Jennie Smith

The cost burden of chronic obstructive pulmonary disease increased significantly between 2000 and 2010 in British Columbia, according to results from a Canadian cohort study.

Hospitalization – and the fact that more COPD patients were diagnosed in the hospital rather than in community settings – appeared to be the primary driver of excess costs in COPD patients, which were about $5,452 more per patient-year than for a matched comparison cohort of people without COPD. (Note: All dollar amounts are in Canadian dollars, which were valued at 95% of the U.S. dollar in 2010).

©designer491/Thinkstockphotos.com

Excess costs related to COPD increased by $296 per person year (P less than .01) over the course of the study, with hospital costs accounting for the great majority, increasing by $258 per person-year (P less than .01).

Inpatient costs accounted for more than half (57%) of total excess COPD-related costs recorded, with more than 40% of people in the COPD cohort diagnosed after hospital admission.

The study authors, led by Amir Khakban, M.Sc, of the University of British Colombia in Vancouver, suggested that low rates of spirometry use and limited awareness of COPD among community practitioners were the key factors leading to more hospitalizations over the course of a decade, and consequently to higher costs.

For their research, published in the September issue of CHEST (2015;148[3]:640-46), Mr. Khakban and colleagues used health care billing records from 153,570 COPD patients in British Columbia along with 246,801 age- and sex-matched controls identified in the same government database. Mean age at entry was 66.9 years for both cohorts, and slightly under half of the patients were women.

COPD is a known contributor to high medical costs, due to disease exacerbations that require hospitalization, and has long been recognized in Canada and elsewhere as a leading cause of hospitalization (Respir Med. 2003;97[suppl C]:S23-S31). However, Mr. Khakban and colleagues’ study showed a rapid cost increase over a 10-year period, with costs 38% higher in 2010 than in 2001.

Compared with hospital-related costs (at 57%), outpatient, medication, and community care costs accounted for 16%, 22%, and 5%, respectively, of the excess costs seen among COPD patients in the study.

“Despite improvements, current disease management and care standards seem to be far from optimal and are not likely making any major impact,” the investigators wrote in their analysis. “This is especially evident in the high and growing rate of hospitalization as a major determinant of the burden of COPD.”

Mr. Khakban and colleagues noted that their findings likely represent an underestimate of the true cost burden of COPD, as reliance on narrow definitions from medical billing records means many cases were likely to have been missed. Also, they noted, the database used did not capture information on lung function or smoking, so costs could not be further analyzed according to disease severity or smoking status.

“In addition, not all components of direct costs are captured in the administrative health data. For example, costs of nonprescription medication or devices, and costs of complementary and alternative care are not captured in our results.”

The study was funded by the Institute for Heart + Lung Health, Genome Canada, St. Paul’s Hospital Foundation, PROOF Centre, the National Sanitarium Association, and the Canadian Respiratory Research Network. One coauthor, Carlo Marra, Pharm.D., disclosed financial relationships with GlaxoSmithKline, Pfizer and Abbvie.

The cost burden of chronic obstructive pulmonary disease increased significantly between 2000 and 2010 in British Columbia, according to results from a Canadian cohort study.

Hospitalization – and the fact that more COPD patients were diagnosed in the hospital rather than in community settings – appeared to be the primary driver of excess costs in COPD patients, which were about $5,452 more per patient-year than for a matched comparison cohort of people without COPD. (Note: All dollar amounts are in Canadian dollars, which were valued at 95% of the U.S. dollar in 2010).

©designer491/Thinkstockphotos.com

Excess costs related to COPD increased by $296 per person year (P less than .01) over the course of the study, with hospital costs accounting for the great majority, increasing by $258 per person-year (P less than .01).

Inpatient costs accounted for more than half (57%) of total excess COPD-related costs recorded, with more than 40% of people in the COPD cohort diagnosed after hospital admission.

The study authors, led by Amir Khakban, M.Sc, of the University of British Colombia in Vancouver, suggested that low rates of spirometry use and limited awareness of COPD among community practitioners were the key factors leading to more hospitalizations over the course of a decade, and consequently to higher costs.

For their research, published in the September issue of CHEST (2015;148[3]:640-46), Mr. Khakban and colleagues used health care billing records from 153,570 COPD patients in British Columbia along with 246,801 age- and sex-matched controls identified in the same government database. Mean age at entry was 66.9 years for both cohorts, and slightly under half of the patients were women.

COPD is a known contributor to high medical costs, due to disease exacerbations that require hospitalization, and has long been recognized in Canada and elsewhere as a leading cause of hospitalization (Respir Med. 2003;97[suppl C]:S23-S31). However, Mr. Khakban and colleagues’ study showed a rapid cost increase over a 10-year period, with costs 38% higher in 2010 than in 2001.

Compared with hospital-related costs (at 57%), outpatient, medication, and community care costs accounted for 16%, 22%, and 5%, respectively, of the excess costs seen among COPD patients in the study.

“Despite improvements, current disease management and care standards seem to be far from optimal and are not likely making any major impact,” the investigators wrote in their analysis. “This is especially evident in the high and growing rate of hospitalization as a major determinant of the burden of COPD.”

Mr. Khakban and colleagues noted that their findings likely represent an underestimate of the true cost burden of COPD, as reliance on narrow definitions from medical billing records means many cases were likely to have been missed. Also, they noted, the database used did not capture information on lung function or smoking, so costs could not be further analyzed according to disease severity or smoking status.

“In addition, not all components of direct costs are captured in the administrative health data. For example, costs of nonprescription medication or devices, and costs of complementary and alternative care are not captured in our results.”

The study was funded by the Institute for Heart + Lung Health, Genome Canada, St. Paul’s Hospital Foundation, PROOF Centre, the National Sanitarium Association, and the Canadian Respiratory Research Network. One coauthor, Carlo Marra, Pharm.D., disclosed financial relationships with GlaxoSmithKline, Pfizer and Abbvie.

The cost burden of chronic obstructive pulmonary disease increased significantly between 2000 and 2010 in British Columbia, according to results from a Canadian cohort study.

Hospitalization – and the fact that more COPD patients were diagnosed in the hospital rather than in community settings – appeared to be the primary driver of excess costs in COPD patients, which were about $5,452 more per patient-year than for a matched comparison cohort of people without COPD. (Note: All dollar amounts are in Canadian dollars, which were valued at 95% of the U.S. dollar in 2010).

©designer491/Thinkstockphotos.com

Excess costs related to COPD increased by $296 per person year (P less than .01) over the course of the study, with hospital costs accounting for the great majority, increasing by $258 per person-year (P less than .01).

Inpatient costs accounted for more than half (57%) of total excess COPD-related costs recorded, with more than 40% of people in the COPD cohort diagnosed after hospital admission.

The study authors, led by Amir Khakban, M.Sc, of the University of British Colombia in Vancouver, suggested that low rates of spirometry use and limited awareness of COPD among community practitioners were the key factors leading to more hospitalizations over the course of a decade, and consequently to higher costs.

For their research, published in the September issue of CHEST (2015;148[3]:640-46), Mr. Khakban and colleagues used health care billing records from 153,570 COPD patients in British Columbia along with 246,801 age- and sex-matched controls identified in the same government database. Mean age at entry was 66.9 years for both cohorts, and slightly under half of the patients were women.

COPD is a known contributor to high medical costs, due to disease exacerbations that require hospitalization, and has long been recognized in Canada and elsewhere as a leading cause of hospitalization (Respir Med. 2003;97[suppl C]:S23-S31). However, Mr. Khakban and colleagues’ study showed a rapid cost increase over a 10-year period, with costs 38% higher in 2010 than in 2001.

Compared with hospital-related costs (at 57%), outpatient, medication, and community care costs accounted for 16%, 22%, and 5%, respectively, of the excess costs seen among COPD patients in the study.

“Despite improvements, current disease management and care standards seem to be far from optimal and are not likely making any major impact,” the investigators wrote in their analysis. “This is especially evident in the high and growing rate of hospitalization as a major determinant of the burden of COPD.”

Mr. Khakban and colleagues noted that their findings likely represent an underestimate of the true cost burden of COPD, as reliance on narrow definitions from medical billing records means many cases were likely to have been missed. Also, they noted, the database used did not capture information on lung function or smoking, so costs could not be further analyzed according to disease severity or smoking status.

“In addition, not all components of direct costs are captured in the administrative health data. For example, costs of nonprescription medication or devices, and costs of complementary and alternative care are not captured in our results.”

The study was funded by the Institute for Heart + Lung Health, Genome Canada, St. Paul’s Hospital Foundation, PROOF Centre, the National Sanitarium Association, and the Canadian Respiratory Research Network. One coauthor, Carlo Marra, Pharm.D., disclosed financial relationships with GlaxoSmithKline, Pfizer and Abbvie.

More than one-tenth of Americans were current users of illicit drugs in 2014, and drug use among adults – marijuana in particular – was on the rise.

An estimated 27 million people, or 10.2% of Americans, used an illicit drug within the previous month, according to the 2014 National Survey on Drug Use and Health (NSDUH), released Sept. 10 by the Substance Abuse and Mental Health Services Administration (SAMHSA).

©Thinkstock.com

About 22 million of those people used marijuana within the previous month, and 4.3 million took prescription pain relievers for nonmedical purposes.

Some 8.4% of Americans aged 12 and older reported current marijuana use, an increase from previous survey years, and 1.6% reported current nonmedical use of pain drugs, a trend that has remained fairly steady, according to the survey.

A significant uptick in nonmedical use of marijuana was seen among adults aged 26 and older, Kana Enomoto, SAMHSA’s acting administrator, said at a Sept. 10 news conference.

Some 6.6% of these adults, or about 13.5 million people, reported being users of marijuana last year, compared with 5.6% in 2013 (P less than .5). Steady increases in marijuana use in this age group have been noted for about a decade.

Heroin use also was higher than in previous years, with an estimated 435,000 users in the United States in 2014, a statistically significant jump from 0.1% of the population aged 12 and older in 2013 to 0.2% last year, with most of the increase driven by people 26 and older.

An estimated 1.5 million Americans, or 0.6% of the population aged 12 and older, were current users of cocaine, including some 354,000 current users of crack cocaine. Cocaine use was similar to patterns seen in recent years.

Overall, current illicit drug use trends appeared to be holding steady or declining in younger age groups, but the increases in adult use are “concerning,” particularly for heroin, said Ms. Enomoto.

