Norovirus Infection Causes Substantial Problems in Elders.

Hospitalization rates and mortality rose during outbreaks in nursing homes.

Gastroenteritis outbreaks, 86% of which are caused by norovirus, are common in nursing homes. Norovirus infection is thought to be associated with substantial morbidity and mortality in nursing home residents, but the exact risk is undefined.

In this retrospective cohort study, researchers used linked databases of infection outbreaks and Medicare nursing homes to assess the incidences of hospitalizations and deaths during norovirus outbreaks in 308 nursing homes in Oregon, Wisconsin, and Pennsylvania. Four hundred seven outbreaks were reported during 2009 and 2010, with a median of 26 cases per outbreak. In analyses adjusted for seasonal differences, risk for hospitalization was 9% higher and risk for death was 11% higher during outbreaks than at other times.

Comment: These results put some hard numbers to the trends that are observed clinically: Risks for hospitalization and death rise during norovirus outbreaks in nursing homes. The authors estimate that about 100 excess hospitalizations and 45 excess deaths occurred in these homes during the study period, which translates to 500 to 600 excess deaths in nursing home residents nationwide during 2 years. Norovirus vaccine development (now under way) and more aggressive infection control strategies are warranted.

Source: Journal Watch General Medicine




GAO: Excess Self-Referrals Cost Medicare Over $100 Million for Imaging in 2010 .

Medicare providers who acquire computed tomography and magnetic resonance imaging equipment self-refer for imaging at almost double the rate they did before obtaining the equipment, according to a U.S. Government Accountability Office report released this week.

Providers who already owned the equipment or who did not self-refer slightly decreased their use of advanced imaging over the same study period (2008 to 2010). In general, self-referrers used advanced imaging at double the rate of those who did not self-refer.

The report’s findings “suggest that financial incentives for self-referring providers were likely a major factor driving the increase in referrals.” The GAO estimates that there were 400,000 excess referrals in 2010, costing Medicare $109 million.

Source:  GAO report


FDA Taking Closer Look at Extended-Release Generics .

The failure of an extended-release form of generic Wellbutrin (bupropion) to perform as well as its brand-name counterpart has prompted the FDA to take a closer look at the way all extended-release generics are made, reports the New York Times.

“This has actually prompted us to change our policy,” Gregory P. Geba, director of the FDA’s office of generic drugs, told the Times in an interview.

While generic drugs are required to have the same active ingredient as brand-name versions, critics say that manufacturers of generics do not always succeed in designing ways to deliver extended-release formulations, and the FDA has been slow to act on this.

The 300-mg formulation of extended-release bupropion made by Impax Laboratories was pulled from the market in October after an FDA analysis found that it was not therapeutically equivalent to Wellbutrin XL 300 mg.

Source:  New York Times


Low-Dose Steroids in Sepsis Are Associated with Increased In-Hospital Mortality.

This study from the Surviving Sepsis Campaign does not support use of steroids in septic shock.

Research has provided conflicting results regarding the benefit of steroids in septic shock. As part of the Surviving Sepsis Campaign, investigators analyzed data from 17,847 patients who were eligible for low-dose steroids because they required vasopressor therapy after fluid resuscitation. Eligible patients had at least two systemic inflammatory response syndrome criteria, at least one organ dysfunction criterion, and a suspected site of infection.

Just over half of patients received low-dose steroids (50 mg intravenously four times per day or 100 mg three times per day), most within 8 hours of presentation. Patients in Europe and South America were more likely to receive steroids than those in North America (59%, 52%, and 46%, respectively). Patients with pneumonia and those on mechanical ventilation were more likely to receive steroids than their counterparts.

Hospital mortality was significantly higher in patients who received low-dose steroids than in those who did not (41% vs. 35%; adjusted odds ratio, 1.18).

Comment: Although some patients with sepsis have diminished response to exogenous corticotropin despite normal glucocorticoid levels, this observational study shows that administering steroids to septic patients does not improve outcomes and is not indicated.

Source: Journal Watch Emergency Medicine.

Rapid Influenza Diagnostic Tests: Negative Results Might Not Exclude Infection.

Rapid diagnostic tests for influenza provide variable results and might not detect virus at low concentrations, according to a CDC analysis in MMWR.

