M. Alexander Otto

Partners for Kids, one of the nation’s largest pediatric accountable care organizations (ACO), had lower cost growth than did Medicaid fee-for-service and managed care programs in Ohio from 2008 to 2013, without reducing overall quality of care, according to an observational, retrospective study published Feb. 9 in Pediatrics.

Accountable care organizations have been shown to reduce costs for adults without negatively impacting quality of care; however, there’s been little proof before now that the model works for children.

The per-patient/per-month cost increase for Partners for Kids (PFK), which covers more than 300,000 low-income children in central and southeastern Ohio, was $2.40/year from 2008 to 2013, vs. $16.15/year for the Ohio Medicaid fee-for-service program (P = .001) and $6.47/year for Ohio Medicaid managed care programs (almost statistically significant at P = .121).

© KatarzynaBialasiewicz/Thinkstock

Results on key quality measures were mixed. Slight improvements were seen over that time in PFK’s gastroenteritis admissions, pediatric acute care, and pediatric composite scores, as well as reduced neonatal ICU admissions and increased well-child visits. However, modest increases were seen in short-term admissions for diabetes and perioperative hemorrhages and hematomas (Pediatrics 2015 Feb. 9 [doi:10.1542/peds.2014-2725]).

Overall, the care differences were a wash; quality measures held fairly steady over the 5 years.

“PFK delivered on the promise of the ACO. ... We suggest that the PFK model achieved these results because pediatric ACOs are better positioned to bridge coordination gaps in care than either an individualized patient-centered medical home or an insurer could do alone; the ACOs are, in effect, the medical neighborhood for the medical home,” said lead author Kelly Kelleher, vice president of health services research at the Research Institute at Nationwide Children’s Hospital and professor of pediatrics at Ohio State University, both in Columbus. “At least for Medicaid, pediatric ACOs may be efficient models of reforming health care. The lower rate of cost growth achieved by PFK bodes well for the short-term success of PFK’s business model and other pediatric ACOs,” said Dr. Kelleher.

Most PFK pediatricians are employees of Nationwide Children’s Hospital. Those who aren’t keep a percentage of their Medicaid fees over cost as an incentive. Also, Ohio’s Medicaid managed care plans pay PFK a monthly capitation fee based on their patients’ age and sex, and PFK keeps whatever they don’t spend on their patients.

The system seemed to work in the study because “PFK is able to provide a single set of provider guidelines for common conditions, a single set of collaborative activities for clinicians, and unified care coordination with pediatric specialty teams. As a physician/hospital organization, PFK is also more directly involved in the specialty care than a typical insurance company and can provide a unified voice on coordination and guidelines,” Dr. Kelleher said.

aotto@frontlinemedcom.com

Partners for Kids, one of the nation’s largest pediatric accountable care organizations (ACO), had lower cost growth than did Medicaid fee-for-service and managed care programs in Ohio from 2008 to 2013, without reducing overall quality of care, according to an observational, retrospective study published Feb. 9 in Pediatrics.

Accountable care organizations have been shown to reduce costs for adults without negatively impacting quality of care; however, there’s been little proof before now that the model works for children.

The per-patient/per-month cost increase for Partners for Kids (PFK), which covers more than 300,000 low-income children in central and southeastern Ohio, was $2.40/year from 2008 to 2013, vs. $16.15/year for the Ohio Medicaid fee-for-service program (P = .001) and $6.47/year for Ohio Medicaid managed care programs (almost statistically significant at P = .121).

© KatarzynaBialasiewicz/Thinkstock

Results on key quality measures were mixed. Slight improvements were seen over that time in PFK’s gastroenteritis admissions, pediatric acute care, and pediatric composite scores, as well as reduced neonatal ICU admissions and increased well-child visits. However, modest increases were seen in short-term admissions for diabetes and perioperative hemorrhages and hematomas (Pediatrics 2015 Feb. 9 [doi:10.1542/peds.2014-2725]).

Overall, the care differences were a wash; quality measures held fairly steady over the 5 years.

“PFK delivered on the promise of the ACO. ... We suggest that the PFK model achieved these results because pediatric ACOs are better positioned to bridge coordination gaps in care than either an individualized patient-centered medical home or an insurer could do alone; the ACOs are, in effect, the medical neighborhood for the medical home,” said lead author Kelly Kelleher, vice president of health services research at the Research Institute at Nationwide Children’s Hospital and professor of pediatrics at Ohio State University, both in Columbus. “At least for Medicaid, pediatric ACOs may be efficient models of reforming health care. The lower rate of cost growth achieved by PFK bodes well for the short-term success of PFK’s business model and other pediatric ACOs,” said Dr. Kelleher.

Most PFK pediatricians are employees of Nationwide Children’s Hospital. Those who aren’t keep a percentage of their Medicaid fees over cost as an incentive. Also, Ohio’s Medicaid managed care plans pay PFK a monthly capitation fee based on their patients’ age and sex, and PFK keeps whatever they don’t spend on their patients.

The system seemed to work in the study because “PFK is able to provide a single set of provider guidelines for common conditions, a single set of collaborative activities for clinicians, and unified care coordination with pediatric specialty teams. As a physician/hospital organization, PFK is also more directly involved in the specialty care than a typical insurance company and can provide a unified voice on coordination and guidelines,” Dr. Kelleher said.

aotto@frontlinemedcom.com

Partners for Kids, one of the nation’s largest pediatric accountable care organizations (ACO), had lower cost growth than did Medicaid fee-for-service and managed care programs in Ohio from 2008 to 2013, without reducing overall quality of care, according to an observational, retrospective study published Feb. 9 in Pediatrics.

Accountable care organizations have been shown to reduce costs for adults without negatively impacting quality of care; however, there’s been little proof before now that the model works for children.

The per-patient/per-month cost increase for Partners for Kids (PFK), which covers more than 300,000 low-income children in central and southeastern Ohio, was $2.40/year from 2008 to 2013, vs. $16.15/year for the Ohio Medicaid fee-for-service program (P = .001) and $6.47/year for Ohio Medicaid managed care programs (almost statistically significant at P = .121).

© KatarzynaBialasiewicz/Thinkstock

Results on key quality measures were mixed. Slight improvements were seen over that time in PFK’s gastroenteritis admissions, pediatric acute care, and pediatric composite scores, as well as reduced neonatal ICU admissions and increased well-child visits. However, modest increases were seen in short-term admissions for diabetes and perioperative hemorrhages and hematomas (Pediatrics 2015 Feb. 9 [doi:10.1542/peds.2014-2725]).

Overall, the care differences were a wash; quality measures held fairly steady over the 5 years.

“PFK delivered on the promise of the ACO. ... We suggest that the PFK model achieved these results because pediatric ACOs are better positioned to bridge coordination gaps in care than either an individualized patient-centered medical home or an insurer could do alone; the ACOs are, in effect, the medical neighborhood for the medical home,” said lead author Kelly Kelleher, vice president of health services research at the Research Institute at Nationwide Children’s Hospital and professor of pediatrics at Ohio State University, both in Columbus. “At least for Medicaid, pediatric ACOs may be efficient models of reforming health care. The lower rate of cost growth achieved by PFK bodes well for the short-term success of PFK’s business model and other pediatric ACOs,” said Dr. Kelleher.

Most PFK pediatricians are employees of Nationwide Children’s Hospital. Those who aren’t keep a percentage of their Medicaid fees over cost as an incentive. Also, Ohio’s Medicaid managed care plans pay PFK a monthly capitation fee based on their patients’ age and sex, and PFK keeps whatever they don’t spend on their patients.

The system seemed to work in the study because “PFK is able to provide a single set of provider guidelines for common conditions, a single set of collaborative activities for clinicians, and unified care coordination with pediatric specialty teams. As a physician/hospital organization, PFK is also more directly involved in the specialty care than a typical insurance company and can provide a unified voice on coordination and guidelines,” Dr. Kelleher said.

aotto@frontlinemedcom.com

Effective immediately, Medicare will cover annual lung cancer screening with low-dose CT for certain beneficiaries, according to a Feb. 5 national coverage determination.

To qualify, beneficiaries must be 55-77 years old, have a smoking history of at least a 30 pack-years, exhibit no signs or symptoms of lung cancer, and currently smoke or have quit within 15 years. They also must have a written screening order from their provider.

Coverage includes a counseling visit for shared decision-making, so patients know beforehand the “benefits and harms of screening, follow-up diagnostic testing, over-diagnosis, false positive[s], and total radiation exposure,” among other things, according to the decision memo from the Centers for Medicare & Medicaid Services.

Imaging centers are required to collect data on each screening and submit it to a CMS-approved registry.

“This is an important new Medicare preventive benefit since lung cancer is the third most common cancer and the leading cause of cancer deaths in the United States,” Dr. Patrick Conway, CMS chief medical officer, said in a statement. “We believe this final decision strikes an appropriate balance between providing access to this important preventive service and ensuring, to the best extent possible, that Medicare beneficiaries receive maximum benefit from a lung cancer screening program.”

"Thanks to the hard work of lung cancer experts from CHEST,  ​Drs. Peter Mazzone, Frank Detterbeck, Michael Gould, Peter Bach, and Charles Powell, we were able to see our policy statement make a meaningful impact on the final decision of CMS to cover LDCT screening for lung cancer for the targeted population. Hats off for the hard work of this group on behalf of ​members of ​the American College of Chest Physicians​ (CHEST)​, patients, and the lung cancer community." said Gerard Silvestri, MD, FCCP, President-Designate of CHEST and statement author.

