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Clinical Rounds

doi: 10.1097/01.NURSE.0000530417.99439.d7
Department: CLINICAL ROUNDS
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INFLUENZA

Repeated vaccination protects older adults

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A team of researchers looked at the effect of repeated influenza vaccinations in the current and three previous seasons in people age 65 and older admitted to 20 Spanish hospitals in 2013-2014 and 2014-2015. Adding to the body of evidence that vaccination can lessen influenza severity, they found that repeated vaccination in older adults reduced hospital admissions and disease severity. These findings were consistent regardless of flu season, virus subtypes, or age of patient.

“Repeated vaccination for influenza was highly effective in preventing severe and fatal infection caused by influenza in older adults,” the authors concluded. “The prevention of severe and fatal infection caused by influenza was observed mainly in patients who were vaccinated in both the current and previous seasons, which reinforces the recommendation of annual vaccination for influenza in older adults.”

Sources: Casado I, Domínguez Á, Toledo D, et al. Repeated influenza vaccination for preventing severe and fatal influenza infection in older adults: a multicentre case-control study. CMAJ. 2018;190(1):E3-E12. Repeated influenza vaccination helps prevent severe flu in older adults. Canadian Medical Association Journal. News release. January 8, 2018.

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CHRONIC TINNITUS

Noninvasive device softens phantom sounds

An estimated 50 million Americans experience tinnitus, and for about 2 million, symptoms are extreme and debilitating. Tinnitus isn't curable and treatment options are limited, but a noninvasive device shows promise for symptom management.

Called stimulus timing-dependent plasticity (STDP), the device uses precisely timed sound and skin stimulation to target fusiform nerve cells in the brain, which other research suggests trigger the perception of phantom sounds. Sound directed into the ears is alternated with mild electrical pulses via transcutaneous electrodes positioned over either the trigeminal ganglion or the cervical spinal cord in the C2 region.

In a trial, 10 patients received STDP therapy and 10 received therapy sounds only, without electrical stimulation (unimodal therapy), 30 minutes a day for 4 weeks. After a month-long break, patients switched treatments. Researchers found that 28 days of STDP stimulation reduced tinnitus loudness and intrusiveness, but that unimodal auditory stimulation failed to provide either benefit. They conclude that STDP “may hold promise for suppressing chronic tinnitus, which reduces quality of life for millions of tinnitus sufferers worldwide.”

Sources: Marks KL, Martel DT, Wu C, et al. Auditory-somatosensory bimodal stimulation desynchronizes brain circuitry to reduce tinnitus in guinea pigs and humans. Sci Transl Med. 2018;10(422):eaal3175. New hope for “ringing” in the ears. Health Day. January 3, 2018. Understanding the facts. American Tinnitus Association. www.ata.org/understanding-facts.

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DRUG-RESISTANT BACTERIA

Experts address duration of contact precautions

The Society for Healthcare Epidemiology of America (SHEA) has published new guidelines to help clinicians in acute care settings decide when they can safely discontinue contact precautions for patients with infections caused by methicillin-resistant Staphylococcus aureus, Clostridium difficile, or multidrug-resistant Enterobacteriaceae. Stressing the importance of assessing patient characteristics and applying clinical judgment, the SHEA guidelines state that:

  • in most cases, contact precautions can be discontinued after one to three negative cultures, but clinicians should weigh how much time has elapsed since the last positive culture.
  • contact precautions for patients with C. difficile infections (CDIs) can be continued for at least 48 hours after resolution of diarrhea. However, clinicians could consider extending the duration of contact precautions if CDI rates in the facility are elevated despite infection prevention and control measures.
  • evidence is insufficient to support a formal recommendation on whether patients with CDI should be placed on contact precautions if readmitted to the hospital. The facility's infection prevention and control leadership should oversee and revisit decision-making, especially in outbreak situations.

The authors advise hospitals to carefully assess institutional risks, priorities, and resources before adopting a new policy.

Sources: Banach DB, Bearman G, Barnden M, et al. Duration of contact precautions for acute-care settings. Infect Control Hosp Epidemiol. 2018:1-18. New expert guidance on contact precautions for drug-resistant infections. Society for Healthcare Epidemiology of America. News release. January 11, 2018.

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In March, celebrate

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TELEMEDICINE

How nurses “advance beyond the system”

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The increasing prevalence of telemedicine requires nurses to perform patient care and monitoring from a distance, yet little research has been done about how computerized decision support systems used in a telemedicine setting affect clinical reasoning. A new study explored factors influencing reasoning and decision-making by telemedicine nurses in a Norwegian clinic caring for patients with chronic obstructive pulmonary disease (COPD). Researchers used a combination of data collection methods, including participatory observations, the think-aloud technique, and a focus group interview. The study subjects were nurses using a computerized decision support system to manage the care of patients with complex, unstable COPD. The nurses were observed when performing clinical reasoning, decision-making, and video consultations with their patients. Approximately 60 patient consultations were observed during 60 fieldwork hours.

