships relevant to this study.
SAN DIEGO – There was an encouraging 22% reduction in hospital-acquired infections (HAIs) after adjustment for clinical variables when 2015 and 2011 data from national Centers for Disease Control and Prevention hospital surveys were compared.
“The data suggest that national efforts toward preventing HAIs are succeeding,” reported Shelley S. Magill, MD, PhD, a medical epidemiologist in the Division of Healthcare Quality Promotion at the CDC who summarized the data at an annual scientific meeting on infectious diseases .
The comparative data were drawn from point prevalence surveys conducted in 2011 and 2015 as part of the CDC’s Emerging Infections Program. In this type of survey, the data are collected over 1 day, providing a snapshot in time among selected hospitals. The analysis presented by Dr. Magill was restricted to the 148 hospitals that participated in both the 2011 and 2015 surveys, although the 2015 survey included a total of 199 hospitals, of which other data analyses are planned.
Due to the change in incidence, the rank order of HAIs was different in 2015 relative to 2011. While surgical site infections (SSIs) represented the most frequent HAI in 2011, they fell to the third most frequent HAI in 2015; pneumonia and gastrointestinal (GI) infections assumed the first and second spots, respectively. The GI HAI infection category includes Clostridium difficile infection.
The incidence of SSI HAI among all hospitalized patients in the survey fell by 41% between 2011 and 2015 (from 1.00% to 0.59%; P = .001). The other big contributor to the overall reduction in HAIs was the fall in the incidence of urinary tract infections, which fell 36% (from 0.55% to 0.35%; P = .04). The decrease in pneumonia (from 0.97% to 0.89%) was not significant, nor was the even more modest reduction in bloodstream HAI (from 0.45% to 0.43%). There was a modest increase in GI/Clostridium difficile infections (from 0.56% to 0.59%).
The surveys do not permit the reduction in HAI rates to be attributed to any specific prevention practices, but Dr. Magill pointed out that the overall reductions correlate with reduced use of urinary catheters and central lines; reductions of both have been advocated as a means for improved infection control. Of several factors that might contribute to a reduction in SSI HAI, Dr. Magill speculated that better adherence to guidelines and more rigorous steps at preoperative infection control strategies might be among them.
Detailed analyses of the data collected from all of the hospitals that participated in the 2015 survey are planned, including an evaluation of which antibiotics were used to treat the HAIs found in this survey. Although the findings so far encourage speculation that infection control practices, such as prudent use of urinary catheters, are having a positive effect, Dr. Magill said that the data also point out the challenges.
“Given that pneumonia continues to represent a large proportion of HAIs in hospitals, more work is needed to identify risk factors; understand the factors that are preventable, particularly in the nonventilated patients; and develop better preventive approaches,” Dr. Magill said.
Dr. Magill reported no financial relationships relevant to this study.
AT ID WEEK 2017
Key clinical point:
Major finding: In two point prevalence surveys conducted in the same hospitals, the rate of HAI was 22% lower in 2015 (P = .001), compared with 2011.
Data source: CDC national surveys of HAIs in 148 hospitals in two different years (2011 and 2015) were compared.
Disclosures: Dr. Magill reported no financial relationships relevant to this study.
Cases of Legionnaires’ continue to rise in the United States
SAN DIEGO –
“Improved testing and surveillance are needed to improve understanding of disease and outbreak burden,” Laura A. Cooley, MD, said at an annual scientific meeting on infectious diseases. “There is more to learn about environmental sources of Legionella for cases not associated with known outbreaks and about the distribution of Legionella in the environment.”
A Gram-negative bacillus, Legionella is an intracellular parasite of free-living protozoa primarily found in freshwater. “It can live and grow in biofilm, and there are more than 60 species of the bacterium,” she said at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.
Cases are higher in the warmer months, and the rates are highest among the elderly, men, and those of black race. Currently, L. pneumophila accounts for about 90% of cases in the United States. “Once it’s transmitted, it has to hit a susceptible population to cause disease, generally older individuals and people with underlying conditions,” Dr. Cooley said.
A separate analysis evaluated Legionella cases reported among U.S. residents between 2005 and 2009 (MMWR. 2011;60[32]:1083-6). It found that only 4% were associated with outbreaks, and 96% were sporadic. “That doesn’t mean that [the cases] weren’t associated with the same kind of source, they just weren’t identified as an outbreak,” Dr. Cooley said. “It shows that there is a lot to learn about transmission of Legionella.”
Data from the National Notifiable Diseases Surveillance System indicate that rates of Legionella continue to rise nationwide, especially in the Midwest and Northeast. “Why? It’s possible that there are differences in testing preferences and reporting preferences in this region of the country,” Dr. Cooley noted. “Maybe people are more tuned in to the potential for outbreaks, but there are reasons why there could be differences in disease, like differences in infrastructure, climate, population density, and cooling tower density.” CDC data from 2015 indicate that most cases are not associated with a known exposure, and that the case fatality rate differs by exposure type: 12% for cases reporting health care exposure during the 10 days before symptom onset (25% for definite cases), 9% for cases reporting assisted or senior living exposure, 7% when no specific exposure is reported, and 4% for cases reporting travel exposure (MMWR. 2017;66[22]:584-9).