The decision has been in the works for a while. In 2011, the National Cancer Institute–sponsored National Lung Screening Trial (NLST) showed that people aged 55-74 years with a history of heavy smoking are 20% less likely to die from lung cancer if they are screened with low-dose helical CT instead of standard chest x-ray (N. Engl. J. Med. 2011;365:395-409). Previous studies had shown that screening with standard chest x-rays does not reduce mortality from lung cancer.

Results from NLST and other studies prompted the U.S. Preventive Services Task Force in 2013 to recommend annual low-dose CT screening for adults aged 55-80 years with a 30 pack-year history; the recommendation in turn led to formal requests to CMS for coverage. In proposing coverage, the task force received almost 500 public comments “generally supportive of [expanding] Medicare coverage to include lung cancer screening,” it said.

Low-dose CT is performed at acquisition settings to minimize radiation exposure. For lung cancer screening, CMS is requiring a volumetric CT dose index (CTDIvol) of ≤ 3.0 mGy for standard-size patients – defined to be 5 feet 7 inches tall and approximately 155 pounds – with appropriate reductions or increases for smaller or larger patients.

aotto@frontlinemedcom.com

Effective immediately, Medicare will cover annual lung cancer screening with low-dose CT for certain beneficiaries, according to a Feb. 5 national coverage determination.

To qualify, beneficiaries must be 55-77 years old, have a smoking history of at least a 30 pack-years, exhibit no signs or symptoms of lung cancer, and currently smoke or have quit within 15 years. They also must have a written screening order from their provider.

Coverage includes a counseling visit for shared decision-making, so patients know beforehand the “benefits and harms of screening, follow-up diagnostic testing, over-diagnosis, false positive[s], and total radiation exposure,” among other things, according to the decision memo from the Centers for Medicare & Medicaid Services.

Imaging centers are required to collect data on each screening and submit it to a CMS-approved registry.

“This is an important new Medicare preventive benefit since lung cancer is the third most common cancer and the leading cause of cancer deaths in the United States,” Dr. Patrick Conway, CMS chief medical officer, said in a statement. “We believe this final decision strikes an appropriate balance between providing access to this important preventive service and ensuring, to the best extent possible, that Medicare beneficiaries receive maximum benefit from a lung cancer screening program.”

"Thanks to the hard work of lung cancer experts from CHEST,  ​Drs. Peter Mazzone, Frank Detterbeck, Michael Gould, Peter Bach, and Charles Powell, we were able to see our policy statement make a meaningful impact on the final decision of CMS to cover LDCT screening for lung cancer for the targeted population. Hats off for the hard work of this group on behalf of ​members of ​the American College of Chest Physicians​ (CHEST)​, patients, and the lung cancer community." said Gerard Silvestri, MD, FCCP, President-Designate of CHEST and statement author.

The decision has been in the works for a while. In 2011, the National Cancer Institute–sponsored National Lung Screening Trial (NLST) showed that people aged 55-74 years with a history of heavy smoking are 20% less likely to die from lung cancer if they are screened with low-dose helical CT instead of standard chest x-ray (N. Engl. J. Med. 2011;365:395-409). Previous studies had shown that screening with standard chest x-rays does not reduce mortality from lung cancer.

Results from NLST and other studies prompted the U.S. Preventive Services Task Force in 2013 to recommend annual low-dose CT screening for adults aged 55-80 years with a 30 pack-year history; the recommendation in turn led to formal requests to CMS for coverage. In proposing coverage, the task force received almost 500 public comments “generally supportive of [expanding] Medicare coverage to include lung cancer screening,” it said.

Low-dose CT is performed at acquisition settings to minimize radiation exposure. For lung cancer screening, CMS is requiring a volumetric CT dose index (CTDIvol) of ≤ 3.0 mGy for standard-size patients – defined to be 5 feet 7 inches tall and approximately 155 pounds – with appropriate reductions or increases for smaller or larger patients.

aotto@frontlinemedcom.com

Effective immediately, Medicare will cover annual lung cancer screening with low-dose CT for certain beneficiaries, according to a Feb. 5 national coverage determination.

To qualify, beneficiaries must be 55-77 years old, have a smoking history of at least a 30 pack-years, exhibit no signs or symptoms of lung cancer, and currently smoke or have quit within 15 years. They also must have a written screening order from their provider.

Coverage includes a counseling visit for shared decision-making, so patients know beforehand the “benefits and harms of screening, follow-up diagnostic testing, over-diagnosis, false positive[s], and total radiation exposure,” among other things, according to the decision memo from the Centers for Medicare & Medicaid Services.

Imaging centers are required to collect data on each screening and submit it to a CMS-approved registry.

“This is an important new Medicare preventive benefit since lung cancer is the third most common cancer and the leading cause of cancer deaths in the United States,” Dr. Patrick Conway, CMS chief medical officer, said in a statement. “We believe this final decision strikes an appropriate balance between providing access to this important preventive service and ensuring, to the best extent possible, that Medicare beneficiaries receive maximum benefit from a lung cancer screening program.”

"Thanks to the hard work of lung cancer experts from CHEST,  ​Drs. Peter Mazzone, Frank Detterbeck, Michael Gould, Peter Bach, and Charles Powell, we were able to see our policy statement make a meaningful impact on the final decision of CMS to cover LDCT screening for lung cancer for the targeted population. Hats off for the hard work of this group on behalf of ​members of ​the American College of Chest Physicians​ (CHEST)​, patients, and the lung cancer community." said Gerard Silvestri, MD, FCCP, President-Designate of CHEST and statement author.

The decision has been in the works for a while. In 2011, the National Cancer Institute–sponsored National Lung Screening Trial (NLST) showed that people aged 55-74 years with a history of heavy smoking are 20% less likely to die from lung cancer if they are screened with low-dose helical CT instead of standard chest x-ray (N. Engl. J. Med. 2011;365:395-409). Previous studies had shown that screening with standard chest x-rays does not reduce mortality from lung cancer.

Results from NLST and other studies prompted the U.S. Preventive Services Task Force in 2013 to recommend annual low-dose CT screening for adults aged 55-80 years with a 30 pack-year history; the recommendation in turn led to formal requests to CMS for coverage. In proposing coverage, the task force received almost 500 public comments “generally supportive of [expanding] Medicare coverage to include lung cancer screening,” it said.

Low-dose CT is performed at acquisition settings to minimize radiation exposure. For lung cancer screening, CMS is requiring a volumetric CT dose index (CTDIvol) of ≤ 3.0 mGy for standard-size patients – defined to be 5 feet 7 inches tall and approximately 155 pounds – with appropriate reductions or increases for smaller or larger patients.

aotto@frontlinemedcom.com

Effective immediately, Medicare will cover annual lung cancer screening with low-dose CT for certain beneficiaries, according to a Feb. 5 national coverage determination.

To qualify, beneficiaries must be 55-77 years old, have a smoking history of at least a 30 pack-years, exhibit no signs or symptoms of lung cancer, and currently smoke or have quit within 15 years. They also must have a written screening order from their provider.

Coverage includes a counseling visit for shared decision-making, so patients know beforehand the “benefits and harms of screening, follow-up diagnostic testing, over-diagnosis, false positive[s], and total radiation exposure,” among other things, according to the decision memo from the Centers for Medicare & Medicaid Services.

Imaging centers are required to collect data on each screening and submit it to a CMS-approved registry.

The decision has been in the works for a while. In 2011, the National Cancer Institute–sponsored National Lung Screening Trial (NLST) showed that people aged 55-74 years with a history of heavy smoking are 20% less likely to die from lung cancer if they are screened with low-dose helical CT instead of standard chest x-ray (N. Engl. J. Med. 2011;365:395-409). Previous studies had shown that screening with standard chest x-rays does not reduce mortality from lung cancer.

Results from NLST and other studies prompted the U.S. Preventive Services Task Force in 2013 to recommend annual low-dose CT screening for adults aged 55-80 years with a 30 pack-year history; the recommendation in turn led to formal requests to CMS for coverage. In proposing coverage, the task force received almost 500 public comments “generally supportive of [expanding] Medicare coverage to include lung cancer screening,” it said.

Low-dose CT is performed at acquisition settings to minimize radiation exposure. For lung cancer screening, CMS is requiring a volumetric CT dose index (CTDIvol) of ≤ 3.0 mGy for standard-size patients – defined to be 5 feet 7 inches tall and approximately 155 pounds – with appropriate reductions or increases for smaller or larger patients.

aotto@frontlinemedcom.com

Effective immediately, Medicare will cover annual lung cancer screening with low-dose CT for certain beneficiaries, according to a Feb. 5 national coverage determination.

To qualify, beneficiaries must be 55-77 years old, have a smoking history of at least a 30 pack-years, exhibit no signs or symptoms of lung cancer, and currently smoke or have quit within 15 years. They also must have a written screening order from their provider.

Coverage includes a counseling visit for shared decision-making, so patients know beforehand the “benefits and harms of screening, follow-up diagnostic testing, over-diagnosis, false positive[s], and total radiation exposure,” among other things, according to the decision memo from the Centers for Medicare & Medicaid Services.

Imaging centers are required to collect data on each screening and submit it to a CMS-approved registry.