Recent declines in alcohol and tobacco use among young people appeared to be holding up. Among adolescents aged 12-17, 4.9% had smoked cigarettes in the previous month, down from 5.6% in 2013 and 6.6% in 2012.

Alcohol use and use patterns among young people were little changed from 2013, and overall incidence of substance use disorders hovered at 8.1% for 2014 among people 12 and older.

The incidence of mental health disorders, including any mental illness and serious mental illness (18.1% and 4.1% of adults over 18, respectively), remained little changed from recent years. Co-occurring mental illness and substance use disorders were at 3.3% of all adults, similar to rates seen since 2006.

The NSDUH data were collected through face-to-face interviews with nearly 68,000 Americans in 2014.

More than one-tenth of Americans were current users of illicit drugs in 2014, and drug use among adults – marijuana in particular – was on the rise.

An estimated 27 million people, or 10.2% of Americans, used an illicit drug within the previous month, according to the 2014 National Survey on Drug Use and Health (NSDUH), released Sept. 10 by the Substance Abuse and Mental Health Services Administration (SAMHSA).

©Thinkstock.com

About 22 million of those people used marijuana within the previous month, and 4.3 million took prescription pain relievers for nonmedical purposes.

Some 8.4% of Americans aged 12 and older reported current marijuana use, an increase from previous survey years, and 1.6% reported current nonmedical use of pain drugs, a trend that has remained fairly steady, according to the survey.

A significant uptick in nonmedical use of marijuana was seen among adults aged 26 and older, Kana Enomoto, SAMHSA’s acting administrator, said at a Sept. 10 news conference.

Some 6.6% of these adults, or about 13.5 million people, reported being users of marijuana last year, compared with 5.6% in 2013 (P less than .5). Steady increases in marijuana use in this age group have been noted for about a decade.

Heroin use also was higher than in previous years, with an estimated 435,000 users in the United States in 2014, a statistically significant jump from 0.1% of the population aged 12 and older in 2013 to 0.2% last year, with most of the increase driven by people 26 and older.

An estimated 1.5 million Americans, or 0.6% of the population aged 12 and older, were current users of cocaine, including some 354,000 current users of crack cocaine. Cocaine use was similar to patterns seen in recent years.

Overall, current illicit drug use trends appeared to be holding steady or declining in younger age groups, but the increases in adult use are “concerning,” particularly for heroin, said Ms. Enomoto.

Recent declines in alcohol and tobacco use among young people appeared to be holding up. Among adolescents aged 12-17, 4.9% had smoked cigarettes in the previous month, down from 5.6% in 2013 and 6.6% in 2012.

Alcohol use and use patterns among young people were little changed from 2013, and overall incidence of substance use disorders hovered at 8.1% for 2014 among people 12 and older.

The incidence of mental health disorders, including any mental illness and serious mental illness (18.1% and 4.1% of adults over 18, respectively), remained little changed from recent years. Co-occurring mental illness and substance use disorders were at 3.3% of all adults, similar to rates seen since 2006.

The NSDUH data were collected through face-to-face interviews with nearly 68,000 Americans in 2014.

More than one-tenth of Americans were current users of illicit drugs in 2014, and drug use among adults – marijuana in particular – was on the rise.

An estimated 27 million people, or 10.2% of Americans, used an illicit drug within the previous month, according to the 2014 National Survey on Drug Use and Health (NSDUH), released Sept. 10 by the Substance Abuse and Mental Health Services Administration (SAMHSA).

©Thinkstock.com

About 22 million of those people used marijuana within the previous month, and 4.3 million took prescription pain relievers for nonmedical purposes.

Some 8.4% of Americans aged 12 and older reported current marijuana use, an increase from previous survey years, and 1.6% reported current nonmedical use of pain drugs, a trend that has remained fairly steady, according to the survey.

A significant uptick in nonmedical use of marijuana was seen among adults aged 26 and older, Kana Enomoto, SAMHSA’s acting administrator, said at a Sept. 10 news conference.

Some 6.6% of these adults, or about 13.5 million people, reported being users of marijuana last year, compared with 5.6% in 2013 (P less than .5). Steady increases in marijuana use in this age group have been noted for about a decade.

Heroin use also was higher than in previous years, with an estimated 435,000 users in the United States in 2014, a statistically significant jump from 0.1% of the population aged 12 and older in 2013 to 0.2% last year, with most of the increase driven by people 26 and older.

An estimated 1.5 million Americans, or 0.6% of the population aged 12 and older, were current users of cocaine, including some 354,000 current users of crack cocaine. Cocaine use was similar to patterns seen in recent years.

Overall, current illicit drug use trends appeared to be holding steady or declining in younger age groups, but the increases in adult use are “concerning,” particularly for heroin, said Ms. Enomoto.

Recent declines in alcohol and tobacco use among young people appeared to be holding up. Among adolescents aged 12-17, 4.9% had smoked cigarettes in the previous month, down from 5.6% in 2013 and 6.6% in 2012.

Alcohol use and use patterns among young people were little changed from 2013, and overall incidence of substance use disorders hovered at 8.1% for 2014 among people 12 and older.

The incidence of mental health disorders, including any mental illness and serious mental illness (18.1% and 4.1% of adults over 18, respectively), remained little changed from recent years. Co-occurring mental illness and substance use disorders were at 3.3% of all adults, similar to rates seen since 2006.

The NSDUH data were collected through face-to-face interviews with nearly 68,000 Americans in 2014.

Patients with psoriasis are at increased risk of arrhythmia, with the risk even greater for younger patients and those with psoriatic arthritis, according to a population-based cohort study conducted in Taiwan.

Dr. Hsien-Yi Chiu of National Taiwan University and Wei-Lun Chang of National Yang-Ming University, both in Taipei, and their colleagues, looked at records from 40,637 patients diagnosed with psoriasis and 162,548 age- and sex-matched controls without psoriasis, over a mean follow-up of about 6 years, for the incidence of arrhythmias over a mean of 6 years.

© Schlegelfotos/iStockphoto

In an article published in the September issue of the Journal of the American Academy of Dermatology, the investigators reported that those patients with psoriasis were at a significantly higher risk of developing arrhythmia, independent of traditional cardiovascular risk factors (adjusted hazard ratio, 1.34; 95% confidence interval, 1.29-1.39). Increased risk for patients with mild disease (aHR,1.35; 95% CI, 1.30-1.41) was comparable to that of patients with severe disease (aHR, 1.25; 95% CI 1.12-1.39) and more pronounced in the subgroup of patients with psoriatic arthritis (aHR, 1.46; 95% CI, 1.22-1.74). Younger patients, between aged 20 and 39 years, were at a higher risk (aHR, 1.39; 95% CI, 1.26-1.54) than older patients in the cohort (J Am Acad Dermatol. 2015 Sep;73:429-38).

Although previous studies have shown severe psoriasis to be associated with a nearly 60% increase in cardiovascular morbidity and mortality beyond traditional risk factors, less is known about arrhythmias specifically. “Inflammation may contribute to the alteration of cardiomyocyte electrophysiology, such as dysregulation of ion channel function, leading to increased risk of arrhythmia,” the investigators wrote.

The authors noted that limitations of their study were the potential surveillance bias for psoriasis patients due to increased hospital visits, and the fact that alcohol and tobacco use was not captured in the patient data. Treatment with systemic therapies may lower cardiovascular risk in psoriasis patients, they added, which may have explained why the arrhythmia risk among patients with severe disease was similar to those with mild disease.

The findings indicate “that psoriasis can be added to future risk-stratification scores for arrhythmia,” the investigators wrote, adding that patients with psoriasis, “especially young patients and those with PsA [psoriatic arthritis] , should be more closely screened for various types of arrhythmia,” with the hope of earlier intervention leading to reduction of cardiovascular morbidity and mortality.

Patients with psoriasis are at increased risk of arrhythmia, with the risk even greater for younger patients and those with psoriatic arthritis, according to a population-based cohort study conducted in Taiwan.

Dr. Hsien-Yi Chiu of National Taiwan University and Wei-Lun Chang of National Yang-Ming University, both in Taipei, and their colleagues, looked at records from 40,637 patients diagnosed with psoriasis and 162,548 age- and sex-matched controls without psoriasis, over a mean follow-up of about 6 years, for the incidence of arrhythmias over a mean of 6 years.

© Schlegelfotos/iStockphoto

In an article published in the September issue of the Journal of the American Academy of Dermatology, the investigators reported that those patients with psoriasis were at a significantly higher risk of developing arrhythmia, independent of traditional cardiovascular risk factors (adjusted hazard ratio, 1.34; 95% confidence interval, 1.29-1.39). Increased risk for patients with mild disease (aHR,1.35; 95% CI, 1.30-1.41) was comparable to that of patients with severe disease (aHR, 1.25; 95% CI 1.12-1.39) and more pronounced in the subgroup of patients with psoriatic arthritis (aHR, 1.46; 95% CI, 1.22-1.74). Younger patients, between aged 20 and 39 years, were at a higher risk (aHR, 1.39; 95% CI, 1.26-1.54) than older patients in the cohort (J Am Acad Dermatol. 2015 Sep;73:429-38).

Although previous studies have shown severe psoriasis to be associated with a nearly 60% increase in cardiovascular morbidity and mortality beyond traditional risk factors, less is known about arrhythmias specifically. “Inflammation may contribute to the alteration of cardiomyocyte electrophysiology, such as dysregulation of ion channel function, leading to increased risk of arrhythmia,” the investigators wrote.

The authors noted that limitations of their study were the potential surveillance bias for psoriasis patients due to increased hospital visits, and the fact that alcohol and tobacco use was not captured in the patient data. Treatment with systemic therapies may lower cardiovascular risk in psoriasis patients, they added, which may have explained why the arrhythmia risk among patients with severe disease was similar to those with mild disease.

The findings indicate “that psoriasis can be added to future risk-stratification scores for arrhythmia,” the investigators wrote, adding that patients with psoriasis, “especially young patients and those with PsA [psoriatic arthritis] , should be more closely screened for various types of arrhythmia,” with the hope of earlier intervention leading to reduction of cardiovascular morbidity and mortality.

Patients with psoriasis are at increased risk of arrhythmia, with the risk even greater for younger patients and those with psoriatic arthritis, according to a population-based cohort study conducted in Taiwan.