The U.S. case definition of Legionnaires’ disease consists of clinical or radiologic pneumonia plus confirmatory laboratory testing, either by urinary antigen test (UAT), lower respiratory culture, or appropriate serological testing. Polymerase chain reaction can be used as a presumptive test for a suspect case. “UAT is easy and it detects L. pneumophila serogroup 1 (Lp1), but it has some gaps,” Dr. Cooley said. “It isn’t completely sensitive for Lp1, and it doesn’t detect any other species or serogroups. That’s why we also recommend that a culture of respiratory secretions on selective media be performed at the same time. That being said, in the U.S., nearly all reported cases of Legionella are diagnosed by UAT only.”
A 2016 CDC MMWR and Vital Signs report found that almost all Legionella outbreaks could be prevented with effective water management, and the CDC has published a step-by-step guide to creating a water management program to reduce Legionella growth and spread in buildings. The 2017 MMWR Report found that definite health care–associated Legionnaires’ disease is deadly for one in four people who get it. The report also found that this issue is widespread; 76% of complete reporting jurisdictions reported at least one definite case of health care–associated Legionella disease in 2015. More recently, the Centers for Medicare & Medicaid Services issued a requirement to reduce risk in health care facility water systems to prevent cases and outbreaks. It applies to hospitals, skilled nursing facilities, and critical access hospitals.
Dr. Cooley reported having no financial disclosures.
SAN DIEGO –
“Improved testing and surveillance are needed to improve understanding of disease and outbreak burden,” Laura A. Cooley, MD, said at an annual scientific meeting on infectious diseases. “There is more to learn about environmental sources of Legionella for cases not associated with known outbreaks and about the distribution of Legionella in the environment.”
A Gram-negative bacillus, Legionella is an intracellular parasite of free-living protozoa primarily found in freshwater. “It can live and grow in biofilm, and there are more than 60 species of the bacterium,” she said at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.
Cases are higher in the warmer months, and the rates are highest among the elderly, men, and those of black race. Currently, L. pneumophila accounts for about 90% of cases in the United States. “Once it’s transmitted, it has to hit a susceptible population to cause disease, generally older individuals and people with underlying conditions,” Dr. Cooley said.
A separate analysis evaluated Legionella cases reported among U.S. residents between 2005 and 2009 (MMWR. 2011;60[32]:1083-6). It found that only 4% were associated with outbreaks, and 96% were sporadic. “That doesn’t mean that [the cases] weren’t associated with the same kind of source, they just weren’t identified as an outbreak,” Dr. Cooley said. “It shows that there is a lot to learn about transmission of Legionella.”
Data from the National Notifiable Diseases Surveillance System indicate that rates of Legionella continue to rise nationwide, especially in the Midwest and Northeast. “Why? It’s possible that there are differences in testing preferences and reporting preferences in this region of the country,” Dr. Cooley noted. “Maybe people are more tuned in to the potential for outbreaks, but there are reasons why there could be differences in disease, like differences in infrastructure, climate, population density, and cooling tower density.” CDC data from 2015 indicate that most cases are not associated with a known exposure, and that the case fatality rate differs by exposure type: 12% for cases reporting health care exposure during the 10 days before symptom onset (25% for definite cases), 9% for cases reporting assisted or senior living exposure, 7% when no specific exposure is reported, and 4% for cases reporting travel exposure (MMWR. 2017;66[22]:584-9).
The U.S. case definition of Legionnaires’ disease consists of clinical or radiologic pneumonia plus confirmatory laboratory testing, either by urinary antigen test (UAT), lower respiratory culture, or appropriate serological testing. Polymerase chain reaction can be used as a presumptive test for a suspect case. “UAT is easy and it detects L. pneumophila serogroup 1 (Lp1), but it has some gaps,” Dr. Cooley said. “It isn’t completely sensitive for Lp1, and it doesn’t detect any other species or serogroups. That’s why we also recommend that a culture of respiratory secretions on selective media be performed at the same time. That being said, in the U.S., nearly all reported cases of Legionella are diagnosed by UAT only.”
A 2016 CDC MMWR and Vital Signs report found that almost all Legionella outbreaks could be prevented with effective water management, and the CDC has published a step-by-step guide to creating a water management program to reduce Legionella growth and spread in buildings. The 2017 MMWR Report found that definite health care–associated Legionnaires’ disease is deadly for one in four people who get it. The report also found that this issue is widespread; 76% of complete reporting jurisdictions reported at least one definite case of health care–associated Legionella disease in 2015. More recently, the Centers for Medicare & Medicaid Services issued a requirement to reduce risk in health care facility water systems to prevent cases and outbreaks. It applies to hospitals, skilled nursing facilities, and critical access hospitals.