The decision has been in the works for a while. In 2011, the National Cancer Institute–sponsored National Lung Screening Trial (NLST) showed that people aged 55-74 years with a history of heavy smoking are 20% less likely to die from lung cancer if they are screened with low-dose helical CT instead of standard chest x-ray (N. Engl. J. Med. 2011;365:395-409). Previous studies had shown that screening with standard chest x-rays does not reduce mortality from lung cancer.

Results from NLST and other studies prompted the U.S. Preventive Services Task Force in 2013 to recommend annual low-dose CT screening for adults aged 55-80 years with a 30 pack-year history; the recommendation in turn led to formal requests to CMS for coverage. In proposing coverage, the task force received almost 500 public comments “generally supportive of [expanding] Medicare coverage to include lung cancer screening,” it said.

Low-dose CT is performed at acquisition settings to minimize radiation exposure. For lung cancer screening, CMS is requiring a volumetric CT dose index (CTDIvol) of ≤ 3.0 mGy for standard-size patients – defined to be 5 feet 7 inches tall and approximately 155 pounds – with appropriate reductions or increases for smaller or larger patients.

aotto@frontlinemedcom.com

Effective immediately, Medicare will cover annual lung cancer screening with low-dose CT for certain beneficiaries, according to a Feb. 5 national coverage determination.

To qualify, beneficiaries must be 55-77 years old, have a smoking history of at least a 30 pack-years, exhibit no signs or symptoms of lung cancer, and currently smoke or have quit within 15 years. They also must have a written screening order from their provider.

Coverage includes a counseling visit for shared decision-making, so patients know beforehand the “benefits and harms of screening, follow-up diagnostic testing, over-diagnosis, false positive[s], and total radiation exposure,” among other things, according to the decision memo from the Centers for Medicare & Medicaid Services.

Imaging centers are required to collect data on each screening and submit it to a CMS-approved registry.

The decision has been in the works for a while. In 2011, the National Cancer Institute–sponsored National Lung Screening Trial (NLST) showed that people aged 55-74 years with a history of heavy smoking are 20% less likely to die from lung cancer if they are screened with low-dose helical CT instead of standard chest x-ray (N. Engl. J. Med. 2011;365:395-409). Previous studies had shown that screening with standard chest x-rays does not reduce mortality from lung cancer.

Results from NLST and other studies prompted the U.S. Preventive Services Task Force in 2013 to recommend annual low-dose CT screening for adults aged 55-80 years with a 30 pack-year history; the recommendation in turn led to formal requests to CMS for coverage. In proposing coverage, the task force received almost 500 public comments “generally supportive of [expanding] Medicare coverage to include lung cancer screening,” it said.

Low-dose CT is performed at acquisition settings to minimize radiation exposure. For lung cancer screening, CMS is requiring a volumetric CT dose index (CTDIvol) of ≤ 3.0 mGy for standard-size patients – defined to be 5 feet 7 inches tall and approximately 155 pounds – with appropriate reductions or increases for smaller or larger patients.

aotto@frontlinemedcom.com

PHOENIX – The NSAID ketorolac is safe to use in very young children after cardiac surgery, and dramatically decreases the length of intubation and ICU stay as well as the use of opioids, according to a retrospective cohort study from the Cohen Children’s Medical Center in New Hyde Park, N.Y.

Ketorolac is catching on in some places for postoperative pain control, but there are still significant concerns about nephrotoxicity and bleeding, especially in children, said Dr. Tracie Lin, a pediatrics resident at the medical center.

M. Alexander Otto/Frontline Medical News

Those potential side effects didn’t turn out to be problems when her team compared outcomes in 26 children who received ketorolac – 0.5 mg/kg to a maximum of 30 mg/day – to 34 who did not receive it following congenital heart surgery.

“Think twice before holding back on ketorolac. There seems to be a lot of benefit, and less harm than someone might expect,” Dr. Lin said at the meeting sponsored by the Society for Critical Care Medicine.

Patients who received ketorolac, a mean of 35.5 months old, received less than 0.5 mg/kg per day of morphine IV equivalents in the first day after surgery, even less on day 2, and virtually none on day 3. They were, on average, intubated less than a day, in the ICU for 110 hours, and in the hospital for 5 days.

Patients in the no-ketorolac group, a mean of 2 months old, received almost 4 mg/kg per day of morphine IV equivalents in the first and second postop day, and about 2 mg/kg per day on day 3. They were intubated for an average of 3 days, in the ICU for 188 hours, and in the hospital for 17 days.

The age difference between the two groups probably reflects the hesitancy to use ketorolac in children under 6 months old. Only a couple children under 6 months old received ketorolac in the study; it didn’t cause them any kidney problems, Dr. Lin said.

Pain control was statistically equal in both groups, with pain-free assessments over 75% of the time during the first 3 postop days in both groups, and there were no statistically significant differences in the rates of breakthrough pain.

Meanwhile, “we found no additional nephrotoxicity” in the children taking ketorolac, Dr. Lin said.

At ICU arrival and after cardiac surgery, about 60% of those taking ketorolac had some degree of acute kidney injury, mostly stage 1 or 2; the finding was the same at 2 weeks post op. About 40% of children in the no-ketorolac group arrived at the ICU with some degree of acute kidney injury, again the majority stage 1 and 2; at 2 weeks assessment, that number had increased to almost 60%.

The investigators did not directly assess postoperative bleeding, but children taking ketorolac had their chest tubes pulled at about 3 days, while those in the no-ketorolac group retained their chest tubes for about 5 days. The finding suggests that ketorolac didn’t cause bleeding problems that prevented chest tube removal, Dr. Lin said.

There were other differences between the groups; ketorolac patients had RACH-1 [Risk Adjustment for Congenital Heart Surgery] scores of 3 or less, and almost all had sternotomies.

Children in the no-ketorolac group had RACH-1 scores ranging from 1 to 5, and although the majority had sternotomies, about a quarter had thoracotomies. The differences in incision types were most likely related to age-specific indications for surgery.

Dr. Lin and her team adjusted for all those differences on multivariate analysis, and found that the benefits of ketorolac remained; they “were not due to confounders,” she said.

The investigators have no relevant disclosures, and there was no external funding for the project.

aotto@frontlinemedcom.com

PHOENIX – The NSAID ketorolac is safe to use in very young children after cardiac surgery, and dramatically decreases the length of intubation and ICU stay as well as the use of opioids, according to a retrospective cohort study from the Cohen Children’s Medical Center in New Hyde Park, N.Y.

Ketorolac is catching on in some places for postoperative pain control, but there are still significant concerns about nephrotoxicity and bleeding, especially in children, said Dr. Tracie Lin, a pediatrics resident at the medical center.

M. Alexander Otto/Frontline Medical News

Those potential side effects didn’t turn out to be problems when her team compared outcomes in 26 children who received ketorolac – 0.5 mg/kg to a maximum of 30 mg/day – to 34 who did not receive it following congenital heart surgery.

“Think twice before holding back on ketorolac. There seems to be a lot of benefit, and less harm than someone might expect,” Dr. Lin said at the meeting sponsored by the Society for Critical Care Medicine.

Patients who received ketorolac, a mean of 35.5 months old, received less than 0.5 mg/kg per day of morphine IV equivalents in the first day after surgery, even less on day 2, and virtually none on day 3. They were, on average, intubated less than a day, in the ICU for 110 hours, and in the hospital for 5 days.

Patients in the no-ketorolac group, a mean of 2 months old, received almost 4 mg/kg per day of morphine IV equivalents in the first and second postop day, and about 2 mg/kg per day on day 3. They were intubated for an average of 3 days, in the ICU for 188 hours, and in the hospital for 17 days.

The age difference between the two groups probably reflects the hesitancy to use ketorolac in children under 6 months old. Only a couple children under 6 months old received ketorolac in the study; it didn’t cause them any kidney problems, Dr. Lin said.

Pain control was statistically equal in both groups, with pain-free assessments over 75% of the time during the first 3 postop days in both groups, and there were no statistically significant differences in the rates of breakthrough pain.

Meanwhile, “we found no additional nephrotoxicity” in the children taking ketorolac, Dr. Lin said.

At ICU arrival and after cardiac surgery, about 60% of those taking ketorolac had some degree of acute kidney injury, mostly stage 1 or 2; the finding was the same at 2 weeks post op. About 40% of children in the no-ketorolac group arrived at the ICU with some degree of acute kidney injury, again the majority stage 1 and 2; at 2 weeks assessment, that number had increased to almost 60%.

The investigators did not directly assess postoperative bleeding, but children taking ketorolac had their chest tubes pulled at about 3 days, while those in the no-ketorolac group retained their chest tubes for about 5 days. The finding suggests that ketorolac didn’t cause bleeding problems that prevented chest tube removal, Dr. Lin said.

There were other differences between the groups; ketorolac patients had RACH-1 [Risk Adjustment for Congenital Heart Surgery] scores of 3 or less, and almost all had sternotomies.

Children in the no-ketorolac group had RACH-1 scores ranging from 1 to 5, and although the majority had sternotomies, about a quarter had thoracotomies. The differences in incision types were most likely related to age-specific indications for surgery.

Dr. Lin and her team adjusted for all those differences on multivariate analysis, and found that the benefits of ketorolac remained; they “were not due to confounders,” she said.