Dr. Hsien-Yi Chiu of National Taiwan University and Wei-Lun Chang of National Yang-Ming University, both in Taipei, and their colleagues, looked at records from 40,637 patients diagnosed with psoriasis and 162,548 age- and sex-matched controls without psoriasis, over a mean follow-up of about 6 years, for the incidence of arrhythmias over a mean of 6 years.

© Schlegelfotos/iStockphoto

In an article published in the September issue of the Journal of the American Academy of Dermatology, the investigators reported that those patients with psoriasis were at a significantly higher risk of developing arrhythmia, independent of traditional cardiovascular risk factors (adjusted hazard ratio, 1.34; 95% confidence interval, 1.29-1.39). Increased risk for patients with mild disease (aHR,1.35; 95% CI, 1.30-1.41) was comparable to that of patients with severe disease (aHR, 1.25; 95% CI 1.12-1.39) and more pronounced in the subgroup of patients with psoriatic arthritis (aHR, 1.46; 95% CI, 1.22-1.74). Younger patients, between aged 20 and 39 years, were at a higher risk (aHR, 1.39; 95% CI, 1.26-1.54) than older patients in the cohort (J Am Acad Dermatol. 2015 Sep;73:429-38).

Although previous studies have shown severe psoriasis to be associated with a nearly 60% increase in cardiovascular morbidity and mortality beyond traditional risk factors, less is known about arrhythmias specifically. “Inflammation may contribute to the alteration of cardiomyocyte electrophysiology, such as dysregulation of ion channel function, leading to increased risk of arrhythmia,” the investigators wrote.

The authors noted that limitations of their study were the potential surveillance bias for psoriasis patients due to increased hospital visits, and the fact that alcohol and tobacco use was not captured in the patient data. Treatment with systemic therapies may lower cardiovascular risk in psoriasis patients, they added, which may have explained why the arrhythmia risk among patients with severe disease was similar to those with mild disease.

The findings indicate “that psoriasis can be added to future risk-stratification scores for arrhythmia,” the investigators wrote, adding that patients with psoriasis, “especially young patients and those with PsA [psoriatic arthritis] , should be more closely screened for various types of arrhythmia,” with the hope of earlier intervention leading to reduction of cardiovascular morbidity and mortality.

Patients with psoriasis are at increased risk of arrhythmia, with the risk even greater for younger patients and those with psoriatic arthritis, according to a population-based cohort study conducted in Taiwan.

Dr. Hsien-Yi Chiu of National Taiwan University and Wei-Lun Chang of National Yang-Ming University, both in Taipei, and their colleagues, looked at records from 40,637 patients diagnosed with psoriasis and 162,548 age- and sex-matched controls without psoriasis, over a mean follow-up of about 6 years, for the incidence of arrhythmias over a mean of 6 years.

© Schlegelfotos/iStockphoto

In an article published in the September issue of the Journal of the American Academy of Dermatology, the investigators reported that those patients with psoriasis were at a significantly higher risk of developing arrhythmia, independent of traditional cardiovascular risk factors (adjusted hazard ratio, 1.34; 95% confidence interval, 1.29-1.39). Increased risk for patients with mild disease (aHR,1.35; 95% CI, 1.30-1.41) was comparable to that of patients with severe disease (aHR, 1.25; 95% CI 1.12-1.39) and more pronounced in the subgroup of patients with psoriatic arthritis (aHR, 1.46; 95% CI, 1.22-1.74). Younger patients, between aged 20 and 39 years, were at a higher risk (aHR, 1.39; 95% CI, 1.26-1.54) than older patients in the cohort (J Am Acad Dermatol. 2015 Sep;73:429-38).

Although previous studies have shown severe psoriasis to be associated with a nearly 60% increase in cardiovascular morbidity and mortality beyond traditional risk factors, less is known about arrhythmias specifically. “Inflammation may contribute to the alteration of cardiomyocyte electrophysiology, such as dysregulation of ion channel function, leading to increased risk of arrhythmia,” the investigators wrote.

The authors noted that limitations of their study were the potential surveillance bias for psoriasis patients due to increased hospital visits, and the fact that alcohol and tobacco use was not captured in the patient data. Treatment with systemic therapies may lower cardiovascular risk in psoriasis patients, they added, which may have explained why the arrhythmia risk among patients with severe disease was similar to those with mild disease.

The findings indicate “that psoriasis can be added to future risk-stratification scores for arrhythmia,” the investigators wrote, adding that patients with psoriasis, “especially young patients and those with PsA [psoriatic arthritis] , should be more closely screened for various types of arrhythmia,” with the hope of earlier intervention leading to reduction of cardiovascular morbidity and mortality.

Patients with psoriasis are at increased risk of arrhythmia, with the risk even greater for younger patients and those with psoriatic arthritis, according to a population-based cohort study conducted in Taiwan.

Dr. Hsien-Yi Chiu of National Taiwan University and Wei-Lun Chang of National Yang-Ming University, both in Taipei, and their colleagues, looked at records from 40,637 patients diagnosed with psoriasis and 162,548 age- and sex-matched controls without psoriasis, over a mean follow-up of about 6 years, for the incidence of arrhythmias over a mean of 6 years.

© Schlegelfotos/iStockphoto

In an article published in the September issue of the Journal of the American Academy of Dermatology, the investigators reported that those patients with psoriasis were at a significantly higher risk of developing arrhythmia, independent of traditional cardiovascular risk factors (adjusted hazard ratio, 1.34; 95% confidence interval, 1.29-1.39). Increased risk for patients with mild disease (aHR,1.35; 95% CI, 1.30-1.41) was comparable to that of patients with severe disease (aHR, 1.25; 95% CI 1.12-1.39) and more pronounced in the subgroup of patients with psoriatic arthritis (aHR, 1.46; 95% CI, 1.22-1.74). Younger patients, between aged 20 and 39 years, were at a higher risk (aHR, 1.39; 95% CI, 1.26-1.54) than older patients in the cohort (J Am Acad Dermatol. 2015 Sep;73:429-38).

Although previous studies have shown severe psoriasis to be associated with a nearly 60% increase in cardiovascular morbidity and mortality beyond traditional risk factors, less is known about arrhythmias specifically. “Inflammation may contribute to the alteration of cardiomyocyte electrophysiology, such as dysregulation of ion channel function, leading to increased risk of arrhythmia,” the investigators wrote.

The authors noted that limitations of their study were the potential surveillance bias for psoriasis patients due to increased hospital visits, and the fact that alcohol and tobacco use was not captured in the patient data. Treatment with systemic therapies may lower cardiovascular risk in psoriasis patients, they added, which may have explained why the arrhythmia risk among patients with severe disease was similar to those with mild disease.

The findings indicate “that psoriasis can be added to future risk-stratification scores for arrhythmia,” the investigators wrote, adding that patients with psoriasis, “especially young patients and those with PsA [psoriatic arthritis] , should be more closely screened for various types of arrhythmia,” with the hope of earlier intervention leading to reduction of cardiovascular morbidity and mortality.

Patients with psoriasis are at increased risk of arrhythmia, with the risk even greater for younger patients and those with psoriatic arthritis, according to a population-based cohort study conducted in Taiwan.

Dr. Hsien-Yi Chiu of National Taiwan University and Wei-Lun Chang of National Yang-Ming University, both in Taipei, and their colleagues, looked at records from 40,637 patients diagnosed with psoriasis and 162,548 age- and sex-matched controls without psoriasis, over a mean follow-up of about 6 years, for the incidence of arrhythmias over a mean of 6 years.

© Schlegelfotos/iStockphoto

In an article published in the September issue of the Journal of the American Academy of Dermatology, the investigators reported that those patients with psoriasis were at a significantly higher risk of developing arrhythmia, independent of traditional cardiovascular risk factors (adjusted hazard ratio, 1.34; 95% confidence interval, 1.29-1.39). Increased risk for patients with mild disease (aHR,1.35; 95% CI, 1.30-1.41) was comparable to that of patients with severe disease (aHR, 1.25; 95% CI 1.12-1.39) and more pronounced in the subgroup of patients with psoriatic arthritis (aHR, 1.46; 95% CI, 1.22-1.74). Younger patients, between aged 20 and 39 years, were at a higher risk (aHR, 1.39; 95% CI, 1.26-1.54) than older patients in the cohort (J Am Acad Dermatol. 2015 Sep;73:429-38).

Although previous studies have shown severe psoriasis to be associated with a nearly 60% increase in cardiovascular morbidity and mortality beyond traditional risk factors, less is known about arrhythmias specifically. “Inflammation may contribute to the alteration of cardiomyocyte electrophysiology, such as dysregulation of ion channel function, leading to increased risk of arrhythmia,” the investigators wrote.

The authors noted that limitations of their study were the potential surveillance bias for psoriasis patients due to increased hospital visits, and the fact that alcohol and tobacco use was not captured in the patient data. Treatment with systemic therapies may lower cardiovascular risk in psoriasis patients, they added, which may have explained why the arrhythmia risk among patients with severe disease was similar to those with mild disease.

The findings indicate “that psoriasis can be added to future risk-stratification scores for arrhythmia,” the investigators wrote, adding that patients with psoriasis, “especially young patients and those with PsA [psoriatic arthritis] , should be more closely screened for various types of arrhythmia,” with the hope of earlier intervention leading to reduction of cardiovascular morbidity and mortality.

SAN ANTONIO – Alarm fatigue, the desensitization that can occur when clinicians are exposed to an excessive number of nonactionable clinical alarms, is an urgent concern for pediatric hospitalists, who are studying the phenomenon in both intensive care and ward settings, according to Dr. Christopher P. Bonafide.

This year the ECRI Institute named alarm fatigue the top health technology hazard of 2015. And a Joint Commission national patient safety goal, issued in 2014, demands that hospitals begin implementing alarm system management strategies by January 2016 to combat fatigue and other potential downstream consequences of being overwhelmed with alarms.

©praisaeng/Thinkstock.com

At the Pediatric Hospital Medicine 2015 meeting, Dr. Bonafide discussed ongoing work at his institution, the Children’s Hospital of Philadelphia, to pinpoint how and why alarm fatigue might be occurring there.

Dr. Bonafide and his colleagues evaluated data from in-room video cameras, bedside cardiorespiratory and pulse-oximetry monitors, and text messages communicating monitor alerts to nurses. They examined whether an alert was valid (consistent with the patient’s actual physiologic state) and actionable (meriting intervention or consultation), as well as how long it took nurses to respond.