Dr. Cooley reported having no financial disclosures.
SAN DIEGO –
“Improved testing and surveillance are needed to improve understanding of disease and outbreak burden,” Laura A. Cooley, MD, said at an annual scientific meeting on infectious diseases. “There is more to learn about environmental sources of Legionella for cases not associated with known outbreaks and about the distribution of Legionella in the environment.”
A Gram-negative bacillus, Legionella is an intracellular parasite of free-living protozoa primarily found in freshwater. “It can live and grow in biofilm, and there are more than 60 species of the bacterium,” she said at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.
Cases are higher in the warmer months, and the rates are highest among the elderly, men, and those of black race. Currently, L. pneumophila accounts for about 90% of cases in the United States. “Once it’s transmitted, it has to hit a susceptible population to cause disease, generally older individuals and people with underlying conditions,” Dr. Cooley said.
A separate analysis evaluated Legionella cases reported among U.S. residents between 2005 and 2009 (MMWR. 2011;60[32]:1083-6). It found that only 4% were associated with outbreaks, and 96% were sporadic. “That doesn’t mean that [the cases] weren’t associated with the same kind of source, they just weren’t identified as an outbreak,” Dr. Cooley said. “It shows that there is a lot to learn about transmission of Legionella.”
Data from the National Notifiable Diseases Surveillance System indicate that rates of Legionella continue to rise nationwide, especially in the Midwest and Northeast. “Why? It’s possible that there are differences in testing preferences and reporting preferences in this region of the country,” Dr. Cooley noted. “Maybe people are more tuned in to the potential for outbreaks, but there are reasons why there could be differences in disease, like differences in infrastructure, climate, population density, and cooling tower density.” CDC data from 2015 indicate that most cases are not associated with a known exposure, and that the case fatality rate differs by exposure type: 12% for cases reporting health care exposure during the 10 days before symptom onset (25% for definite cases), 9% for cases reporting assisted or senior living exposure, 7% when no specific exposure is reported, and 4% for cases reporting travel exposure (MMWR. 2017;66[22]:584-9).
The U.S. case definition of Legionnaires’ disease consists of clinical or radiologic pneumonia plus confirmatory laboratory testing, either by urinary antigen test (UAT), lower respiratory culture, or appropriate serological testing. Polymerase chain reaction can be used as a presumptive test for a suspect case. “UAT is easy and it detects L. pneumophila serogroup 1 (Lp1), but it has some gaps,” Dr. Cooley said. “It isn’t completely sensitive for Lp1, and it doesn’t detect any other species or serogroups. That’s why we also recommend that a culture of respiratory secretions on selective media be performed at the same time. That being said, in the U.S., nearly all reported cases of Legionella are diagnosed by UAT only.”
A 2016 CDC MMWR and Vital Signs report found that almost all Legionella outbreaks could be prevented with effective water management, and the CDC has published a step-by-step guide to creating a water management program to reduce Legionella growth and spread in buildings. The 2017 MMWR Report found that definite health care–associated Legionnaires’ disease is deadly for one in four people who get it. The report also found that this issue is widespread; 76% of complete reporting jurisdictions reported at least one definite case of health care–associated Legionella disease in 2015. More recently, the Centers for Medicare & Medicaid Services issued a requirement to reduce risk in health care facility water systems to prevent cases and outbreaks. It applies to hospitals, skilled nursing facilities, and critical access hospitals.
Dr. Cooley reported having no financial disclosures.
REPORTING FROM ID WEEK 2017
Stroke Deaths: Reversing a Healthy Trend?
After decades of decline, progress has slowed in preventing stroke deaths, according to a CDC Vital Signs report. The report is a “wake-up call,” CDC Director Brenda Fitzgerald says.
About 3 in every 4 states showed stalled rates of decline between 2000 and 2015. In some states, the trend of declining stroke deaths has actually reversed. It is a “disturbing” finding, the researchers say—particularly because 80% of strokes are preventable.
Every 40 seconds, someone in the U.S. has a stroke. Each year, > 140,000 die. Blacks continue to be hardest hit by stroke but stroke deaths are on the rise among Hispanics (by 6% each year between 2013 and 2015) and people living in the South.
Death rates continued to drop steadily between the years 2000 and 2015 among adults aged ≥ 35 years. However, people are dying of stroke at younger ages. Over the past 15 years, stroke hospitalizations have increased among adults aged 18 to 54 years. But the researchers note that risk factors, such as high blood pressure, high cholesterol, obesity, and diabetes are also appearing in younger people. Moreover, those risk factors may not be recognized and treated in middle-aged adults aged 35 to 64 years.
The study categorizes stroke deaths in the U.S. from 2000 to 2015, by age, sex, race/ethnicity, and geographic area. It does not, however, address causes for the slowdown, although it cites other studies that point to obesity and diabetes as contributors. High blood pressure is the single “most important preventable and treatable risk factor for stroke,” the CDC says.