The investigators have no relevant disclosures, and there was no external funding for the project.

aotto@frontlinemedcom.com

PHOENIX – The NSAID ketorolac is safe to use in very young children after cardiac surgery, and dramatically decreases the length of intubation and ICU stay as well as the use of opioids, according to a retrospective cohort study from the Cohen Children’s Medical Center in New Hyde Park, N.Y.

Ketorolac is catching on in some places for postoperative pain control, but there are still significant concerns about nephrotoxicity and bleeding, especially in children, said Dr. Tracie Lin, a pediatrics resident at the medical center.

M. Alexander Otto/Frontline Medical News

Those potential side effects didn’t turn out to be problems when her team compared outcomes in 26 children who received ketorolac – 0.5 mg/kg to a maximum of 30 mg/day – to 34 who did not receive it following congenital heart surgery.

“Think twice before holding back on ketorolac. There seems to be a lot of benefit, and less harm than someone might expect,” Dr. Lin said at the meeting sponsored by the Society for Critical Care Medicine.

Patients who received ketorolac, a mean of 35.5 months old, received less than 0.5 mg/kg per day of morphine IV equivalents in the first day after surgery, even less on day 2, and virtually none on day 3. They were, on average, intubated less than a day, in the ICU for 110 hours, and in the hospital for 5 days.

Patients in the no-ketorolac group, a mean of 2 months old, received almost 4 mg/kg per day of morphine IV equivalents in the first and second postop day, and about 2 mg/kg per day on day 3. They were intubated for an average of 3 days, in the ICU for 188 hours, and in the hospital for 17 days.

The age difference between the two groups probably reflects the hesitancy to use ketorolac in children under 6 months old. Only a couple children under 6 months old received ketorolac in the study; it didn’t cause them any kidney problems, Dr. Lin said.

Pain control was statistically equal in both groups, with pain-free assessments over 75% of the time during the first 3 postop days in both groups, and there were no statistically significant differences in the rates of breakthrough pain.

Meanwhile, “we found no additional nephrotoxicity” in the children taking ketorolac, Dr. Lin said.

At ICU arrival and after cardiac surgery, about 60% of those taking ketorolac had some degree of acute kidney injury, mostly stage 1 or 2; the finding was the same at 2 weeks post op. About 40% of children in the no-ketorolac group arrived at the ICU with some degree of acute kidney injury, again the majority stage 1 and 2; at 2 weeks assessment, that number had increased to almost 60%.

The investigators did not directly assess postoperative bleeding, but children taking ketorolac had their chest tubes pulled at about 3 days, while those in the no-ketorolac group retained their chest tubes for about 5 days. The finding suggests that ketorolac didn’t cause bleeding problems that prevented chest tube removal, Dr. Lin said.

There were other differences between the groups; ketorolac patients had RACH-1 [Risk Adjustment for Congenital Heart Surgery] scores of 3 or less, and almost all had sternotomies.

Children in the no-ketorolac group had RACH-1 scores ranging from 1 to 5, and although the majority had sternotomies, about a quarter had thoracotomies. The differences in incision types were most likely related to age-specific indications for surgery.

Dr. Lin and her team adjusted for all those differences on multivariate analysis, and found that the benefits of ketorolac remained; they “were not due to confounders,” she said.

The investigators have no relevant disclosures, and there was no external funding for the project.

aotto@frontlinemedcom.com

PHOENIX – Intravenous acetaminophen was no better than oral acetaminophen at relieving pain in neurocritical ICU patients with stroke and other conditions in a retrospective study at Virginia Commonwealth University in Richmond.

From May 2012 to April 2013, 312 patients – about a quarter of all neuroscience ICU admissions – got a median of three 1,000-mg doses of IV acetaminophen (Ofirmev), usually every 6 hours as needed. By 3 hours after their first dose, those with a median baseline pain score of 4 on a 10-point scale had dropped 1.5 points and remained there when reassessed at 6 hours. Pain was measured either by patient report or nurse assessment, using vital signs, grimacing, and other measures.

About the same number of patients received oral acetaminophen, usually 650 mg, also every 6 hours. At 3 hours, patients with an initial median score of 4 had dropped a mean of 1.7 points; at 6 hours, they had fallen by about 2 points from baseline. Many of the patients in both the intravenous and oral groups needed rescue opioids, usually fentanyl.

Intracranial hemorrhages were the most common diagnoses in both the oral and intravenous groups, followed by subarachnoid hemorrhages and traumatic brain injuries.

The study begins to answer a question on the minds of many health care providers: Is it worth paying $33 for a dose of intravenous acetaminophen when oral acetaminophen costs 5 cents a pill?

Alex Otto/Frontline Medical News

“This was completely surprising to us. Everything that we learn in pharmacy school says IV is going to be more effective than oral. We thought we’d see a difference, but we didn’t,” said lead investigator Dan Nichols, a third-year pharmacy student at Virginia Commonwealth University, Richmond.

“In fact, oral was actually more effective in traumatic brain injury patients,” as well as in patients who received rescue opioids and the small number in whom acetaminophen was the only pain medication needed, he said at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.

As with any intravenous drug, IV acetaminophen bypasses the vagaries of the gastrointestinal tract, so its pharmacokinetics are much quicker than oral formulations. Peak plasma concentrations come at the end of the 15 minute infusion.

That might translate to quicker pain relief; the investigators next plan to compare pain scores at 1 and 2 hours, and analyze whether Glasgow Coma Score, surgery, and other confounders make a difference.

In the meantime, “we and every institution I’ve spoken to have restricted its use, because we don’t have data saying it’s more effective. At $33 a dose” – recently up from $10 – “it’s harder to justify. At least in the 0-3 hour window, it didn’t have any additional benefit over oral. It might still be better at 1 hour; kinetically, that would make sense, but there’s nothing yet to say from what we did that it’s better,” said senior investigator Gretchen M. Brophy, Pharm.D., of the departments of pharmacy and neurosurgery at VCU.

For now, VCU has restricted intravenous acetaminophen to one dose per patient.

The mean age in the study was 55 years, and just over half the patients were men.

Dr. Brophy is a speaker for Cadence Pharmaceuticals, the maker of intravenous acetaminophen. There was no outside funding for the work.

aotto@frontlinemedcom.com

PHOENIX – Intravenous acetaminophen was no better than oral acetaminophen at relieving pain in neurocritical ICU patients with stroke and other conditions in a retrospective study at Virginia Commonwealth University in Richmond.

From May 2012 to April 2013, 312 patients – about a quarter of all neuroscience ICU admissions – got a median of three 1,000-mg doses of IV acetaminophen (Ofirmev), usually every 6 hours as needed. By 3 hours after their first dose, those with a median baseline pain score of 4 on a 10-point scale had dropped 1.5 points and remained there when reassessed at 6 hours. Pain was measured either by patient report or nurse assessment, using vital signs, grimacing, and other measures.

About the same number of patients received oral acetaminophen, usually 650 mg, also every 6 hours. At 3 hours, patients with an initial median score of 4 had dropped a mean of 1.7 points; at 6 hours, they had fallen by about 2 points from baseline. Many of the patients in both the intravenous and oral groups needed rescue opioids, usually fentanyl.

Intracranial hemorrhages were the most common diagnoses in both the oral and intravenous groups, followed by subarachnoid hemorrhages and traumatic brain injuries.

The study begins to answer a question on the minds of many health care providers: Is it worth paying $33 for a dose of intravenous acetaminophen when oral acetaminophen costs 5 cents a pill?

Alex Otto/Frontline Medical News

“This was completely surprising to us. Everything that we learn in pharmacy school says IV is going to be more effective than oral. We thought we’d see a difference, but we didn’t,” said lead investigator Dan Nichols, a third-year pharmacy student at Virginia Commonwealth University, Richmond.

“In fact, oral was actually more effective in traumatic brain injury patients,” as well as in patients who received rescue opioids and the small number in whom acetaminophen was the only pain medication needed, he said at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.

As with any intravenous drug, IV acetaminophen bypasses the vagaries of the gastrointestinal tract, so its pharmacokinetics are much quicker than oral formulations. Peak plasma concentrations come at the end of the 15 minute infusion.

That might translate to quicker pain relief; the investigators next plan to compare pain scores at 1 and 2 hours, and analyze whether Glasgow Coma Score, surgery, and other confounders make a difference.

In the meantime, “we and every institution I’ve spoken to have restricted its use, because we don’t have data saying it’s more effective. At $33 a dose” – recently up from $10 – “it’s harder to justify. At least in the 0-3 hour window, it didn’t have any additional benefit over oral. It might still be better at 1 hour; kinetically, that would make sense, but there’s nothing yet to say from what we did that it’s better,” said senior investigator Gretchen M. Brophy, Pharm.D., of the departments of pharmacy and neurosurgery at VCU.

For now, VCU has restricted intravenous acetaminophen to one dose per patient.

The mean age in the study was 55 years, and just over half the patients were men.

Dr. Brophy is a speaker for Cadence Pharmaceuticals, the maker of intravenous acetaminophen. There was no outside funding for the work.

aotto@frontlinemedcom.com

PHOENIX – Intravenous acetaminophen was no better than oral acetaminophen at relieving pain in neurocritical ICU patients with stroke and other conditions in a retrospective study at Virginia Commonwealth University in Richmond.

From May 2012 to April 2013, 312 patients – about a quarter of all neuroscience ICU admissions – got a median of three 1,000-mg doses of IV acetaminophen (Ofirmev), usually every 6 hours as needed. By 3 hours after their first dose, those with a median baseline pain score of 4 on a 10-point scale had dropped 1.5 points and remained there when reassessed at 6 hours. Pain was measured either by patient report or nurse assessment, using vital signs, grimacing, and other measures.