The study was conducted during day shifts. Using data from about 5,000 alarms, and 210 hours of video from both the pediatric ward and the pediatric intensive care unit, the investigators found that 76% of alarms in the PICU were valid, and 13% were actionable. In the pediatric ward, 41% of alarms were valid, and only 1% were actionable.

Exposure to more nonactionable alarms was significantly correlated with longer response times to the patient’s bedside, Dr. Bonafide and his colleagues found. Overall, it took nurses exposed to more than 80 nonactionable alarms in the previous 2-hour period more than twice as long to respond to alarms than if they’d been exposed to 29 or fewer alarms in the preceding 2 hours (P less than .01).

“We think alarm fatigue is the most likely explanation for these findings,” Dr. Bonafide said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, the AAP Section on Hospital Medicine, and the Academic Pediatric Association. He noted that a larger study was underway to look more closely at other variables, such as the patient’s acuity and the nurse’s full patient load.

In an interview, Dr. Bonafide called bedside systems such as pulse oximetry and heart rate monitoring “some of the most powerful tools we have” to detect deterioration in the hospital. But a high signal-to-noise ratio can make them “essentially useless,” he said. “They fade into the background.”

Improving alarm systems “is about making alarms less of an every-minute occurrence by improving that signal-to-noise ratio so that when that alarm buzzes, it is a good decision to interrupt what you’re doing and check on the patient to figure out what’s going on,” he said.

Some of the possible solutions to keep alarms rarer include establishing more precise heart rate and respiratory norms for pediatric patients, and adjusting the thresholds for monitoring. “We would love it if for every patient, when that alarm goes off it’s already set to a point where it’s actionable,” he said.

While Dr. Bonafide has focused on measuring and understanding alarm fatigue to date, he said he and his team are “incredibly excited to begin focusing on what we can actually do to reduce nonactionable alarms and improve outcomes for patients.”

To address this, the investigators are conducting a cluster-randomized trial evaluating a data-driven dashboard that helps physicians and nurses identify alarm hot spots, and guides them through the best ways to intervene and reduce alarms.

What’s still lacking in the hospitalist community, Dr. Bonafide said, is “consensus around what is actionable.” This will require hospitalists to meet and talk about consensus guidelines on what constitutes an actionable pulse-oximetry or heart rate alarm, when it is appropriate to intervene, and when it is absolutely necessary to intervene.

Dr. Bonafide said he plans to begin developing a protocol for this work with collaborators from Cincinnati Children’s Hospital and Lucile Packard Children’s Hospital, Stanford, Calif.

“This has the potential to really help inform decision making on thousands of patients per day across the United States,” he said.

Dr. Bonafide’s study was funded by a grant from the Pennsylvania Department of Public Health Commonwealth Universal Research Enhancement Program. His team has received funding from the National Institutes of Health, the Academic Pediatric Association, and the Society of Hospital Medicine. He declared no conflicts of interest.

SAN ANTONIO – Alarm fatigue, the desensitization that can occur when clinicians are exposed to an excessive number of nonactionable clinical alarms, is an urgent concern for pediatric hospitalists, who are studying the phenomenon in both intensive care and ward settings, according to Dr. Christopher P. Bonafide.

This year the ECRI Institute named alarm fatigue the top health technology hazard of 2015. And a Joint Commission national patient safety goal, issued in 2014, demands that hospitals begin implementing alarm system management strategies by January 2016 to combat fatigue and other potential downstream consequences of being overwhelmed with alarms.

©praisaeng/Thinkstock.com

At the Pediatric Hospital Medicine 2015 meeting, Dr. Bonafide discussed ongoing work at his institution, the Children’s Hospital of Philadelphia, to pinpoint how and why alarm fatigue might be occurring there.

Dr. Bonafide and his colleagues evaluated data from in-room video cameras, bedside cardiorespiratory and pulse-oximetry monitors, and text messages communicating monitor alerts to nurses. They examined whether an alert was valid (consistent with the patient’s actual physiologic state) and actionable (meriting intervention or consultation), as well as how long it took nurses to respond.

The study was conducted during day shifts. Using data from about 5,000 alarms, and 210 hours of video from both the pediatric ward and the pediatric intensive care unit, the investigators found that 76% of alarms in the PICU were valid, and 13% were actionable. In the pediatric ward, 41% of alarms were valid, and only 1% were actionable.

Exposure to more nonactionable alarms was significantly correlated with longer response times to the patient’s bedside, Dr. Bonafide and his colleagues found. Overall, it took nurses exposed to more than 80 nonactionable alarms in the previous 2-hour period more than twice as long to respond to alarms than if they’d been exposed to 29 or fewer alarms in the preceding 2 hours (P less than .01).

“We think alarm fatigue is the most likely explanation for these findings,” Dr. Bonafide said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, the AAP Section on Hospital Medicine, and the Academic Pediatric Association. He noted that a larger study was underway to look more closely at other variables, such as the patient’s acuity and the nurse’s full patient load.

In an interview, Dr. Bonafide called bedside systems such as pulse oximetry and heart rate monitoring “some of the most powerful tools we have” to detect deterioration in the hospital. But a high signal-to-noise ratio can make them “essentially useless,” he said. “They fade into the background.”

Improving alarm systems “is about making alarms less of an every-minute occurrence by improving that signal-to-noise ratio so that when that alarm buzzes, it is a good decision to interrupt what you’re doing and check on the patient to figure out what’s going on,” he said.

Some of the possible solutions to keep alarms rarer include establishing more precise heart rate and respiratory norms for pediatric patients, and adjusting the thresholds for monitoring. “We would love it if for every patient, when that alarm goes off it’s already set to a point where it’s actionable,” he said.

While Dr. Bonafide has focused on measuring and understanding alarm fatigue to date, he said he and his team are “incredibly excited to begin focusing on what we can actually do to reduce nonactionable alarms and improve outcomes for patients.”

To address this, the investigators are conducting a cluster-randomized trial evaluating a data-driven dashboard that helps physicians and nurses identify alarm hot spots, and guides them through the best ways to intervene and reduce alarms.

What’s still lacking in the hospitalist community, Dr. Bonafide said, is “consensus around what is actionable.” This will require hospitalists to meet and talk about consensus guidelines on what constitutes an actionable pulse-oximetry or heart rate alarm, when it is appropriate to intervene, and when it is absolutely necessary to intervene.

Dr. Bonafide said he plans to begin developing a protocol for this work with collaborators from Cincinnati Children’s Hospital and Lucile Packard Children’s Hospital, Stanford, Calif.

“This has the potential to really help inform decision making on thousands of patients per day across the United States,” he said.

Dr. Bonafide’s study was funded by a grant from the Pennsylvania Department of Public Health Commonwealth Universal Research Enhancement Program. His team has received funding from the National Institutes of Health, the Academic Pediatric Association, and the Society of Hospital Medicine. He declared no conflicts of interest.

SAN ANTONIO – Alarm fatigue, the desensitization that can occur when clinicians are exposed to an excessive number of nonactionable clinical alarms, is an urgent concern for pediatric hospitalists, who are studying the phenomenon in both intensive care and ward settings, according to Dr. Christopher P. Bonafide.

This year the ECRI Institute named alarm fatigue the top health technology hazard of 2015. And a Joint Commission national patient safety goal, issued in 2014, demands that hospitals begin implementing alarm system management strategies by January 2016 to combat fatigue and other potential downstream consequences of being overwhelmed with alarms.

©praisaeng/Thinkstock.com

At the Pediatric Hospital Medicine 2015 meeting, Dr. Bonafide discussed ongoing work at his institution, the Children’s Hospital of Philadelphia, to pinpoint how and why alarm fatigue might be occurring there.

Dr. Bonafide and his colleagues evaluated data from in-room video cameras, bedside cardiorespiratory and pulse-oximetry monitors, and text messages communicating monitor alerts to nurses. They examined whether an alert was valid (consistent with the patient’s actual physiologic state) and actionable (meriting intervention or consultation), as well as how long it took nurses to respond.

The study was conducted during day shifts. Using data from about 5,000 alarms, and 210 hours of video from both the pediatric ward and the pediatric intensive care unit, the investigators found that 76% of alarms in the PICU were valid, and 13% were actionable. In the pediatric ward, 41% of alarms were valid, and only 1% were actionable.

Exposure to more nonactionable alarms was significantly correlated with longer response times to the patient’s bedside, Dr. Bonafide and his colleagues found. Overall, it took nurses exposed to more than 80 nonactionable alarms in the previous 2-hour period more than twice as long to respond to alarms than if they’d been exposed to 29 or fewer alarms in the preceding 2 hours (P less than .01).

“We think alarm fatigue is the most likely explanation for these findings,” Dr. Bonafide said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, the AAP Section on Hospital Medicine, and the Academic Pediatric Association. He noted that a larger study was underway to look more closely at other variables, such as the patient’s acuity and the nurse’s full patient load.

In an interview, Dr. Bonafide called bedside systems such as pulse oximetry and heart rate monitoring “some of the most powerful tools we have” to detect deterioration in the hospital. But a high signal-to-noise ratio can make them “essentially useless,” he said. “They fade into the background.”

Improving alarm systems “is about making alarms less of an every-minute occurrence by improving that signal-to-noise ratio so that when that alarm buzzes, it is a good decision to interrupt what you’re doing and check on the patient to figure out what’s going on,” he said.

Some of the possible solutions to keep alarms rarer include establishing more precise heart rate and respiratory norms for pediatric patients, and adjusting the thresholds for monitoring. “We would love it if for every patient, when that alarm goes off it’s already set to a point where it’s actionable,” he said.

While Dr. Bonafide has focused on measuring and understanding alarm fatigue to date, he said he and his team are “incredibly excited to begin focusing on what we can actually do to reduce nonactionable alarms and improve outcomes for patients.”

To address this, the investigators are conducting a cluster-randomized trial evaluating a data-driven dashboard that helps physicians and nurses identify alarm hot spots, and guides them through the best ways to intervene and reduce alarms.

What’s still lacking in the hospitalist community, Dr. Bonafide said, is “consensus around what is actionable.” This will require hospitalists to meet and talk about consensus guidelines on what constitutes an actionable pulse-oximetry or heart rate alarm, when it is appropriate to intervene, and when it is absolutely necessary to intervene.