Researchers evaluated the performance of 11 FDA-approved rapid influenza diagnostic tests for detecting 23 recently circulating influenza viruses, each at 5 concentrations. Most tests detected virus at the highest concentration, but detection at lower concentrations varied by test and virus type.

“Negative RIDT test results might not exclude influenza virus infection in patients with signs and symptoms suggestive of influenza,” MMWR‘s editors write. They advise clinicians not to use a negative test result as a reason to withhold indicated antiviral treatment from patients with suspected influenza. In addition, they recommend collecting respiratory specimens within 24 to 72 hours after symptom onset, when virus concentrations are highest.

Source: MMWR


Proton-Pump Inhibitor Use and Risk for Community-Acquired Pneumonia.

In patients with community-acquired pneumonia, PPI use was associated with a twofold increased risk for infection with oropharyngeal bacteria but not other pathogenic agents.

The decrease in gastric acidity that results from treatment with proton-pump inhibitors (PPIs) has been linked with bacterial colonization of the stomach and outcomes such as nosocomial pneumonia in the inpatient setting (Ann Intern Med 1994; 120:653) and community-acquired pneumonia (CAP; JAMA 2004; 292:1955).

To further investigate the possible link between PPI use and CAP, investigators prospectively assessed PPI use and microbiological etiology of pneumonia in patients treated for CAP in the emergency room of a large general hospital in the Netherlands. A diagnosis of CAP was based on symptoms and radiographic findings. Microbiological etiology of the pneumonia infection was assessed using sputum and blood cultures, urine antigen tests, and serum antibody tests. Relevant demographic and clinical covariates (e.g., medication use, comorbidities, severity of illness) and treatment outcomes (e.g., length of hospital stay, in-hospital mortality) were assessed.

Of 463 patients with CAP, 29% were using PPIs. The cause of pneumonia in PPI users was more likely to be oral flora than in nonusers (adjusted odds ratio, 2.0; 95% confidence interval, 1.22–3.72). PPI users were more likely than nonusers to be infected with Streptococcus pneumoniae (28% vs. 14%; adjusted OR, 2.23; 95% CI, 1.28–3.75) and had a lower rate of infection with Coxiella burnetii than nonusers (8% vs. 19%), which was not significant after adjustment for covariates. PPI use was not associated with any other pathogens. CAP severity, length of hospital stay, and in-hospital mortality did not differ between PPI users and nonusers.

The authors conclude that PPI use doubles the risk for CAP, possibly from infection with oropharyngeal flora, including S. pneumoniae.

Comment: This study confirms the previously observed increased risk for developing pneumonia from oropharyngeal bacteria in patients with reduced gastric acid. However, in the absence of a controlled study design, a possible mechanism for causality cannot be determined. We can only conclude that in this cohort of patients with CAP, oropharyngeal bacteria — specifically S. pneumoniae — were more common pathogens in PPI users than in nonusers. PPI users in this study had more comorbidities and poorer baseline lung function than the comparison group, suggesting that despite the attempt to control for comorbidities, other factors might have also contributed to the observed difference in risk for CAP.

Source: Journal Watch Gastroenterology


HPV Testing Plus Cytology Might Be Best Follow-Up After Treating CIN .

Two BMJ studies call into question current follow-up strategies after cervical intraepithelial neoplasia treatment, suggesting that combined human papillomavirus testing and cytology can result in an earlier return to routine screening.

In the first, using a Dutch national registry, researchers found that women treated for CIN grades 1–3 who completed follow-up screening based on cytology alone (at 6, 12, and 24 months) still had a fourfold increased risk for cervical cancer than those with normal primary cytology results.

In the second study, researchers developed a mathematical model comparing three follow-up strategies after CIN treatment. They found that an approach in which women underwent both cytology and HPV testing at 6 months — with a negative HPV test meaning a return to routine screening — was more cost-effective and averted more cases of CIN3+ than did annual cytology performed alone for 10 years.

Editorialists, citing these and previous studies, conclude: “Short term monitoring post-treatment of women with combined HPV testing and cytology at 6 months and 24 months seems to be sufficient to detect post-treatment cervical disease.”

In the U.S., current guidelines call for annual cytology for 20 years after high-grade CIN treatment.

Source:  BMJ