About the same number of patients received oral acetaminophen, usually 650 mg, also every 6 hours. At 3 hours, patients with an initial median score of 4 had dropped a mean of 1.7 points; at 6 hours, they had fallen by about 2 points from baseline. Many of the patients in both the intravenous and oral groups needed rescue opioids, usually fentanyl.

Intracranial hemorrhages were the most common diagnoses in both the oral and intravenous groups, followed by subarachnoid hemorrhages and traumatic brain injuries.

The study begins to answer a question on the minds of many health care providers: Is it worth paying $33 for a dose of intravenous acetaminophen when oral acetaminophen costs 5 cents a pill?

Alex Otto/Frontline Medical News

“This was completely surprising to us. Everything that we learn in pharmacy school says IV is going to be more effective than oral. We thought we’d see a difference, but we didn’t,” said lead investigator Dan Nichols, a third-year pharmacy student at Virginia Commonwealth University, Richmond.

“In fact, oral was actually more effective in traumatic brain injury patients,” as well as in patients who received rescue opioids and the small number in whom acetaminophen was the only pain medication needed, he said at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.

As with any intravenous drug, IV acetaminophen bypasses the vagaries of the gastrointestinal tract, so its pharmacokinetics are much quicker than oral formulations. Peak plasma concentrations come at the end of the 15 minute infusion.

That might translate to quicker pain relief; the investigators next plan to compare pain scores at 1 and 2 hours, and analyze whether Glasgow Coma Score, surgery, and other confounders make a difference.

In the meantime, “we and every institution I’ve spoken to have restricted its use, because we don’t have data saying it’s more effective. At $33 a dose” – recently up from $10 – “it’s harder to justify. At least in the 0-3 hour window, it didn’t have any additional benefit over oral. It might still be better at 1 hour; kinetically, that would make sense, but there’s nothing yet to say from what we did that it’s better,” said senior investigator Gretchen M. Brophy, Pharm.D., of the departments of pharmacy and neurosurgery at VCU.

For now, VCU has restricted intravenous acetaminophen to one dose per patient.

The mean age in the study was 55 years, and just over half the patients were men.

Dr. Brophy is a speaker for Cadence Pharmaceuticals, the maker of intravenous acetaminophen. There was no outside funding for the work.

aotto@frontlinemedcom.com

The future looks bright for new atopic dermatitis treatments, according to Dr. Charles Ellis, a dermatology professor at the University of Michigan in Ann Arbor.

“I think we are at the point where we were with psoriasis some years ago; if you think back 15 years, we had methotrexate and that was about it” systemically for psoriasis, but then the biologics arrived. “We are at that point now” for atopic dermatitis, with biologics in the pipeline. “I think we’ve turned the corner,” Dr. Ellis said at the meeting sponsored by Global Academy for Medical Education.

It “should make a big difference for patients; there’s an unmet need for systemic treatments. The leading candidate is dupilumab; the data look good,” he said.

Trials of the human monoclonal antibody report that over 80% of patients achieve 50% reductions in Eczema Area and Severity Index scores, versus about a third with placebo (N. Engl. J. Med. 2014;371:130-9). Dupilumab is currently in phase III testing.

A Food and Drug Administration advisory panel recently and unanimously recommended approval of another human monoclonal antibody, secukinumab, for plaque psoriasis. “It could be useful in atopic dermatitis. It’s certainly something that we want to look into,” Dr. Ellis said.

Both agents are interleukin blockers, and more are in development, along with drugs and biologics with different targets.

Meanwhile, the phosphodiesterase inhibitor apremilast, approved by the FDA in 2014 for plaque psoriasis and psoriatic arthritis, is being studied for atopic dermatitis, although results aren’t due until 2016.

Overall, and at least with current treatments, “I think the main thing that we do” at the University of Michigan “is treat aggressively. When you treat aggressively, you show patients that the therapy works, so they are much more likely to use it,” Dr. Ellis said.

One-percent hydrocortisone cream is the strongest thing that a lot of patients have tried by the time they walk through the doors in Ann Arbor; many are close to losing hope in medical treatment.

Because of that, “we are more likely to use higher-potency topical corticosteroids, and use them more often and under occlusion. We are very likely to try triamcinolone in children and sometimes even more potent corticosteroids in adults. We [also] use a fair amount of methotrexate.” The heightened approach can “make a big difference,” he said.

Continue for customer service importance >>

Customer service is another focus at the university. If patients or parents feel better about their visits – not just with the doctor, but from their appointment phone calls right through to their checkouts – they are more likely to stick with treatments.

Dr. Ellis leads a service excellence program to train physicians, nurses, and ancillary staff to ensure that visits go well and patient needs are met. It’s “similar to what you might find in a fancy hotel chain,” and has proven itself with high patient satisfaction scores, he said.

A thorough history is part of good customer service. One thing to pay attention to is calcium channel blocker and thiazide use in older patients.

Both can cause chronic eczematous eruptions that look like atopic dermatitis, and elderly people might have been on the drugs for so long that the relationship with skin problems is easy to miss.

“If you haven’t contemplated particularly calcium channel blockers as a potential cause, you might not give patients a chance to go off them for a while to see if it helps,” he said.

Global Academy and this news organization are owned by the same parent company.

Dr. Ellis is a consultant for Celgene, Ferndale, Otsuka, and Johnson & Johnson.

The future looks bright for new atopic dermatitis treatments, according to Dr. Charles Ellis, a dermatology professor at the University of Michigan in Ann Arbor.

“I think we are at the point where we were with psoriasis some years ago; if you think back 15 years, we had methotrexate and that was about it” systemically for psoriasis, but then the biologics arrived. “We are at that point now” for atopic dermatitis, with biologics in the pipeline. “I think we’ve turned the corner,” Dr. Ellis said at the meeting sponsored by Global Academy for Medical Education.

It “should make a big difference for patients; there’s an unmet need for systemic treatments. The leading candidate is dupilumab; the data look good,” he said.

Trials of the human monoclonal antibody report that over 80% of patients achieve 50% reductions in Eczema Area and Severity Index scores, versus about a third with placebo (N. Engl. J. Med. 2014;371:130-9). Dupilumab is currently in phase III testing.

A Food and Drug Administration advisory panel recently and unanimously recommended approval of another human monoclonal antibody, secukinumab, for plaque psoriasis. “It could be useful in atopic dermatitis. It’s certainly something that we want to look into,” Dr. Ellis said.

Both agents are interleukin blockers, and more are in development, along with drugs and biologics with different targets.

Meanwhile, the phosphodiesterase inhibitor apremilast, approved by the FDA in 2014 for plaque psoriasis and psoriatic arthritis, is being studied for atopic dermatitis, although results aren’t due until 2016.

Overall, and at least with current treatments, “I think the main thing that we do” at the University of Michigan “is treat aggressively. When you treat aggressively, you show patients that the therapy works, so they are much more likely to use it,” Dr. Ellis said.

One-percent hydrocortisone cream is the strongest thing that a lot of patients have tried by the time they walk through the doors in Ann Arbor; many are close to losing hope in medical treatment.

Because of that, “we are more likely to use higher-potency topical corticosteroids, and use them more often and under occlusion. We are very likely to try triamcinolone in children and sometimes even more potent corticosteroids in adults. We [also] use a fair amount of methotrexate.” The heightened approach can “make a big difference,” he said.

Continue for customer service importance >>

Customer service is another focus at the university. If patients or parents feel better about their visits – not just with the doctor, but from their appointment phone calls right through to their checkouts – they are more likely to stick with treatments.

Dr. Ellis leads a service excellence program to train physicians, nurses, and ancillary staff to ensure that visits go well and patient needs are met. It’s “similar to what you might find in a fancy hotel chain,” and has proven itself with high patient satisfaction scores, he said.

A thorough history is part of good customer service. One thing to pay attention to is calcium channel blocker and thiazide use in older patients.

Both can cause chronic eczematous eruptions that look like atopic dermatitis, and elderly people might have been on the drugs for so long that the relationship with skin problems is easy to miss.

“If you haven’t contemplated particularly calcium channel blockers as a potential cause, you might not give patients a chance to go off them for a while to see if it helps,” he said.

Global Academy and this news organization are owned by the same parent company.

Dr. Ellis is a consultant for Celgene, Ferndale, Otsuka, and Johnson & Johnson.

The future looks bright for new atopic dermatitis treatments, according to Dr. Charles Ellis, a dermatology professor at the University of Michigan in Ann Arbor.

“I think we are at the point where we were with psoriasis some years ago; if you think back 15 years, we had methotrexate and that was about it” systemically for psoriasis, but then the biologics arrived. “We are at that point now” for atopic dermatitis, with biologics in the pipeline. “I think we’ve turned the corner,” Dr. Ellis said at the meeting sponsored by Global Academy for Medical Education.

It “should make a big difference for patients; there’s an unmet need for systemic treatments. The leading candidate is dupilumab; the data look good,” he said.

Trials of the human monoclonal antibody report that over 80% of patients achieve 50% reductions in Eczema Area and Severity Index scores, versus about a third with placebo (N. Engl. J. Med. 2014;371:130-9). Dupilumab is currently in phase III testing.