After decades of decline, progress has slowed in preventing stroke deaths, according to a CDC Vital Signs report. The report is a “wake-up call,” CDC Director Brenda Fitzgerald says.
About 3 in every 4 states showed stalled rates of decline between 2000 and 2015. In some states, the trend of declining stroke deaths has actually reversed. It is a “disturbing” finding, the researchers say—particularly because 80% of strokes are preventable.
Every 40 seconds, someone in the U.S. has a stroke. Each year, > 140,000 die. Blacks continue to be hardest hit by stroke but stroke deaths are on the rise among Hispanics (by 6% each year between 2013 and 2015) and people living in the South.
Death rates continued to drop steadily between the years 2000 and 2015 among adults aged ≥ 35 years. However, people are dying of stroke at younger ages. Over the past 15 years, stroke hospitalizations have increased among adults aged 18 to 54 years. But the researchers note that risk factors, such as high blood pressure, high cholesterol, obesity, and diabetes are also appearing in younger people. Moreover, those risk factors may not be recognized and treated in middle-aged adults aged 35 to 64 years.
The study categorizes stroke deaths in the U.S. from 2000 to 2015, by age, sex, race/ethnicity, and geographic area. It does not, however, address causes for the slowdown, although it cites other studies that point to obesity and diabetes as contributors. High blood pressure is the single “most important preventable and treatable risk factor for stroke,” the CDC says.
After decades of decline, progress has slowed in preventing stroke deaths, according to a CDC Vital Signs report. The report is a “wake-up call,” CDC Director Brenda Fitzgerald says.
About 3 in every 4 states showed stalled rates of decline between 2000 and 2015. In some states, the trend of declining stroke deaths has actually reversed. It is a “disturbing” finding, the researchers say—particularly because 80% of strokes are preventable.
Every 40 seconds, someone in the U.S. has a stroke. Each year, > 140,000 die. Blacks continue to be hardest hit by stroke but stroke deaths are on the rise among Hispanics (by 6% each year between 2013 and 2015) and people living in the South.
Death rates continued to drop steadily between the years 2000 and 2015 among adults aged ≥ 35 years. However, people are dying of stroke at younger ages. Over the past 15 years, stroke hospitalizations have increased among adults aged 18 to 54 years. But the researchers note that risk factors, such as high blood pressure, high cholesterol, obesity, and diabetes are also appearing in younger people. Moreover, those risk factors may not be recognized and treated in middle-aged adults aged 35 to 64 years.
The study categorizes stroke deaths in the U.S. from 2000 to 2015, by age, sex, race/ethnicity, and geographic area. It does not, however, address causes for the slowdown, although it cites other studies that point to obesity and diabetes as contributors. High blood pressure is the single “most important preventable and treatable risk factor for stroke,” the CDC says.
Nearly 80% of health care personnel stepped up for flu shots
Nearly four out of five health care personnel in the United States received a flu vaccination during the 2016-2017 flu season, but a majority of those working in long-term care settings were not vaccinated, based on data from an Internet survey of more than 2,000 individuals that was conducted by the Centers for Disease Control and Prevention.
A total of 78.6% of the survey’s respondents said they’d been vaccinated during the 2016-2017 season. Vaccination coverage for health care personnel overall has remained in the 77%-79% range in recent years, but that represents an increase from 64% in 2010-2011.
“As in previous seasons, the highest coverage was among HCP whose workplace had vaccination requirements,” noted Carla L. Black, PhD, of the CDC, and colleagues (MMWR Morb Mortal Wkly Rep. 2017 Sep 29;66[38]:1009-15). The researchers reviewed data collected from an Internet panel survey of 2,438 health care personnel between March 28, 2017, and April 19, 2017.
Physicians boasted the highest vaccination coverage in 2016-2017 (96%), followed by pharmacists (94%), nurses (93%), nurse practitioners and physician assistants (92%), other clinical providers (80%), nonclinical health care providers (74%), and aides and assistants (69%).
Flu vaccination rates were highest among HCPs working in a hospital setting (92%); 94% of survey respondents in hospitals reported either having a vaccination requirement at work or being provided at least 1 day of on-site vaccination.
Vaccination rates were lowest among health care personnel in long-term care settings (68%), where only 26% reported a workplace vaccination requirement. However, vaccination rates in long-term care rose to 90% when employers required vaccination.
The report’s findings were limited by several factors, including the use of a volunteer sample, the reliance on self-reports, and the potential differences between Internet survey results and population-based estimates of flu vaccination.
However, “in the absence of vaccination requirements, the findings in this study support the recommendations found in the Guide to Community Preventive Services, which include active promotion of on-site vaccination at no cost or low cost to increase influenza vaccination coverage among HCPs,” the researchers said.
The researchers had no financial conflicts to disclose.
Nearly four out of five health care personnel in the United States received a flu vaccination during the 2016-2017 flu season, but a majority of those working in long-term care settings were not vaccinated, based on data from an Internet survey of more than 2,000 individuals that was conducted by the Centers for Disease Control and Prevention.