Dr. Bonafide said he plans to begin developing a protocol for this work with collaborators from Cincinnati Children’s Hospital and Lucile Packard Children’s Hospital, Stanford, Calif.

“This has the potential to really help inform decision making on thousands of patients per day across the United States,” he said.

Dr. Bonafide’s study was funded by a grant from the Pennsylvania Department of Public Health Commonwealth Universal Research Enhancement Program. His team has received funding from the National Institutes of Health, the Academic Pediatric Association, and the Society of Hospital Medicine. He declared no conflicts of interest.

SAN ANTONIO – Current guidelines on community-acquired pneumonia recommend penicillin, amoxicillin, or ampicillin as first-line treatment in children with CAP.

However, a small minority will have Staphylococcus aureus infections not treatable with these antibiotics, raising some concern about how many of these cases might be missed.

©CDC/Janice Haney Carr

At the Pediatric Hospital Medicine 2015 meeting, Dr. Meghan E. Hofto of Children’s of Alabama at the University of Alabama, Birmingham, presented research from a study of 554 patients admitted to the hospital with community acquired pneumonia, including 78 patients with complicated pneumonia.

Seven patients in the cohort (1.3%) had S. aureus infections, Dr. Hofto and her colleagues found. Of those, six were recorded as having complicated pneumonia, characterized by pleural effusion or cavitation.

Six patients with S. aureus had been started on antibiotics in other health care settings prior to admission (amoxicillin n = 4, multiple agents n = 2). One patient positive for flu was first treated with oseltamavir only. However, all staph patients once admitted were started on vancomycin, which is effective against S. aureus, within 24 hours. Five were diagnosed by pleural fluid culture; one case was identified by clinical presentation, and another by sputum culture, Dr. Hofto said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, the AAP Section on Hospital Medicine, and the Academic Pediatric Association.

The S. aureus patients were younger than the cohort as a whole (median 18 months vs. 40.5 months). Length of stay was significantly longer for these patients, compared with the rest of the cohort (median 10 vs. 2 days, P less than .01), and S. aureus patients had significantly higher incidence of anemia (P less than .01), a finding that Dr. Hofto said was striking.

Within 24 hours of presentation, six out the seven staph cases had anemia, she said, while of all the 78 patients with complicated disease, 12 had anemia. Community acquired S. aureus pneumonia has been linked in other studies to severe leukopenia, Dr. Hofto noted (BMC Infect Dis. 2013;13:359) and (Paediatric Respiratory Reviews 2011 Sept;12:182-9).In an interview, Dr. Hofto said the findings supported current guidance in favor of first-line penicillin, amoxicillin, or ampicillin. “Part of what we’re looking at with guideline adherence is the barriers to treating with empiric narrow spectrum antibiotics – and obviously, one of the things people are concerned about is that are we going to miss something,” she said.

“I think we can pretty confidently say that if it’s uncomplicated CAP – if there’s no pleural effusion, no necrosis, no cavitation – you can treat with narrow spectrum, and the likelihood of it being staph is slim to none.”

If within 48 hours, patients are not responding to the first-line treatment, “you should start thinking about other causes,” Dr. Hofto said, noting that her review found all staph aureus patients were started on antibiotics effective against S. aureus – mostly vancomycin and ceftriaxone – within 24 hours of presentation.

Dr. Hofto noted as a limitation of her study, which used retrospective chart reviews of more than 3,400 children hospitalized for suspected pneumonia over a 3-year period, that additional S. aureus cases could have been missed because of a lack of proper coding or microbial confirmation. Another limitation was the single-site design and the relatively small number of S. aureus cases.

Dr. Hofto said she is conducting a more in-depth chart review ensure that no further cases of S. aureus CAP were missed in her sample.

The study received no outside funding, and Dr. Hofto disclosed no conflicts of interest.

SAN ANTONIO – Current guidelines on community-acquired pneumonia recommend penicillin, amoxicillin, or ampicillin as first-line treatment in children with CAP.

However, a small minority will have Staphylococcus aureus infections not treatable with these antibiotics, raising some concern about how many of these cases might be missed.

©CDC/Janice Haney Carr

At the Pediatric Hospital Medicine 2015 meeting, Dr. Meghan E. Hofto of Children’s of Alabama at the University of Alabama, Birmingham, presented research from a study of 554 patients admitted to the hospital with community acquired pneumonia, including 78 patients with complicated pneumonia.

Seven patients in the cohort (1.3%) had S. aureus infections, Dr. Hofto and her colleagues found. Of those, six were recorded as having complicated pneumonia, characterized by pleural effusion or cavitation.

Six patients with S. aureus had been started on antibiotics in other health care settings prior to admission (amoxicillin n = 4, multiple agents n = 2). One patient positive for flu was first treated with oseltamavir only. However, all staph patients once admitted were started on vancomycin, which is effective against S. aureus, within 24 hours. Five were diagnosed by pleural fluid culture; one case was identified by clinical presentation, and another by sputum culture, Dr. Hofto said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, the AAP Section on Hospital Medicine, and the Academic Pediatric Association.

The S. aureus patients were younger than the cohort as a whole (median 18 months vs. 40.5 months). Length of stay was significantly longer for these patients, compared with the rest of the cohort (median 10 vs. 2 days, P less than .01), and S. aureus patients had significantly higher incidence of anemia (P less than .01), a finding that Dr. Hofto said was striking.

Within 24 hours of presentation, six out the seven staph cases had anemia, she said, while of all the 78 patients with complicated disease, 12 had anemia. Community acquired S. aureus pneumonia has been linked in other studies to severe leukopenia, Dr. Hofto noted (BMC Infect Dis. 2013;13:359) and (Paediatric Respiratory Reviews 2011 Sept;12:182-9).In an interview, Dr. Hofto said the findings supported current guidance in favor of first-line penicillin, amoxicillin, or ampicillin. “Part of what we’re looking at with guideline adherence is the barriers to treating with empiric narrow spectrum antibiotics – and obviously, one of the things people are concerned about is that are we going to miss something,” she said.

“I think we can pretty confidently say that if it’s uncomplicated CAP – if there’s no pleural effusion, no necrosis, no cavitation – you can treat with narrow spectrum, and the likelihood of it being staph is slim to none.”

If within 48 hours, patients are not responding to the first-line treatment, “you should start thinking about other causes,” Dr. Hofto said, noting that her review found all staph aureus patients were started on antibiotics effective against S. aureus – mostly vancomycin and ceftriaxone – within 24 hours of presentation.

Dr. Hofto noted as a limitation of her study, which used retrospective chart reviews of more than 3,400 children hospitalized for suspected pneumonia over a 3-year period, that additional S. aureus cases could have been missed because of a lack of proper coding or microbial confirmation. Another limitation was the single-site design and the relatively small number of S. aureus cases.

Dr. Hofto said she is conducting a more in-depth chart review ensure that no further cases of S. aureus CAP were missed in her sample.

The study received no outside funding, and Dr. Hofto disclosed no conflicts of interest.

SAN ANTONIO – Current guidelines on community-acquired pneumonia recommend penicillin, amoxicillin, or ampicillin as first-line treatment in children with CAP.

However, a small minority will have Staphylococcus aureus infections not treatable with these antibiotics, raising some concern about how many of these cases might be missed.

©CDC/Janice Haney Carr

At the Pediatric Hospital Medicine 2015 meeting, Dr. Meghan E. Hofto of Children’s of Alabama at the University of Alabama, Birmingham, presented research from a study of 554 patients admitted to the hospital with community acquired pneumonia, including 78 patients with complicated pneumonia.

Seven patients in the cohort (1.3%) had S. aureus infections, Dr. Hofto and her colleagues found. Of those, six were recorded as having complicated pneumonia, characterized by pleural effusion or cavitation.

Six patients with S. aureus had been started on antibiotics in other health care settings prior to admission (amoxicillin n = 4, multiple agents n = 2). One patient positive for flu was first treated with oseltamavir only. However, all staph patients once admitted were started on vancomycin, which is effective against S. aureus, within 24 hours. Five were diagnosed by pleural fluid culture; one case was identified by clinical presentation, and another by sputum culture, Dr. Hofto said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, the AAP Section on Hospital Medicine, and the Academic Pediatric Association.

The S. aureus patients were younger than the cohort as a whole (median 18 months vs. 40.5 months). Length of stay was significantly longer for these patients, compared with the rest of the cohort (median 10 vs. 2 days, P less than .01), and S. aureus patients had significantly higher incidence of anemia (P less than .01), a finding that Dr. Hofto said was striking.

Within 24 hours of presentation, six out the seven staph cases had anemia, she said, while of all the 78 patients with complicated disease, 12 had anemia. Community acquired S. aureus pneumonia has been linked in other studies to severe leukopenia, Dr. Hofto noted (BMC Infect Dis. 2013;13:359) and (Paediatric Respiratory Reviews 2011 Sept;12:182-9).In an interview, Dr. Hofto said the findings supported current guidance in favor of first-line penicillin, amoxicillin, or ampicillin. “Part of what we’re looking at with guideline adherence is the barriers to treating with empiric narrow spectrum antibiotics – and obviously, one of the things people are concerned about is that are we going to miss something,” she said.

“I think we can pretty confidently say that if it’s uncomplicated CAP – if there’s no pleural effusion, no necrosis, no cavitation – you can treat with narrow spectrum, and the likelihood of it being staph is slim to none.”

If within 48 hours, patients are not responding to the first-line treatment, “you should start thinking about other causes,” Dr. Hofto said, noting that her review found all staph aureus patients were started on antibiotics effective against S. aureus – mostly vancomycin and ceftriaxone – within 24 hours of presentation.

Dr. Hofto noted as a limitation of her study, which used retrospective chart reviews of more than 3,400 children hospitalized for suspected pneumonia over a 3-year period, that additional S. aureus cases could have been missed because of a lack of proper coding or microbial confirmation. Another limitation was the single-site design and the relatively small number of S. aureus cases.

Dr. Hofto said she is conducting a more in-depth chart review ensure that no further cases of S. aureus CAP were missed in her sample.

The study received no outside funding, and Dr. Hofto disclosed no conflicts of interest.

SAN ANTONIO – More community hospitals are offering continuous albuterol to pediatric patients as an intermediate-care service, a level of care that’s higher than usual for the pediatric ward, but not as high as in pediatric intensive care units, according to Dr. Michelle Hofmann.