A Food and Drug Administration advisory panel recently and unanimously recommended approval of another human monoclonal antibody, secukinumab, for plaque psoriasis. “It could be useful in atopic dermatitis. It’s certainly something that we want to look into,” Dr. Ellis said.

Both agents are interleukin blockers, and more are in development, along with drugs and biologics with different targets.

Meanwhile, the phosphodiesterase inhibitor apremilast, approved by the FDA in 2014 for plaque psoriasis and psoriatic arthritis, is being studied for atopic dermatitis, although results aren’t due until 2016.

Overall, and at least with current treatments, “I think the main thing that we do” at the University of Michigan “is treat aggressively. When you treat aggressively, you show patients that the therapy works, so they are much more likely to use it,” Dr. Ellis said.

One-percent hydrocortisone cream is the strongest thing that a lot of patients have tried by the time they walk through the doors in Ann Arbor; many are close to losing hope in medical treatment.

Because of that, “we are more likely to use higher-potency topical corticosteroids, and use them more often and under occlusion. We are very likely to try triamcinolone in children and sometimes even more potent corticosteroids in adults. We [also] use a fair amount of methotrexate.” The heightened approach can “make a big difference,” he said.

Continue for customer service importance >>

Customer service is another focus at the university. If patients or parents feel better about their visits – not just with the doctor, but from their appointment phone calls right through to their checkouts – they are more likely to stick with treatments.

Dr. Ellis leads a service excellence program to train physicians, nurses, and ancillary staff to ensure that visits go well and patient needs are met. It’s “similar to what you might find in a fancy hotel chain,” and has proven itself with high patient satisfaction scores, he said.

A thorough history is part of good customer service. One thing to pay attention to is calcium channel blocker and thiazide use in older patients.

Both can cause chronic eczematous eruptions that look like atopic dermatitis, and elderly people might have been on the drugs for so long that the relationship with skin problems is easy to miss.

“If you haven’t contemplated particularly calcium channel blockers as a potential cause, you might not give patients a chance to go off them for a while to see if it helps,” he said.

Global Academy and this news organization are owned by the same parent company.

Dr. Ellis is a consultant for Celgene, Ferndale, Otsuka, and Johnson & Johnson.

The future looks bright for new atopic dermatitis treatments, according to Dr. Charles Ellis, a dermatology professor at the University of Michigan in Ann Arbor.

“I think we are at the point where we were with psoriasis some years ago; if you think back 15 years, we had methotrexate and that was about it” systemically for psoriasis, but then the biologics arrived. “We are at that point now” for atopic dermatitis, with biologics in the pipeline. “I think we’ve turned the corner,” Dr. Ellis said at the meeting sponsored by Global Academy for Medical Education.

It “should make a big difference for patients; there’s an unmet need for systemic treatments. The leading candidate is dupilumab; the data look good,” he said.

Trials of the human monoclonal antibody report that over 80% of patients achieve 50% reductions in Eczema Area and Severity Index scores, versus about a third with placebo (N. Engl. J. Med. 2014;371:130-9). Dupilumab is currently in phase III testing.

A Food and Drug Administration advisory panel recently and unanimously recommended approval of another human monoclonal antibody, secukinumab, for plaque psoriasis. “It could be useful in atopic dermatitis. It’s certainly something that we want to look into,” Dr. Ellis said.

Both agents are interleukin blockers, and more are in development, along with drugs and biologics with different targets.

Meanwhile, the phosphodiesterase inhibitor apremilast, approved by the FDA in 2014 for plaque psoriasis and psoriatic arthritis, is being studied for atopic dermatitis, although results aren’t due until 2016.

Overall, and at least with current treatments, “I think the main thing that we do” at the University of Michigan “is treat aggressively. When you treat aggressively, you show patients that the therapy works, so they are much more likely to use it,” Dr. Ellis said.

One-percent hydrocortisone cream is the strongest thing that a lot of patients have tried by the time they walk through the doors in Ann Arbor; many are close to losing hope in medical treatment.

Because of that, “we are more likely to use higher-potency topical corticosteroids, and use them more often and under occlusion. We are very likely to try triamcinolone in children and sometimes even more potent corticosteroids in adults. We [also] use a fair amount of methotrexate.” The heightened approach can “make a big difference,” he said.

Customer service is another focus at the university. If patients or parents feel better about their visits – not just with the doctor, but from their appointment phone calls right through to their checkouts – they are more likely to stick with treatments.

Dr. Ellis leads a service excellence program to train physicians, nurses, and ancillary staff to ensure that visits go well and patient needs are met. It’s “similar to what you might find in a fancy hotel chain,” and has proven itself with high patient satisfaction scores, he said.

A thorough history is part of good customer service. One thing to pay attention to is calcium channel blocker and thiazide use in older patients.

Both can cause chronic eczematous eruptions that look like atopic dermatitis, and elderly people might have been on the drugs for so long that the relationship with skin problems is easy to miss.

“If you haven’t contemplated particularly calcium channel blockers as a potential cause, you might not give patients a chance to go off them for a while to see if it helps,” he said.

Global Academy and this news organization are owned by the same parent company.

Dr. Ellis is a consultant for Celgene, Ferndale, Otsuka, and Johnson & Johnson.

aotto@frontlinemedcom.com

The future looks bright for new atopic dermatitis treatments, according to Dr. Charles Ellis, a dermatology professor at the University of Michigan in Ann Arbor.

“I think we are at the point where we were with psoriasis some years ago; if you think back 15 years, we had methotrexate and that was about it” systemically for psoriasis, but then the biologics arrived. “We are at that point now” for atopic dermatitis, with biologics in the pipeline. “I think we’ve turned the corner,” Dr. Ellis said at the meeting sponsored by Global Academy for Medical Education.

It “should make a big difference for patients; there’s an unmet need for systemic treatments. The leading candidate is dupilumab; the data look good,” he said.

Trials of the human monoclonal antibody report that over 80% of patients achieve 50% reductions in Eczema Area and Severity Index scores, versus about a third with placebo (N. Engl. J. Med. 2014;371:130-9). Dupilumab is currently in phase III testing.

A Food and Drug Administration advisory panel recently and unanimously recommended approval of another human monoclonal antibody, secukinumab, for plaque psoriasis. “It could be useful in atopic dermatitis. It’s certainly something that we want to look into,” Dr. Ellis said.

Both agents are interleukin blockers, and more are in development, along with drugs and biologics with different targets.

Meanwhile, the phosphodiesterase inhibitor apremilast, approved by the FDA in 2014 for plaque psoriasis and psoriatic arthritis, is being studied for atopic dermatitis, although results aren’t due until 2016.

Overall, and at least with current treatments, “I think the main thing that we do” at the University of Michigan “is treat aggressively. When you treat aggressively, you show patients that the therapy works, so they are much more likely to use it,” Dr. Ellis said.

One-percent hydrocortisone cream is the strongest thing that a lot of patients have tried by the time they walk through the doors in Ann Arbor; many are close to losing hope in medical treatment.

Because of that, “we are more likely to use higher-potency topical corticosteroids, and use them more often and under occlusion. We are very likely to try triamcinolone in children and sometimes even more potent corticosteroids in adults. We [also] use a fair amount of methotrexate.” The heightened approach can “make a big difference,” he said.

Customer service is another focus at the university. If patients or parents feel better about their visits – not just with the doctor, but from their appointment phone calls right through to their checkouts – they are more likely to stick with treatments.

Dr. Ellis leads a service excellence program to train physicians, nurses, and ancillary staff to ensure that visits go well and patient needs are met. It’s “similar to what you might find in a fancy hotel chain,” and has proven itself with high patient satisfaction scores, he said.

A thorough history is part of good customer service. One thing to pay attention to is calcium channel blocker and thiazide use in older patients.

Both can cause chronic eczematous eruptions that look like atopic dermatitis, and elderly people might have been on the drugs for so long that the relationship with skin problems is easy to miss.

“If you haven’t contemplated particularly calcium channel blockers as a potential cause, you might not give patients a chance to go off them for a while to see if it helps,” he said.

Global Academy and this news organization are owned by the same parent company.

Dr. Ellis is a consultant for Celgene, Ferndale, Otsuka, and Johnson & Johnson.

aotto@frontlinemedcom.com

The future looks bright for new atopic dermatitis treatments, according to Dr. Charles Ellis, a dermatology professor at the University of Michigan in Ann Arbor.

“I think we are at the point where we were with psoriasis some years ago; if you think back 15 years, we had methotrexate and that was about it” systemically for psoriasis, but then the biologics arrived. “We are at that point now” for atopic dermatitis, with biologics in the pipeline. “I think we’ve turned the corner,” Dr. Ellis said at the meeting sponsored by Global Academy for Medical Education.

It “should make a big difference for patients; there’s an unmet need for systemic treatments. The leading candidate is dupilumab; the data look good,” he said.

Trials of the human monoclonal antibody report that over 80% of patients achieve 50% reductions in Eczema Area and Severity Index scores, versus about a third with placebo (N. Engl. J. Med. 2014;371:130-9). Dupilumab is currently in phase III testing.

A Food and Drug Administration advisory panel recently and unanimously recommended approval of another human monoclonal antibody, secukinumab, for plaque psoriasis. “It could be useful in atopic dermatitis. It’s certainly something that we want to look into,” Dr. Ellis said.

Both agents are interleukin blockers, and more are in development, along with drugs and biologics with different targets.