A total of 78.6% of the survey’s respondents said they’d been vaccinated during the 2016-2017 season. Vaccination coverage for health care personnel overall has remained in the 77%-79% range in recent years, but that represents an increase from 64% in 2010-2011.
“As in previous seasons, the highest coverage was among HCP whose workplace had vaccination requirements,” noted Carla L. Black, PhD, of the CDC, and colleagues (MMWR Morb Mortal Wkly Rep. 2017 Sep 29;66[38]:1009-15). The researchers reviewed data collected from an Internet panel survey of 2,438 health care personnel between March 28, 2017, and April 19, 2017.
Physicians boasted the highest vaccination coverage in 2016-2017 (96%), followed by pharmacists (94%), nurses (93%), nurse practitioners and physician assistants (92%), other clinical providers (80%), nonclinical health care providers (74%), and aides and assistants (69%).
Flu vaccination rates were highest among HCPs working in a hospital setting (92%); 94% of survey respondents in hospitals reported either having a vaccination requirement at work or being provided at least 1 day of on-site vaccination.
Vaccination rates were lowest among health care personnel in long-term care settings (68%), where only 26% reported a workplace vaccination requirement. However, vaccination rates in long-term care rose to 90% when employers required vaccination.
The report’s findings were limited by several factors, including the use of a volunteer sample, the reliance on self-reports, and the potential differences between Internet survey results and population-based estimates of flu vaccination.
However, “in the absence of vaccination requirements, the findings in this study support the recommendations found in the Guide to Community Preventive Services, which include active promotion of on-site vaccination at no cost or low cost to increase influenza vaccination coverage among HCPs,” the researchers said.
The researchers had no financial conflicts to disclose.
Nearly four out of five health care personnel in the United States received a flu vaccination during the 2016-2017 flu season, but a majority of those working in long-term care settings were not vaccinated, based on data from an Internet survey of more than 2,000 individuals that was conducted by the Centers for Disease Control and Prevention.
A total of 78.6% of the survey’s respondents said they’d been vaccinated during the 2016-2017 season. Vaccination coverage for health care personnel overall has remained in the 77%-79% range in recent years, but that represents an increase from 64% in 2010-2011.
“As in previous seasons, the highest coverage was among HCP whose workplace had vaccination requirements,” noted Carla L. Black, PhD, of the CDC, and colleagues (MMWR Morb Mortal Wkly Rep. 2017 Sep 29;66[38]:1009-15). The researchers reviewed data collected from an Internet panel survey of 2,438 health care personnel between March 28, 2017, and April 19, 2017.
Physicians boasted the highest vaccination coverage in 2016-2017 (96%), followed by pharmacists (94%), nurses (93%), nurse practitioners and physician assistants (92%), other clinical providers (80%), nonclinical health care providers (74%), and aides and assistants (69%).
Flu vaccination rates were highest among HCPs working in a hospital setting (92%); 94% of survey respondents in hospitals reported either having a vaccination requirement at work or being provided at least 1 day of on-site vaccination.
Vaccination rates were lowest among health care personnel in long-term care settings (68%), where only 26% reported a workplace vaccination requirement. However, vaccination rates in long-term care rose to 90% when employers required vaccination.
The report’s findings were limited by several factors, including the use of a volunteer sample, the reliance on self-reports, and the potential differences between Internet survey results and population-based estimates of flu vaccination.
However, “in the absence of vaccination requirements, the findings in this study support the recommendations found in the Guide to Community Preventive Services, which include active promotion of on-site vaccination at no cost or low cost to increase influenza vaccination coverage among HCPs,” the researchers said.
The researchers had no financial conflicts to disclose.
FROM MMWR
Key clinical point:
Major finding: Overall flu vaccination coverage among U.S. health care personnel was 78.6% in the 2016-2017 season
Data source: The data come from an Internet survey of 2,438 health care personnel.
Disclosures: The researchers had no financial conflicts to disclose.
HIV Testing Low Among Transgender Adults
Transgender men and women are at high risk for HIV infection. In a recent analysis of more than 9 million CDC-funded HIV test results, transgender women had the highest percentage of confirmed positive results (2.7%) of any gender category. But this group also tends to have too-low testing numbers. In a CDC study, only 36% of transgender women and 32% of transgender men reported being tested; only 10% of both groups had been tested in the past year. By comparison, gay and bisexual men reported getting tested at roughly twice the rates (61.8% ever and 21.6% past year).
Black transgender women and men had twice the prevalence of ever testing compared with their white counterparts (63%-67% vs 31%-33%). Transgender women who had been diagnosed with a depressive disorder had the highest prevalence of getting tested for HIV (69%).
Transgender persons face “unique barriers to testing,” the CDC researchers say, such as the HIV stigma within the transgender community, gender identity stigma in health care settings, and socioeconomic marginalization. The CDC is working on “innovative approaches” to delivering HIV testing and other prevention and support services to transgender persons who are at risk for or have newly diagnosed HIV.