Researchers found an overall theme, termed “advancing beyond the system,” that linked telemedicine work to the setting, where familiarity with the patient was the foundation for the nurses' clinical reasoning process. Nurses used the system to clarify clinical information and assess the meaning of any health changes, but indicated that it often didn't provide sufficient clinical information regarding each patient's health status. Consequently, system decisions were frequently overridden and nurses sought additional clinical information elsewhere.

The researchers concluded that the continuous flow of digital clinical data, regular video-mediated contact, and shared decision-making with the patient provided a foundation for the nurses' reasoning process. They also found that the nurses' reasoning “frequently advanced beyond the computerized decision support system recommendations.” They call for further research to develop more accurate algorithms and improve integration of digital clinical information with clinical experiences.

Source: Barken TL, Thygesen E, Soderhamn U. Advancing beyond the system: telemedicine nurses' clinical reasoning using a computerised decision support system for patients with COPD—an ethnographic study. BMC Med Inform Decis Mak. 2017;17:181.

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CARDIOVASCULAR DISEASE

Erectile dysfunction may signal higher risk

Early detection of cardiovascular disease (CVD), which continues to be the leading cause of death worldwide, can lead to lifesaving interventions such as use of statin drugs, smoking cessation, BP control, and lifestyle modifications. A new study suggests that erectile dysfunction (ED), particularly in younger men, may be an often-overlooked early warning sign of CVD.

In a systematic review and meta-analysis of 28 studies, researchers studied the association of ED and measures of early CVD. They found significant associations between ED and:

  • impaired endothelial function, considered an early marker of vascular disease, as assessed by flow-mediated dilation of the brachial artery.
  • increased carotid intima-media thickness, an early indicator of atherosclerosis.

The study authors write, “Our study supports a more aggressive CVD risk assessment and management of persons with ED, including among young men who may otherwise have been categorized as low risk due to their young ages. The measures of subclinical disease included in this review... can be assessed by noninvasive office-based procedures with no radiation risk and whose results can be available during a clinic visit.”

Sources: Osondu CU, Vo B, Oni ET, et al. The relationship of erectile dysfunction and subclinical cardiovascular disease: a systematic review and meta-analysis. Vas Med. [e-pub Dec. 15, 2017]. Erectile dysfunction is red flag for silent early cardiovascular disease. Sage. News release. December 15, 2017.

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HEMOPHILIA B

Gene therapy breakthrough?

An experimental gene therapy product has produced dramatic results in a group of 10 men with hemophilia B with factor IX coagulant activity of 2% or less of the normal value. The product was bioengineered to code genes for clotting factor IX Padua, which is 8 to 10 times stronger than the normal factor IX.

One dose of the product was infused into the patients' livers, where factor IX is normally produced. No patients experienced adverse reactions during or after the infusion. On cumulative follow-up of 492 weeks among all the participants (range of follow-up in individual participants, 28 to 78 weeks), the annualized bleeding rate was significantly reduced from a mean rate of 11.1 bleeding events per year before administration of the gene product to 0.4 events per year after administration. In addition, factor use was significantly reduced from a mean dose of 2,908 IU/kg before administration to 49.3 IU/kg after administration. Nine of the patients had no bleeding events in the study period after administration, and eight of them received no factor infusions.

Researchers say the treatment improved the patients' quality of life considerably. More research is needed to determine if the treatment can be applied to a wider range of patients. One challenge is that about one-third of patients with hemophilia B have a preexisting immunity to the virus used as a delivery vector.

Sources: George LA, Sullivan SK, Giermasz A, et al. Hemophilia B gene therapy with a high-specific-activity factor IX variant. N Engl J Med. 2017;377(23):2215-2227. Gene therapy may allow hemophilia patients to go without meds. HealthDay. December 3, 2017.

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IMPAIRED GLUCOSE METABOLISM

Camelina oil improves lipid profile

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Researchers investigated how camelina oil, a plant-based source of alpha-linolenic acid, compares with lean fish and fatty fish in terms of their metabolic effects in patients with impaired glucose metabolism. Although fish proteins have been shown to have beneficial effects on certain cardiovascular risk factors, evidence on how alpha-linolenic acid affects these factors is scant.

The study involved 79 men and women ages 40 to 72 with impaired fasting glucose concentrations. Participants were randomly divided into four groups: the camelina oil group, the fatty fish group, the lean fish group, and a control group. Depending on the group, participants were instructed to eat either fatty or lean fish four times a week, or to take a daily 30 mL dose of camelina oil for 12 weeks. Those in the control group were allowed to eat fish once a week, but were instructed not to consume camelina oil or other oils containing alpha-linolenic acid.

The result: Camelina oil lowered total and low-density lipoprotein cholesterol levels, but no similar effects were observed for fatty or lean fish. No differences in glucose metabolism or low-grade inflammation were found.

Sources: Schwab US, Lankinen MA, de Mello VD, et al. Camelina sativa oil, but not fatty fish or lean fish improved serum lipid profile in subjects with impaired glucose metabolism—a randomized controlled trial. Mol Nutr Food Res. [e-pub December 22, 2017]. Camelina oil improves blood lipid profile. University of Eastern Finland. News release. January 8, 2017.

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