Meanwhile, the phosphodiesterase inhibitor apremilast, approved by the FDA in 2014 for plaque psoriasis and psoriatic arthritis, is being studied for atopic dermatitis, although results aren’t due until 2016.

Overall, and at least with current treatments, “I think the main thing that we do” at the University of Michigan “is treat aggressively. When you treat aggressively, you show patients that the therapy works, so they are much more likely to use it,” Dr. Ellis said.

One-percent hydrocortisone cream is the strongest thing that a lot of patients have tried by the time they walk through the doors in Ann Arbor; many are close to losing hope in medical treatment.

Because of that, “we are more likely to use higher-potency topical corticosteroids, and use them more often and under occlusion. We are very likely to try triamcinolone in children and sometimes even more potent corticosteroids in adults. We [also] use a fair amount of methotrexate.” The heightened approach can “make a big difference,” he said.

Customer service is another focus at the university. If patients or parents feel better about their visits – not just with the doctor, but from their appointment phone calls right through to their checkouts – they are more likely to stick with treatments.

Dr. Ellis leads a service excellence program to train physicians, nurses, and ancillary staff to ensure that visits go well and patient needs are met. It’s “similar to what you might find in a fancy hotel chain,” and has proven itself with high patient satisfaction scores, he said.

A thorough history is part of good customer service. One thing to pay attention to is calcium channel blocker and thiazide use in older patients.

Both can cause chronic eczematous eruptions that look like atopic dermatitis, and elderly people might have been on the drugs for so long that the relationship with skin problems is easy to miss.

“If you haven’t contemplated particularly calcium channel blockers as a potential cause, you might not give patients a chance to go off them for a while to see if it helps,” he said.

Global Academy and this news organization are owned by the same parent company.

Dr. Ellis is a consultant for Celgene, Ferndale, Otsuka, and Johnson & Johnson.

aotto@frontlinemedcom.com

PHOENIX – A pediatric ICU protocol to minimize sedation during intubation did not reduce ventilator days among children with acute respiratory failure, compared with usual care, in a randomized trial of 2,449 children across 31 ICUs.

The results were published online Jan. 20 in JAMA.

Seventeen pediatric ICUs (PICUs) followed a protocol that included sedation adjustment at least every 8 hours based on phase of illness; arousal assessments during titration and weaning; daily extubation readiness testing when spontaneously breathing; and weaning off opioids and benzodiazepines if patients were on them for 5 or more days, instead of simply discontinuing them.

The 1,225 children on the protocol were ventilated a median of 6.5 days, the same length as the 1,224 children in the 14 usual-care PICUs. There were no differences in sedation-related adverse events, including inadequate pain and sedation control, clinically significant drug withdrawal symptoms, and unplanned endotracheal tube removal (JAMA 2015 [doi:10.1001/jama.2014.18399])

It’s become clear in recent years that intubated adults do better with lighter sedation, and the PICU findings don’t necessarily mean that children are somehow different. A more likely explanation of the findings is that the control PICUs were using a lighter touch, too; prior to randomization, all the PICUs implemented the same pain, sedation, and withdrawal scales.

In any case, the study does show that “targeting a sedation goal of patients who are calm, easily aroused, and readily evaluated is attainable and safe in children,” wrote registered nurse Martha Curley, Ph.D., of the University of Pennsylvania, Philadelphia, and her associates . The study results were published to coincide with Dr. Curley’s presentation at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.

The protocol patients had a median 9 days of opioids, versus 10 in the usual-care group, and they were awake and calm while intubated a median of 86% of days, versus 75% in the control group. However, intervention children had pain during about half of their days, while usual-care children reported pain during about quarter of their days. Intervention patients also had more agitation, and postextubation stridor, but fewer pressure sores. There were no differences in mortality between the groups.

Morphine was the primary protocol opioid, while fentanyl was used most often in the control group. Morphine was selected for the protocol because it has a longer duration of action, plus some sedative properties and less development of tolerance. The primary sedative in both groups was midazolam; about a quarter of protocol patients received dexmedetomidine, versus about half in the usual-care group.

Baseline patient characteristics were well matched between the two groups, except that the intervention group enrolled more patients younger than 2 years and more patients with bronchiolitis, both of whom are harder to sedate. Pneumonia, bronchiolitis, and acute respiratory failure due to sepsis were the most common diagnoses in both groups. The mean age of the children was 4.7 years.

The work, dubbed the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) study, was supported by grants from the National Heart, Lung, and Blood Institute and the National Institute of Nursing Research. The lead author had no disclosures. One coauthor is an advisor for Philips, and another reported consultant and other fees from Cerus, Quark Pharmaceuticals, Biogen, GlaxoSmithKline, and other companies.

aotto@frontlinemedcom.com

PHOENIX – A pediatric ICU protocol to minimize sedation during intubation did not reduce ventilator days among children with acute respiratory failure, compared with usual care, in a randomized trial of 2,449 children across 31 ICUs.

The results were published online Jan. 20 in JAMA.

Seventeen pediatric ICUs (PICUs) followed a protocol that included sedation adjustment at least every 8 hours based on phase of illness; arousal assessments during titration and weaning; daily extubation readiness testing when spontaneously breathing; and weaning off opioids and benzodiazepines if patients were on them for 5 or more days, instead of simply discontinuing them.

The 1,225 children on the protocol were ventilated a median of 6.5 days, the same length as the 1,224 children in the 14 usual-care PICUs. There were no differences in sedation-related adverse events, including inadequate pain and sedation control, clinically significant drug withdrawal symptoms, and unplanned endotracheal tube removal (JAMA 2015 [doi:10.1001/jama.2014.18399])

It’s become clear in recent years that intubated adults do better with lighter sedation, and the PICU findings don’t necessarily mean that children are somehow different. A more likely explanation of the findings is that the control PICUs were using a lighter touch, too; prior to randomization, all the PICUs implemented the same pain, sedation, and withdrawal scales.

In any case, the study does show that “targeting a sedation goal of patients who are calm, easily aroused, and readily evaluated is attainable and safe in children,” wrote registered nurse Martha Curley, Ph.D., of the University of Pennsylvania, Philadelphia, and her associates . The study results were published to coincide with Dr. Curley’s presentation at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.

The protocol patients had a median 9 days of opioids, versus 10 in the usual-care group, and they were awake and calm while intubated a median of 86% of days, versus 75% in the control group. However, intervention children had pain during about half of their days, while usual-care children reported pain during about quarter of their days. Intervention patients also had more agitation, and postextubation stridor, but fewer pressure sores. There were no differences in mortality between the groups.

Morphine was the primary protocol opioid, while fentanyl was used most often in the control group. Morphine was selected for the protocol because it has a longer duration of action, plus some sedative properties and less development of tolerance. The primary sedative in both groups was midazolam; about a quarter of protocol patients received dexmedetomidine, versus about half in the usual-care group.

Baseline patient characteristics were well matched between the two groups, except that the intervention group enrolled more patients younger than 2 years and more patients with bronchiolitis, both of whom are harder to sedate. Pneumonia, bronchiolitis, and acute respiratory failure due to sepsis were the most common diagnoses in both groups. The mean age of the children was 4.7 years.

The work, dubbed the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) study, was supported by grants from the National Heart, Lung, and Blood Institute and the National Institute of Nursing Research. The lead author had no disclosures. One coauthor is an advisor for Philips, and another reported consultant and other fees from Cerus, Quark Pharmaceuticals, Biogen, GlaxoSmithKline, and other companies.

aotto@frontlinemedcom.com

PHOENIX – A pediatric ICU protocol to minimize sedation during intubation did not reduce ventilator days among children with acute respiratory failure, compared with usual care, in a randomized trial of 2,449 children across 31 ICUs.

The results were published online Jan. 20 in JAMA.

Seventeen pediatric ICUs (PICUs) followed a protocol that included sedation adjustment at least every 8 hours based on phase of illness; arousal assessments during titration and weaning; daily extubation readiness testing when spontaneously breathing; and weaning off opioids and benzodiazepines if patients were on them for 5 or more days, instead of simply discontinuing them.

The 1,225 children on the protocol were ventilated a median of 6.5 days, the same length as the 1,224 children in the 14 usual-care PICUs. There were no differences in sedation-related adverse events, including inadequate pain and sedation control, clinically significant drug withdrawal symptoms, and unplanned endotracheal tube removal (JAMA 2015 [doi:10.1001/jama.2014.18399])

It’s become clear in recent years that intubated adults do better with lighter sedation, and the PICU findings don’t necessarily mean that children are somehow different. A more likely explanation of the findings is that the control PICUs were using a lighter touch, too; prior to randomization, all the PICUs implemented the same pain, sedation, and withdrawal scales.

In any case, the study does show that “targeting a sedation goal of patients who are calm, easily aroused, and readily evaluated is attainable and safe in children,” wrote registered nurse Martha Curley, Ph.D., of the University of Pennsylvania, Philadelphia, and her associates . The study results were published to coincide with Dr. Curley’s presentation at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.

The protocol patients had a median 9 days of opioids, versus 10 in the usual-care group, and they were awake and calm while intubated a median of 86% of days, versus 75% in the control group. However, intervention children had pain during about half of their days, while usual-care children reported pain during about quarter of their days. Intervention patients also had more agitation, and postextubation stridor, but fewer pressure sores. There were no differences in mortality between the groups.