Transgender men and women are at high risk for HIV infection. In a recent analysis of more than 9 million CDC-funded HIV test results, transgender women had the highest percentage of confirmed positive results (2.7%) of any gender category. But this group also tends to have too-low testing numbers. In a CDC study, only 36% of transgender women and 32% of transgender men reported being tested; only 10% of both groups had been tested in the past year. By comparison, gay and bisexual men reported getting tested at roughly twice the rates (61.8% ever and 21.6% past year).
Black transgender women and men had twice the prevalence of ever testing compared with their white counterparts (63%-67% vs 31%-33%). Transgender women who had been diagnosed with a depressive disorder had the highest prevalence of getting tested for HIV (69%).
Transgender persons face “unique barriers to testing,” the CDC researchers say, such as the HIV stigma within the transgender community, gender identity stigma in health care settings, and socioeconomic marginalization. The CDC is working on “innovative approaches” to delivering HIV testing and other prevention and support services to transgender persons who are at risk for or have newly diagnosed HIV.
Transgender men and women are at high risk for HIV infection. In a recent analysis of more than 9 million CDC-funded HIV test results, transgender women had the highest percentage of confirmed positive results (2.7%) of any gender category. But this group also tends to have too-low testing numbers. In a CDC study, only 36% of transgender women and 32% of transgender men reported being tested; only 10% of both groups had been tested in the past year. By comparison, gay and bisexual men reported getting tested at roughly twice the rates (61.8% ever and 21.6% past year).
Black transgender women and men had twice the prevalence of ever testing compared with their white counterparts (63%-67% vs 31%-33%). Transgender women who had been diagnosed with a depressive disorder had the highest prevalence of getting tested for HIV (69%).
Transgender persons face “unique barriers to testing,” the CDC researchers say, such as the HIV stigma within the transgender community, gender identity stigma in health care settings, and socioeconomic marginalization. The CDC is working on “innovative approaches” to delivering HIV testing and other prevention and support services to transgender persons who are at risk for or have newly diagnosed HIV.
Avoid sildenafil for pulmonary hypertension after corrected valvular disease
BARCELONA – Off-label use of the phosphodiesterase-5 inhibitor sildenafil to treat residual pulmonary hypertension after successful correction of valvular heart disease is not merely ineffective, it’s counterproductive, according to the results of the randomized, placebo-controlled SIOVAC study.
“We believe based upon our results that off-label use of sildenafil in patients with left heart disease-pulmonary hypertension due to valvular disease should be discouraged,” Javier Bermejo, MD, declared at the annual congress of the European Society of Cardiology.
Sildenafil is approved with a solid, evidence-based indication for treating some other types of pulmonary hypertension. Many cardiologists also prescribe the drug off label for residual pulmonary hypertension in patients with corrected valve disease, hoping that it will be of benefit, since there is currently no approved treatment for this common and serious condition associated with increased mortality. But because the anecdotal literature on sildenafil for this specific type of pulmonary hypertension is mixed, Dr. Bermejo and his coinvestigators in the Spanish Network Center for Cardiovascular Research decided to conduct a multicenter randomized trial.
SIOVAC (Sildenafil for Improving Clinical Outcomes After Valvular Correction) comprised 200 patients with residual pulmonary hypertension after corrected valvular heart disease at 17 Spanish general hospitals. The patients were randomized to receive sildenafil at 40 mg t.i.d. or placebo for 6 months in this double-blind trial.
The primary endpoint was a standardized composite clinical score widely used in heart failure trials. It consists of all-cause mortality, hospital admission for heart failure, worsening exercise tolerance, and deterioration in a global self-assessment rating.
The shocker for the investigators – who had expected a positive study – was that 33% of patients in the sildenafil group worsened significantly on the composite clinical score at 6 months, compared with 14% of placebo-treated controls, said Dr. Bermejo, a cardiologist at Gregorio Marañón University Hospital in Madrid.
Moreover, only 27% of the sildenafil group improved, compared with 44% of controls. About one-third of patients in both groups remained unchanged over the course of the 6-month trial.
Dr. Bermejo noted that valvular disease is considered the next cardiac epidemic because of its strong association with advancing age and the rapid aging of the population worldwide. Pulmonary hypertension occurs is virtually all patients with severe mitral disease and in up to two-thirds of those with asymptomatic aortic stenosis. Regression of the pulmonary hypertension is often incomplete after successful surgical or transcatheter correction of the valvular lesion.
Discussant Irene M. Lang, MD, called SIOVAC “a very clear study.” It convincingly establishes that sildenafil – a vasodilator – is ineffective for the treatment of what the current ESC/European Respiratory Society guidelines on pulmonary hypertension call isolated post-capillary pulmonary hypertension, a condition defined hemodynamically by a diastolic pulmonary vascular pressure gradient of less than 7 mm Hg and/or a pulmonary vascular resistance below 3 Wood units (Eur Heart J. 2016 Jan 1;37[1]:67-119.)