A 2014 study established that continuous albuterol can be initiated safely in the nonintensive pediatric care setting, but not all hospitals have followed suit (Pediatrics 2014;134[4]:e976-82).

At the Pediatric Hospital Medicine 2015 meeting, Dr. Hofmann, a pediatric hospitalist with the University of Utah, Salt Lake City, and the Riverton (Utah) Hospital, presented findings from a study she conducted to determine whether initiating continuous albuterol outside the PICU was worthwhile, safe, and feasible in her own community hospital. She found that it was.

“When we looked at the patients we were transferring to the PICU, nothing else was happening to them – all they were getting was continuous albuterol once they got there,” Dr. Hofmann said at the conference. “And we thought, ‘we [hospitalists] are on site 24/7. How do we capitalize on our resource?”

Dr. Hofmann and her colleagues first conducted a 1-year pilot study of pediatric asthma admissions (n = 76) at Primary Children’s Hospital in Salt Lake City, which like Riverton is part of the Intermountain Healthcare network. There, children were treated with continuous albuterol in the PICU only. Dr. Hofmann and her colleagues found that most children required no additional resources beyond continuous albuterol once they were admitted to the PICU from either the floor or the emergency department.

Moreover, patients classified as severe who got started on continuous albuterol in the ED and went right to the PICU did better than those who got admitted to the floor, were given intermittent albuterol, deteriorated, and then were transferred to intensive care, Dr. Hofmann said. This indicated that best practice was not occurring, even at the children’s hospital.

Dr. Hofmann and her colleagues then developed a protocol for her community hospital in which children presenting with asthma could be started on continuous albuterol in the emergency department or on the ward. She set up a pilot study to evaluate its safety and feasibility.

Of 74 asthma admissions over the 1-year pilot period, 22% of patients (n = 16) received continuous albuterol on the floor. Most of these (75%) received all their care on the floor (mean length of stay 30 hours), while those who deteriorated were transferred to the PICU; four additional cases were transferred directly from the ED to the PICU. In only two cases transferred from the community to children’s hospital did patients require care beyond continuous albuterol.

Dr. Hofmann noted that while more community hospitals are administering continuous albuterol outside the PICU, it was important to consider the benefits or drawbacks on a case-by-case basis.

A community hospital has the advantage of “not dealing with all the different layers of physicians involved in care” in a children’s hospital, Dr. Hofmann said in an interview. “Our costs are lower, in part due to shorter length of stay, but also we have a different cost structure. It’s a small self-contained unit, and our facilities are closer to home for many families.”

However, she said, the continuous albuterol intermediate-care protocol may not suit all community hospitals. “There are significant differences in personnel, facilities, and diagnostic and treatment capabilities from hospital to hospital; there’s no set criteria that will apply at every institution for intermediate care,” Dr. Hofmann said. The feasibility of appropriate staffing and continuous monitoring capabilities and the cost-benefit of achieving these in a lower-volume program are important considerations.

Hospitals should consider “what your baseline transfer rate is, and the kinds of patients you’re already seeing. Are you really going to be able to improve it that much, to provide the extra infrastructure and work to develop this process? Will you capture that many more patients?”

Offering intermediate-care services such as continuous albuterol, which can be billed at a higher level of care, is one way to help make community hospitals’ pediatric programs more sustainable. “We tend to operate in the red,” Dr. Hofmann said, because “pediatrics is not a high revenue earner for a facility. Moving to these intermediate-level care options and figuring out what is safe and what we can keep in the community hospital is really important to us – this is just one example of ways we could do that.”

Dr. Hofmann noted as a limitation of her study the low patient volume and the fact that some asthma patients may have been transferred from the community hospital’s ED to the children’s hospital year over year, and these were only captured during the pilot study, though it may be that ED transfer rates are decreasing as well as a result of the protocol.

The meeting was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, the AAP Section on Hospital Medicine, and the Academic Pediatric Association. Dr. Hofmann reported no outside funding for her study or conflicts of interest.

SAN ANTONIO – More community hospitals are offering continuous albuterol to pediatric patients as an intermediate-care service, a level of care that’s higher than usual for the pediatric ward, but not as high as in pediatric intensive care units, according to Dr. Michelle Hofmann.

A 2014 study established that continuous albuterol can be initiated safely in the nonintensive pediatric care setting, but not all hospitals have followed suit (Pediatrics 2014;134[4]:e976-82).

At the Pediatric Hospital Medicine 2015 meeting, Dr. Hofmann, a pediatric hospitalist with the University of Utah, Salt Lake City, and the Riverton (Utah) Hospital, presented findings from a study she conducted to determine whether initiating continuous albuterol outside the PICU was worthwhile, safe, and feasible in her own community hospital. She found that it was.

“When we looked at the patients we were transferring to the PICU, nothing else was happening to them – all they were getting was continuous albuterol once they got there,” Dr. Hofmann said at the conference. “And we thought, ‘we [hospitalists] are on site 24/7. How do we capitalize on our resource?”

Dr. Hofmann and her colleagues first conducted a 1-year pilot study of pediatric asthma admissions (n = 76) at Primary Children’s Hospital in Salt Lake City, which like Riverton is part of the Intermountain Healthcare network. There, children were treated with continuous albuterol in the PICU only. Dr. Hofmann and her colleagues found that most children required no additional resources beyond continuous albuterol once they were admitted to the PICU from either the floor or the emergency department.

Moreover, patients classified as severe who got started on continuous albuterol in the ED and went right to the PICU did better than those who got admitted to the floor, were given intermittent albuterol, deteriorated, and then were transferred to intensive care, Dr. Hofmann said. This indicated that best practice was not occurring, even at the children’s hospital.

Dr. Hofmann and her colleagues then developed a protocol for her community hospital in which children presenting with asthma could be started on continuous albuterol in the emergency department or on the ward. She set up a pilot study to evaluate its safety and feasibility.

Of 74 asthma admissions over the 1-year pilot period, 22% of patients (n = 16) received continuous albuterol on the floor. Most of these (75%) received all their care on the floor (mean length of stay 30 hours), while those who deteriorated were transferred to the PICU; four additional cases were transferred directly from the ED to the PICU. In only two cases transferred from the community to children’s hospital did patients require care beyond continuous albuterol.

Dr. Hofmann noted that while more community hospitals are administering continuous albuterol outside the PICU, it was important to consider the benefits or drawbacks on a case-by-case basis.

A community hospital has the advantage of “not dealing with all the different layers of physicians involved in care” in a children’s hospital, Dr. Hofmann said in an interview. “Our costs are lower, in part due to shorter length of stay, but also we have a different cost structure. It’s a small self-contained unit, and our facilities are closer to home for many families.”

However, she said, the continuous albuterol intermediate-care protocol may not suit all community hospitals. “There are significant differences in personnel, facilities, and diagnostic and treatment capabilities from hospital to hospital; there’s no set criteria that will apply at every institution for intermediate care,” Dr. Hofmann said. The feasibility of appropriate staffing and continuous monitoring capabilities and the cost-benefit of achieving these in a lower-volume program are important considerations.

Hospitals should consider “what your baseline transfer rate is, and the kinds of patients you’re already seeing. Are you really going to be able to improve it that much, to provide the extra infrastructure and work to develop this process? Will you capture that many more patients?”

Offering intermediate-care services such as continuous albuterol, which can be billed at a higher level of care, is one way to help make community hospitals’ pediatric programs more sustainable. “We tend to operate in the red,” Dr. Hofmann said, because “pediatrics is not a high revenue earner for a facility. Moving to these intermediate-level care options and figuring out what is safe and what we can keep in the community hospital is really important to us – this is just one example of ways we could do that.”

Dr. Hofmann noted as a limitation of her study the low patient volume and the fact that some asthma patients may have been transferred from the community hospital’s ED to the children’s hospital year over year, and these were only captured during the pilot study, though it may be that ED transfer rates are decreasing as well as a result of the protocol.

The meeting was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, the AAP Section on Hospital Medicine, and the Academic Pediatric Association. Dr. Hofmann reported no outside funding for her study or conflicts of interest.

SAN ANTONIO – More community hospitals are offering continuous albuterol to pediatric patients as an intermediate-care service, a level of care that’s higher than usual for the pediatric ward, but not as high as in pediatric intensive care units, according to Dr. Michelle Hofmann.

A 2014 study established that continuous albuterol can be initiated safely in the nonintensive pediatric care setting, but not all hospitals have followed suit (Pediatrics 2014;134[4]:e976-82).

At the Pediatric Hospital Medicine 2015 meeting, Dr. Hofmann, a pediatric hospitalist with the University of Utah, Salt Lake City, and the Riverton (Utah) Hospital, presented findings from a study she conducted to determine whether initiating continuous albuterol outside the PICU was worthwhile, safe, and feasible in her own community hospital. She found that it was.

“When we looked at the patients we were transferring to the PICU, nothing else was happening to them – all they were getting was continuous albuterol once they got there,” Dr. Hofmann said at the conference. “And we thought, ‘we [hospitalists] are on site 24/7. How do we capitalize on our resource?”

Dr. Hofmann and her colleagues first conducted a 1-year pilot study of pediatric asthma admissions (n = 76) at Primary Children’s Hospital in Salt Lake City, which like Riverton is part of the Intermountain Healthcare network. There, children were treated with continuous albuterol in the PICU only. Dr. Hofmann and her colleagues found that most children required no additional resources beyond continuous albuterol once they were admitted to the PICU from either the floor or the emergency department.

Moreover, patients classified as severe who got started on continuous albuterol in the ED and went right to the PICU did better than those who got admitted to the floor, were given intermittent albuterol, deteriorated, and then were transferred to intensive care, Dr. Hofmann said. This indicated that best practice was not occurring, even at the children’s hospital.

Dr. Hofmann and her colleagues then developed a protocol for her community hospital in which children presenting with asthma could be started on continuous albuterol in the emergency department or on the ward. She set up a pilot study to evaluate its safety and feasibility.

Of 74 asthma admissions over the 1-year pilot period, 22% of patients (n = 16) received continuous albuterol on the floor. Most of these (75%) received all their care on the floor (mean length of stay 30 hours), while those who deteriorated were transferred to the PICU; four additional cases were transferred directly from the ED to the PICU. In only two cases transferred from the community to children’s hospital did patients require care beyond continuous albuterol.

Dr. Hofmann noted that while more community hospitals are administering continuous albuterol outside the PICU, it was important to consider the benefits or drawbacks on a case-by-case basis.