The SIOVAC findings underscore the strong IIIC recommendation in the European guidelines that the use of approved therapies for pulmonary arterial hypertension is not recommended in patients with left heart disease-pulmonary hypertension, added Dr. Lang, a coauthor of the guidelines and professor of vascular biology at the Medical University of Vienna.
The Spanish government funded SIOVAC. Dr. Bermejo reported having no financial conflicts of interest.
BARCELONA – Off-label use of the phosphodiesterase-5 inhibitor sildenafil to treat residual pulmonary hypertension after successful correction of valvular heart disease is not merely ineffective, it’s counterproductive, according to the results of the randomized, placebo-controlled SIOVAC study.
“We believe based upon our results that off-label use of sildenafil in patients with left heart disease-pulmonary hypertension due to valvular disease should be discouraged,” Javier Bermejo, MD, declared at the annual congress of the European Society of Cardiology.
Sildenafil is approved with a solid, evidence-based indication for treating some other types of pulmonary hypertension. Many cardiologists also prescribe the drug off label for residual pulmonary hypertension in patients with corrected valve disease, hoping that it will be of benefit, since there is currently no approved treatment for this common and serious condition associated with increased mortality. But because the anecdotal literature on sildenafil for this specific type of pulmonary hypertension is mixed, Dr. Bermejo and his coinvestigators in the Spanish Network Center for Cardiovascular Research decided to conduct a multicenter randomized trial.
SIOVAC (Sildenafil for Improving Clinical Outcomes After Valvular Correction) comprised 200 patients with residual pulmonary hypertension after corrected valvular heart disease at 17 Spanish general hospitals. The patients were randomized to receive sildenafil at 40 mg t.i.d. or placebo for 6 months in this double-blind trial.
The primary endpoint was a standardized composite clinical score widely used in heart failure trials. It consists of all-cause mortality, hospital admission for heart failure, worsening exercise tolerance, and deterioration in a global self-assessment rating.
The shocker for the investigators – who had expected a positive study – was that 33% of patients in the sildenafil group worsened significantly on the composite clinical score at 6 months, compared with 14% of placebo-treated controls, said Dr. Bermejo, a cardiologist at Gregorio Marañón University Hospital in Madrid.
Moreover, only 27% of the sildenafil group improved, compared with 44% of controls. About one-third of patients in both groups remained unchanged over the course of the 6-month trial.
Dr. Bermejo noted that valvular disease is considered the next cardiac epidemic because of its strong association with advancing age and the rapid aging of the population worldwide. Pulmonary hypertension occurs is virtually all patients with severe mitral disease and in up to two-thirds of those with asymptomatic aortic stenosis. Regression of the pulmonary hypertension is often incomplete after successful surgical or transcatheter correction of the valvular lesion.
Discussant Irene M. Lang, MD, called SIOVAC “a very clear study.” It convincingly establishes that sildenafil – a vasodilator – is ineffective for the treatment of what the current ESC/European Respiratory Society guidelines on pulmonary hypertension call isolated post-capillary pulmonary hypertension, a condition defined hemodynamically by a diastolic pulmonary vascular pressure gradient of less than 7 mm Hg and/or a pulmonary vascular resistance below 3 Wood units (Eur Heart J. 2016 Jan 1;37[1]:67-119.)
The SIOVAC findings underscore the strong IIIC recommendation in the European guidelines that the use of approved therapies for pulmonary arterial hypertension is not recommended in patients with left heart disease-pulmonary hypertension, added Dr. Lang, a coauthor of the guidelines and professor of vascular biology at the Medical University of Vienna.
The Spanish government funded SIOVAC. Dr. Bermejo reported having no financial conflicts of interest.
BARCELONA – Off-label use of the phosphodiesterase-5 inhibitor sildenafil to treat residual pulmonary hypertension after successful correction of valvular heart disease is not merely ineffective, it’s counterproductive, according to the results of the randomized, placebo-controlled SIOVAC study.
“We believe based upon our results that off-label use of sildenafil in patients with left heart disease-pulmonary hypertension due to valvular disease should be discouraged,” Javier Bermejo, MD, declared at the annual congress of the European Society of Cardiology.
Sildenafil is approved with a solid, evidence-based indication for treating some other types of pulmonary hypertension. Many cardiologists also prescribe the drug off label for residual pulmonary hypertension in patients with corrected valve disease, hoping that it will be of benefit, since there is currently no approved treatment for this common and serious condition associated with increased mortality. But because the anecdotal literature on sildenafil for this specific type of pulmonary hypertension is mixed, Dr. Bermejo and his coinvestigators in the Spanish Network Center for Cardiovascular Research decided to conduct a multicenter randomized trial.
SIOVAC (Sildenafil for Improving Clinical Outcomes After Valvular Correction) comprised 200 patients with residual pulmonary hypertension after corrected valvular heart disease at 17 Spanish general hospitals. The patients were randomized to receive sildenafil at 40 mg t.i.d. or placebo for 6 months in this double-blind trial.
The primary endpoint was a standardized composite clinical score widely used in heart failure trials. It consists of all-cause mortality, hospital admission for heart failure, worsening exercise tolerance, and deterioration in a global self-assessment rating.
The shocker for the investigators – who had expected a positive study – was that 33% of patients in the sildenafil group worsened significantly on the composite clinical score at 6 months, compared with 14% of placebo-treated controls, said Dr. Bermejo, a cardiologist at Gregorio Marañón University Hospital in Madrid.
Moreover, only 27% of the sildenafil group improved, compared with 44% of controls. About one-third of patients in both groups remained unchanged over the course of the 6-month trial.
Dr. Bermejo noted that valvular disease is considered the next cardiac epidemic because of its strong association with advancing age and the rapid aging of the population worldwide. Pulmonary hypertension occurs is virtually all patients with severe mitral disease and in up to two-thirds of those with asymptomatic aortic stenosis. Regression of the pulmonary hypertension is often incomplete after successful surgical or transcatheter correction of the valvular lesion.
Discussant Irene M. Lang, MD, called SIOVAC “a very clear study.” It convincingly establishes that sildenafil – a vasodilator – is ineffective for the treatment of what the current ESC/European Respiratory Society guidelines on pulmonary hypertension call isolated post-capillary pulmonary hypertension, a condition defined hemodynamically by a diastolic pulmonary vascular pressure gradient of less than 7 mm Hg and/or a pulmonary vascular resistance below 3 Wood units (Eur Heart J. 2016 Jan 1;37[1]:67-119.)
The SIOVAC findings underscore the strong IIIC recommendation in the European guidelines that the use of approved therapies for pulmonary arterial hypertension is not recommended in patients with left heart disease-pulmonary hypertension, added Dr. Lang, a coauthor of the guidelines and professor of vascular biology at the Medical University of Vienna.
The Spanish government funded SIOVAC. Dr. Bermejo reported having no financial conflicts of interest.
AT THE ESC CONGRESS 2017
Key clinical point:
Major finding: One-third of patients with residual pulmonary hypertension after successful correction of valvular heart disease experienced significant clinical worsening during 6 months of sildenafil therapy, compared with 14% on placebo.
Data source: SIOVAC, a 6-month, double-blind, placebo-controlled study of 200 patients with residual pulmonary hypertension after correction for valvular heart disease.
Disclosures: The Spanish government funded SIOVAC. The presenter reported having no financial conflicts of interest.
FDA approves implantable device for central sleep apnea
The U.S. Food and Drug Administration on Oct. 6 approved an implantable device for the treatment of moderate to severe central sleep apnea.
The remedē System consists of a battery pack and small, thin wires placed under the skin in the upper chest area. The wires are inserted into the blood vessels in the chest to stimulate the phrenic nerve. The system monitors respiratory signals and, when it stimulates the nerve, the diaphragm moves to restore normal breathing.
The agency’s approval comes on the basis of study results showing that the system reduced the apnea–hypopnea index scores by 50% or more in 51% of patients studied. Control patients in the study saw an 11% reduction in their score.
Adverse events reported in the study included concomitant device interaction, implant site infection, and swelling and local tissue damage or pocket erosion. The remedē System is contraindicated for patients with active infection or who are known to require an MRI.
The U.S. Food and Drug Administration on Oct. 6 approved an implantable device for the treatment of moderate to severe central sleep apnea.
The remedē System consists of a battery pack and small, thin wires placed under the skin in the upper chest area. The wires are inserted into the blood vessels in the chest to stimulate the phrenic nerve. The system monitors respiratory signals and, when it stimulates the nerve, the diaphragm moves to restore normal breathing.
The agency’s approval comes on the basis of study results showing that the system reduced the apnea–hypopnea index scores by 50% or more in 51% of patients studied. Control patients in the study saw an 11% reduction in their score.
Adverse events reported in the study included concomitant device interaction, implant site infection, and swelling and local tissue damage or pocket erosion. The remedē System is contraindicated for patients with active infection or who are known to require an MRI.
The U.S. Food and Drug Administration on Oct. 6 approved an implantable device for the treatment of moderate to severe central sleep apnea.
The remedē System consists of a battery pack and small, thin wires placed under the skin in the upper chest area. The wires are inserted into the blood vessels in the chest to stimulate the phrenic nerve. The system monitors respiratory signals and, when it stimulates the nerve, the diaphragm moves to restore normal breathing.
The agency’s approval comes on the basis of study results showing that the system reduced the apnea–hypopnea index scores by 50% or more in 51% of patients studied. Control patients in the study saw an 11% reduction in their score.
Adverse events reported in the study included concomitant device interaction, implant site infection, and swelling and local tissue damage or pocket erosion. The remedē System is contraindicated for patients with active infection or who are known to require an MRI.