A community hospital has the advantage of “not dealing with all the different layers of physicians involved in care” in a children’s hospital, Dr. Hofmann said in an interview. “Our costs are lower, in part due to shorter length of stay, but also we have a different cost structure. It’s a small self-contained unit, and our facilities are closer to home for many families.”

However, she said, the continuous albuterol intermediate-care protocol may not suit all community hospitals. “There are significant differences in personnel, facilities, and diagnostic and treatment capabilities from hospital to hospital; there’s no set criteria that will apply at every institution for intermediate care,” Dr. Hofmann said. The feasibility of appropriate staffing and continuous monitoring capabilities and the cost-benefit of achieving these in a lower-volume program are important considerations.

Hospitals should consider “what your baseline transfer rate is, and the kinds of patients you’re already seeing. Are you really going to be able to improve it that much, to provide the extra infrastructure and work to develop this process? Will you capture that many more patients?”

Offering intermediate-care services such as continuous albuterol, which can be billed at a higher level of care, is one way to help make community hospitals’ pediatric programs more sustainable. “We tend to operate in the red,” Dr. Hofmann said, because “pediatrics is not a high revenue earner for a facility. Moving to these intermediate-level care options and figuring out what is safe and what we can keep in the community hospital is really important to us – this is just one example of ways we could do that.”

Dr. Hofmann noted as a limitation of her study the low patient volume and the fact that some asthma patients may have been transferred from the community hospital’s ED to the children’s hospital year over year, and these were only captured during the pilot study, though it may be that ED transfer rates are decreasing as well as a result of the protocol.

The meeting was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, the AAP Section on Hospital Medicine, and the Academic Pediatric Association. Dr. Hofmann reported no outside funding for her study or conflicts of interest.

SAN ANTONIO – Despite mounting evidence that blood cultures don’t contribute to the care of immunocompetent children admitted to the hospital with uncomplicated skin and soft tissue infections (SSTIs), they continue to be performed routinely in some hospitals, according to a study presented at the Pediatric Hospital Medicine 2015 meeting.

Current practice guidelines recommend against routine use of blood cultures in uncomplicated SSTIs (Clin Infect Dis. 2014;59(2):e10-52).

(c) CDC/Janice Haney Carr

A 2013 study of children admitted for uncomplicated SSTIs (n = 482) found no positive blood cultures in the cohort, and cultures were also associated with a significantly longer length of stay. More than half of those children, however, had received antibiotics before their blood cultures, leaving open the possibility that some negative results were the result of treatment with antibiotics (Pediatrics. 2013;132(3):454-9).

Dr. Claudette Gonzalez and her colleagues at Nicklaus Children’s Hospital, Miami, presented findings from a study that used a cohort of otherwise healthy infants and children (n = 176) admitted from the emergency department with uncomplicated SSTIs.

Dr. Gonzalez and her associates sought to strengthen the evidence against routine use of cultures by excluding children who had received antibiotics within 2 weeks of presenting to the hospital.Dr. Gonzalez noted that, despite guidelines, blood cultures remained a routine part of the workup at her hospital, with 66% of the study sample receiving cultures (n = 116). Of febrile patients, 80% received cultures; of nonfebrile patients, 59% received cultures. Patients who had a blood culture drawn were significantly more likely to have had fever (P < .01). They also were more likely to have higher white blood cell and C-reactive protein (CRP) counts (P > .05 for both), but despite this, the rate of positive blood cultures was still less than 1%.

Of the 116 blood cultures drawn, 5 grew contaminants and only 1 was a true positive, for methicillin-susceptible Staphylococcus aureus (MSSA).

The study, unlike most previous studies, enrolled patients younger than 1 year of age (n = 28), but Dr. Gonzalez said that “we don’t have a big enough sample to really make conclusions about that age group.” Also in contrast to some previous studies, Dr. Gonzalez and her associates did not find a statistically significant difference in length of stay between the patients who had received cultures and those that did not (mean 3.62 vs. 3.4 days, P > .05).The one patient in the study with true bacteremia was a 1.4-year-old child presenting with no fever, cellulitis of hands and feet, no lymphangitis, and a white blood count of 8.5 × 10³/L and a CRP of less than 0.5 mg/dL. “The WBC count was within normal range and the CRP was not elevated, so you wouldn’t have necessarily picked this kid out to say he needs a blood culture,” Dr. Gonzalez said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, the AAP Section on Hospital Medicine, and the Academic Pediatric Association.

Still, she said, the study strengthens the evidence base against use of blood cultures in this population. “For children 1 year and older I think it’s very clear,” she said. The investigators are now proceeding with an implementation study to determine whether guidance against routine blood cultures should be put into practice at their institution.

Although the initial study revealed that 66% of children with uncomplicated SSTIs were receiving cultures, preliminary unpublished results show “it’s now at about 44%,” she said, following education of residents, fellows, and ED clinicians.

In addition to communicating with the ED to reduce use of blood cultures in this population, Dr. Gonzalez said, “we’re getting guidelines plugged into our order set in the [electronic medical record], so that’s a second reminder not to draw blood cultures. And we’re measuring to see if our rates improve further.”

Dr. Gonzalez received no outside funding for her study and disclosed no conflicts of interest.

SAN ANTONIO – Despite mounting evidence that blood cultures don’t contribute to the care of immunocompetent children admitted to the hospital with uncomplicated skin and soft tissue infections (SSTIs), they continue to be performed routinely in some hospitals, according to a study presented at the Pediatric Hospital Medicine 2015 meeting.

Current practice guidelines recommend against routine use of blood cultures in uncomplicated SSTIs (Clin Infect Dis. 2014;59(2):e10-52).

(c) CDC/Janice Haney Carr

A 2013 study of children admitted for uncomplicated SSTIs (n = 482) found no positive blood cultures in the cohort, and cultures were also associated with a significantly longer length of stay. More than half of those children, however, had received antibiotics before their blood cultures, leaving open the possibility that some negative results were the result of treatment with antibiotics (Pediatrics. 2013;132(3):454-9).

Dr. Claudette Gonzalez and her colleagues at Nicklaus Children’s Hospital, Miami, presented findings from a study that used a cohort of otherwise healthy infants and children (n = 176) admitted from the emergency department with uncomplicated SSTIs.

Dr. Gonzalez and her associates sought to strengthen the evidence against routine use of cultures by excluding children who had received antibiotics within 2 weeks of presenting to the hospital.Dr. Gonzalez noted that, despite guidelines, blood cultures remained a routine part of the workup at her hospital, with 66% of the study sample receiving cultures (n = 116). Of febrile patients, 80% received cultures; of nonfebrile patients, 59% received cultures. Patients who had a blood culture drawn were significantly more likely to have had fever (P < .01). They also were more likely to have higher white blood cell and C-reactive protein (CRP) counts (P > .05 for both), but despite this, the rate of positive blood cultures was still less than 1%.

Of the 116 blood cultures drawn, 5 grew contaminants and only 1 was a true positive, for methicillin-susceptible Staphylococcus aureus (MSSA).

The study, unlike most previous studies, enrolled patients younger than 1 year of age (n = 28), but Dr. Gonzalez said that “we don’t have a big enough sample to really make conclusions about that age group.” Also in contrast to some previous studies, Dr. Gonzalez and her associates did not find a statistically significant difference in length of stay between the patients who had received cultures and those that did not (mean 3.62 vs. 3.4 days, P > .05).The one patient in the study with true bacteremia was a 1.4-year-old child presenting with no fever, cellulitis of hands and feet, no lymphangitis, and a white blood count of 8.5 × 10³/L and a CRP of less than 0.5 mg/dL. “The WBC count was within normal range and the CRP was not elevated, so you wouldn’t have necessarily picked this kid out to say he needs a blood culture,” Dr. Gonzalez said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, the AAP Section on Hospital Medicine, and the Academic Pediatric Association.

Still, she said, the study strengthens the evidence base against use of blood cultures in this population. “For children 1 year and older I think it’s very clear,” she said. The investigators are now proceeding with an implementation study to determine whether guidance against routine blood cultures should be put into practice at their institution.

Although the initial study revealed that 66% of children with uncomplicated SSTIs were receiving cultures, preliminary unpublished results show “it’s now at about 44%,” she said, following education of residents, fellows, and ED clinicians.

In addition to communicating with the ED to reduce use of blood cultures in this population, Dr. Gonzalez said, “we’re getting guidelines plugged into our order set in the [electronic medical record], so that’s a second reminder not to draw blood cultures. And we’re measuring to see if our rates improve further.”

Dr. Gonzalez received no outside funding for her study and disclosed no conflicts of interest.

SAN ANTONIO – Despite mounting evidence that blood cultures don’t contribute to the care of immunocompetent children admitted to the hospital with uncomplicated skin and soft tissue infections (SSTIs), they continue to be performed routinely in some hospitals, according to a study presented at the Pediatric Hospital Medicine 2015 meeting.

Current practice guidelines recommend against routine use of blood cultures in uncomplicated SSTIs (Clin Infect Dis. 2014;59(2):e10-52).

(c) CDC/Janice Haney Carr

A 2013 study of children admitted for uncomplicated SSTIs (n = 482) found no positive blood cultures in the cohort, and cultures were also associated with a significantly longer length of stay. More than half of those children, however, had received antibiotics before their blood cultures, leaving open the possibility that some negative results were the result of treatment with antibiotics (Pediatrics. 2013;132(3):454-9).

Dr. Claudette Gonzalez and her colleagues at Nicklaus Children’s Hospital, Miami, presented findings from a study that used a cohort of otherwise healthy infants and children (n = 176) admitted from the emergency department with uncomplicated SSTIs.

Dr. Gonzalez and her associates sought to strengthen the evidence against routine use of cultures by excluding children who had received antibiotics within 2 weeks of presenting to the hospital.Dr. Gonzalez noted that, despite guidelines, blood cultures remained a routine part of the workup at her hospital, with 66% of the study sample receiving cultures (n = 116). Of febrile patients, 80% received cultures; of nonfebrile patients, 59% received cultures. Patients who had a blood culture drawn were significantly more likely to have had fever (P < .01). They also were more likely to have higher white blood cell and C-reactive protein (CRP) counts (P > .05 for both), but despite this, the rate of positive blood cultures was still less than 1%.

Of the 116 blood cultures drawn, 5 grew contaminants and only 1 was a true positive, for methicillin-susceptible Staphylococcus aureus (MSSA).

The study, unlike most previous studies, enrolled patients younger than 1 year of age (n = 28), but Dr. Gonzalez said that “we don’t have a big enough sample to really make conclusions about that age group.” Also in contrast to some previous studies, Dr. Gonzalez and her associates did not find a statistically significant difference in length of stay between the patients who had received cultures and those that did not (mean 3.62 vs. 3.4 days, P > .05).The one patient in the study with true bacteremia was a 1.4-year-old child presenting with no fever, cellulitis of hands and feet, no lymphangitis, and a white blood count of 8.5 × 10³/L and a CRP of less than 0.5 mg/dL. “The WBC count was within normal range and the CRP was not elevated, so you wouldn’t have necessarily picked this kid out to say he needs a blood culture,” Dr. Gonzalez said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, the AAP Section on Hospital Medicine, and the Academic Pediatric Association.

Still, she said, the study strengthens the evidence base against use of blood cultures in this population. “For children 1 year and older I think it’s very clear,” she said. The investigators are now proceeding with an implementation study to determine whether guidance against routine blood cultures should be put into practice at their institution.

Although the initial study revealed that 66% of children with uncomplicated SSTIs were receiving cultures, preliminary unpublished results show “it’s now at about 44%,” she said, following education of residents, fellows, and ED clinicians.

In addition to communicating with the ED to reduce use of blood cultures in this population, Dr. Gonzalez said, “we’re getting guidelines plugged into our order set in the [electronic medical record], so that’s a second reminder not to draw blood cultures. And we’re measuring to see if our rates improve further.”

Dr. Gonzalez received no outside funding for her study and disclosed no conflicts of interest.

SAN ANTONIO – Nebulized hypertonic saline has emerged as a promising, low-risk, and low-cost treatment option for bronchiolitis, a disease for which few options exist.

Still, the evidence for hypertonic saline remains inconsistent, with many studies failing to show a clear benefit in clinical scores or length of stay compared with normal saline in children hospitalized for bronchiolitis. Supportive care remains the recommended approach for this patient group.

A 2013 Cochrane review of trials comparing normal saline 0.9% with hypertonic saline 3% suggested that hypertonic saline reduced mean hospital length of stay by 1.3 days in children with bronchiolitis as well as improved clinical severity scores. But more recent negative trials have called the Cochrane findings into question.

At the Pediatric Hospital Medicine meeting, Dr. Corinne G. Brooks of the Children’s Hospital at Dartmouth-Hitchcock in Lebanon, N.H., presented an updated evaluation of the Cochrane findings as well as several newer studies, which found that study heterogeneity was excessively high, though resolved by accounting for culturally expected length of stay, which varied from 2 to 7 days across studies.

Studies conducted in countries where average length of stay for bronchiolitis in the placebo arm is longer than 3 days reported a greater benefit than did those in countries like the United States, in which stays typically average fewer than 3 days. Because hospital length of stay should be correlated with severity of illness, Dr. Brooks also evaluated respiratory scores available in each study and found that higher scores also correlated with the utility of hypertonic saline.

The two Chinese studies included in the review had particularly long lengths of stay and were conducted in a city with poor air quality, and in which about 70% of patients were on systemic corticosteroids at baseline. “So there’s some question as to whether they were even measuring the same disease process,” Dr. Brooks told the conference.

Dr. Brooks and her colleagues reevaluated the Cochrane data both with and without the two outlying studies from China, and incorporated results from three additional studies not included in the Cochrane review.

Modeling cumulative results using a length of stay typical in the United States, the benefit from hypertonic saline was a reduction of 0.31 days, or 31 days/100 patients.

Dr. Brooks noted that the current data are consistent with two possibilities, that the longer a patient is treated with hypertonic saline, the better it works or that “perhaps hypertonic saline works better for sicker patients – we don’t know yet.” She acknowledged several limitations of the meta-analysis, including that patient age, additional medications, day of illness at admission, and frequency of treatment could not be correlated.

The existing data “do not support rejecting hypertonic saline for all patients or giving it to all populations,” Dr. Brooks told the conference, noting that “there are good physiologic reasons to believe hypertonic saline might have an impact based on its benefits to other respiratory populations such as cystic fibrosis – and it’s particularly appealing because of its low risk and low cost.”

However, she said, “if we’re going to use this intervention intelligently, we need to find where there is and where there isn’t a benefit.”

Dr. Brooks concluded that hypertonic saline might be worth considering for patients with an expected stay of longer than 3 days or for those with baseline clinical scores higher than average. Her study received no outside funding, and she disclosed no conflicts of interest.

SAN ANTONIO – Nebulized hypertonic saline has emerged as a promising, low-risk, and low-cost treatment option for bronchiolitis, a disease for which few options exist.

Still, the evidence for hypertonic saline remains inconsistent, with many studies failing to show a clear benefit in clinical scores or length of stay compared with normal saline in children hospitalized for bronchiolitis. Supportive care remains the recommended approach for this patient group.

A 2013 Cochrane review of trials comparing normal saline 0.9% with hypertonic saline 3% suggested that hypertonic saline reduced mean hospital length of stay by 1.3 days in children with bronchiolitis as well as improved clinical severity scores. But more recent negative trials have called the Cochrane findings into question.

At the Pediatric Hospital Medicine meeting, Dr. Corinne G. Brooks of the Children’s Hospital at Dartmouth-Hitchcock in Lebanon, N.H., presented an updated evaluation of the Cochrane findings as well as several newer studies, which found that study heterogeneity was excessively high, though resolved by accounting for culturally expected length of stay, which varied from 2 to 7 days across studies.

Studies conducted in countries where average length of stay for bronchiolitis in the placebo arm is longer than 3 days reported a greater benefit than did those in countries like the United States, in which stays typically average fewer than 3 days. Because hospital length of stay should be correlated with severity of illness, Dr. Brooks also evaluated respiratory scores available in each study and found that higher scores also correlated with the utility of hypertonic saline.

The two Chinese studies included in the review had particularly long lengths of stay and were conducted in a city with poor air quality, and in which about 70% of patients were on systemic corticosteroids at baseline. “So there’s some question as to whether they were even measuring the same disease process,” Dr. Brooks told the conference.

Dr. Brooks and her colleagues reevaluated the Cochrane data both with and without the two outlying studies from China, and incorporated results from three additional studies not included in the Cochrane review.

Modeling cumulative results using a length of stay typical in the United States, the benefit from hypertonic saline was a reduction of 0.31 days, or 31 days/100 patients.

Dr. Brooks noted that the current data are consistent with two possibilities, that the longer a patient is treated with hypertonic saline, the better it works or that “perhaps hypertonic saline works better for sicker patients – we don’t know yet.” She acknowledged several limitations of the meta-analysis, including that patient age, additional medications, day of illness at admission, and frequency of treatment could not be correlated.

The existing data “do not support rejecting hypertonic saline for all patients or giving it to all populations,” Dr. Brooks told the conference, noting that “there are good physiologic reasons to believe hypertonic saline might have an impact based on its benefits to other respiratory populations such as cystic fibrosis – and it’s particularly appealing because of its low risk and low cost.”

However, she said, “if we’re going to use this intervention intelligently, we need to find where there is and where there isn’t a benefit.”

Dr. Brooks concluded that hypertonic saline might be worth considering for patients with an expected stay of longer than 3 days or for those with baseline clinical scores higher than average. Her study received no outside funding, and she disclosed no conflicts of interest.

SAN ANTONIO – Nebulized hypertonic saline has emerged as a promising, low-risk, and low-cost treatment option for bronchiolitis, a disease for which few options exist.

Still, the evidence for hypertonic saline remains inconsistent, with many studies failing to show a clear benefit in clinical scores or length of stay compared with normal saline in children hospitalized for bronchiolitis. Supportive care remains the recommended approach for this patient group.

A 2013 Cochrane review of trials comparing normal saline 0.9% with hypertonic saline 3% suggested that hypertonic saline reduced mean hospital length of stay by 1.3 days in children with bronchiolitis as well as improved clinical severity scores. But more recent negative trials have called the Cochrane findings into question.

At the Pediatric Hospital Medicine meeting, Dr. Corinne G. Brooks of the Children’s Hospital at Dartmouth-Hitchcock in Lebanon, N.H., presented an updated evaluation of the Cochrane findings as well as several newer studies, which found that study heterogeneity was excessively high, though resolved by accounting for culturally expected length of stay, which varied from 2 to 7 days across studies.

Studies conducted in countries where average length of stay for bronchiolitis in the placebo arm is longer than 3 days reported a greater benefit than did those in countries like the United States, in which stays typically average fewer than 3 days. Because hospital length of stay should be correlated with severity of illness, Dr. Brooks also evaluated respiratory scores available in each study and found that higher scores also correlated with the utility of hypertonic saline.

The two Chinese studies included in the review had particularly long lengths of stay and were conducted in a city with poor air quality, and in which about 70% of patients were on systemic corticosteroids at baseline. “So there’s some question as to whether they were even measuring the same disease process,” Dr. Brooks told the conference.

Dr. Brooks and her colleagues reevaluated the Cochrane data both with and without the two outlying studies from China, and incorporated results from three additional studies not included in the Cochrane review.

Modeling cumulative results using a length of stay typical in the United States, the benefit from hypertonic saline was a reduction of 0.31 days, or 31 days/100 patients.

Dr. Brooks noted that the current data are consistent with two possibilities, that the longer a patient is treated with hypertonic saline, the better it works or that “perhaps hypertonic saline works better for sicker patients – we don’t know yet.” She acknowledged several limitations of the meta-analysis, including that patient age, additional medications, day of illness at admission, and frequency of treatment could not be correlated.

The existing data “do not support rejecting hypertonic saline for all patients or giving it to all populations,” Dr. Brooks told the conference, noting that “there are good physiologic reasons to believe hypertonic saline might have an impact based on its benefits to other respiratory populations such as cystic fibrosis – and it’s particularly appealing because of its low risk and low cost.”

However, she said, “if we’re going to use this intervention intelligently, we need to find where there is and where there isn’t a benefit.”

Dr. Brooks concluded that hypertonic saline might be worth considering for patients with an expected stay of longer than 3 days or for those with baseline clinical scores higher than average. Her study received no outside funding, and she disclosed no conflicts of interest.