Morphine was the primary protocol opioid, while fentanyl was used most often in the control group. Morphine was selected for the protocol because it has a longer duration of action, plus some sedative properties and less development of tolerance. The primary sedative in both groups was midazolam; about a quarter of protocol patients received dexmedetomidine, versus about half in the usual-care group.

Baseline patient characteristics were well matched between the two groups, except that the intervention group enrolled more patients younger than 2 years and more patients with bronchiolitis, both of whom are harder to sedate. Pneumonia, bronchiolitis, and acute respiratory failure due to sepsis were the most common diagnoses in both groups. The mean age of the children was 4.7 years.

The work, dubbed the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) study, was supported by grants from the National Heart, Lung, and Blood Institute and the National Institute of Nursing Research. The lead author had no disclosures. One coauthor is an advisor for Philips, and another reported consultant and other fees from Cerus, Quark Pharmaceuticals, Biogen, GlaxoSmithKline, and other companies.

aotto@frontlinemedcom.com

PHOENIX – Daily bathing with chlorhexidine wipes did not reduce the incidence of health care–associated infections in a randomized, crossover study of 9,340 patients at five adult ICUs at Vanderbilt University in Nashville, published online in JAMA Jan. 20.

Although a common practice in ICUs, “these findings do not support daily bathing of critically ill patients with chlorhexidine. [It] incurs a cost, and exposure to chlorhexidine may increase microbial resistance. Such bathing may not be necessary, resulting in cost savings and avoidance of unnecessary exposure without adversely affecting clinical outcome,” Dr. Michael Noto of Vanderbilt University, Nashville, Tenn., and his associates said in a journal article published to coincide with his presentation at the Critical Care Congress sponsored by the Society for Critical Care Medicine (JAMA 2015 Jan. 20 [doi:10.1001/jama.2014.18400]).

The ICUs were randomized for 10 weeks to bathe patients with disposable 2% chlorhexidine cloths or nonantimicrobial cloths; they then switched to the alternate bathing treatment for 10 weeks. Each unit crossed over between bathing assignments three times.

CDC / Jennifer Hulsey

Chlorhexidine baths made no difference in the composite rate of central line–associated bloodstream infections; catheter-associated urinary tract infections (CAUTIs); ventilator-associated pneumonia; and Clostridium difficile infections. There were 55 such infections during the chlorhexidine bathing period and 60 during the control bathing period; in both cases, CAUTIs were most common.

That calculated to a rate of 2.86 infections/1,000 patient-days with chlorhexidine, and 2.90/1,000 patient-days with nonantimicrobial wipes, a nonsignificant difference (P = .95). After adjusting for age, sex, race, unit of admission, time, comorbid conditions, and admission white blood cell count, there was no significant difference between groups in the composite rate of infections (relative risk for chlorhexidine group 0.94; 95% confidence interval, 0.65-1.37; P = .83).

There was no difference in infection rates in any of the individual ICUs, and chlorhexidine made no difference in secondary outcomes, such as hospital-acquired bloodstream infections, blood culture contamination, in-hospital mortality, or multidrug-resistant cultures.

Vanderbilt’s ICU infection rates are similar to national benchmarks, “suggesting these findings are generalizable to other medical centers,” the investigators said.

Patient characteristics were well balanced in the study, with no significant differences in baseline lab values, comorbidities, and demographics. There were 4,488 patients in the chlorhexidine group and 4,852 in the control group. In both, 60% were men, the median age was almost 60 years old, and respiratory and cardiovascular complications were the most common reasons for ICU admission.

A previous study reported that chlorhexidine bathing significantly reduced ICU acquisition of multidrug-resistant organisms and health care–associated bloodstream infections. The study also included bone marrow transplant patients, who have a greater risk of infection, and the wipes were used for 6 months instead of periods of 10 weeks. The company that makes the wipes paid in part for the study (N. Engl. J. Med. 2013;368:533-542).

“It is possible that a longer intervention may have ecological consequences that reduce infectious outcomes,” but “the reduction in health care–associated bloodstream infections ... was driven primarily by a reduction in positive blood culture results caused by ... skin commensal coagulase-negative staphylococci, and it is not clear if this observation was a result of blood culture contamination or true infection,” Dr. Noto and his team said.

Dr. Noto reported no disclosures. One author reported that his spouse receives research funding from Gilead, MedImmune, and SanofiPasteur and is an advisor for Teva. The work was funded by the National Institutes of Health and Vanderbilt.

aotto@frontlinemedcom.com

PHOENIX – Daily bathing with chlorhexidine wipes did not reduce the incidence of health care–associated infections in a randomized, crossover study of 9,340 patients at five adult ICUs at Vanderbilt University in Nashville, published online in JAMA Jan. 20.

Although a common practice in ICUs, “these findings do not support daily bathing of critically ill patients with chlorhexidine. [It] incurs a cost, and exposure to chlorhexidine may increase microbial resistance. Such bathing may not be necessary, resulting in cost savings and avoidance of unnecessary exposure without adversely affecting clinical outcome,” Dr. Michael Noto of Vanderbilt University, Nashville, Tenn., and his associates said in a journal article published to coincide with his presentation at the Critical Care Congress sponsored by the Society for Critical Care Medicine (JAMA 2015 Jan. 20 [doi:10.1001/jama.2014.18400]).

The ICUs were randomized for 10 weeks to bathe patients with disposable 2% chlorhexidine cloths or nonantimicrobial cloths; they then switched to the alternate bathing treatment for 10 weeks. Each unit crossed over between bathing assignments three times.

CDC / Jennifer Hulsey

Chlorhexidine baths made no difference in the composite rate of central line–associated bloodstream infections; catheter-associated urinary tract infections (CAUTIs); ventilator-associated pneumonia; and Clostridium difficile infections. There were 55 such infections during the chlorhexidine bathing period and 60 during the control bathing period; in both cases, CAUTIs were most common.

That calculated to a rate of 2.86 infections/1,000 patient-days with chlorhexidine, and 2.90/1,000 patient-days with nonantimicrobial wipes, a nonsignificant difference (P = .95). After adjusting for age, sex, race, unit of admission, time, comorbid conditions, and admission white blood cell count, there was no significant difference between groups in the composite rate of infections (relative risk for chlorhexidine group 0.94; 95% confidence interval, 0.65-1.37; P = .83).

There was no difference in infection rates in any of the individual ICUs, and chlorhexidine made no difference in secondary outcomes, such as hospital-acquired bloodstream infections, blood culture contamination, in-hospital mortality, or multidrug-resistant cultures.

Vanderbilt’s ICU infection rates are similar to national benchmarks, “suggesting these findings are generalizable to other medical centers,” the investigators said.

Patient characteristics were well balanced in the study, with no significant differences in baseline lab values, comorbidities, and demographics. There were 4,488 patients in the chlorhexidine group and 4,852 in the control group. In both, 60% were men, the median age was almost 60 years old, and respiratory and cardiovascular complications were the most common reasons for ICU admission.

A previous study reported that chlorhexidine bathing significantly reduced ICU acquisition of multidrug-resistant organisms and health care–associated bloodstream infections. The study also included bone marrow transplant patients, who have a greater risk of infection, and the wipes were used for 6 months instead of periods of 10 weeks. The company that makes the wipes paid in part for the study (N. Engl. J. Med. 2013;368:533-542).

“It is possible that a longer intervention may have ecological consequences that reduce infectious outcomes,” but “the reduction in health care–associated bloodstream infections ... was driven primarily by a reduction in positive blood culture results caused by ... skin commensal coagulase-negative staphylococci, and it is not clear if this observation was a result of blood culture contamination or true infection,” Dr. Noto and his team said.

Dr. Noto reported no disclosures. One author reported that his spouse receives research funding from Gilead, MedImmune, and SanofiPasteur and is an advisor for Teva. The work was funded by the National Institutes of Health and Vanderbilt.

aotto@frontlinemedcom.com

PHOENIX – Daily bathing with chlorhexidine wipes did not reduce the incidence of health care–associated infections in a randomized, crossover study of 9,340 patients at five adult ICUs at Vanderbilt University in Nashville, published online in JAMA Jan. 20.

Although a common practice in ICUs, “these findings do not support daily bathing of critically ill patients with chlorhexidine. [It] incurs a cost, and exposure to chlorhexidine may increase microbial resistance. Such bathing may not be necessary, resulting in cost savings and avoidance of unnecessary exposure without adversely affecting clinical outcome,” Dr. Michael Noto of Vanderbilt University, Nashville, Tenn., and his associates said in a journal article published to coincide with his presentation at the Critical Care Congress sponsored by the Society for Critical Care Medicine (JAMA 2015 Jan. 20 [doi:10.1001/jama.2014.18400]).

The ICUs were randomized for 10 weeks to bathe patients with disposable 2% chlorhexidine cloths or nonantimicrobial cloths; they then switched to the alternate bathing treatment for 10 weeks. Each unit crossed over between bathing assignments three times.

CDC / Jennifer Hulsey

Chlorhexidine baths made no difference in the composite rate of central line–associated bloodstream infections; catheter-associated urinary tract infections (CAUTIs); ventilator-associated pneumonia; and Clostridium difficile infections. There were 55 such infections during the chlorhexidine bathing period and 60 during the control bathing period; in both cases, CAUTIs were most common.

That calculated to a rate of 2.86 infections/1,000 patient-days with chlorhexidine, and 2.90/1,000 patient-days with nonantimicrobial wipes, a nonsignificant difference (P = .95). After adjusting for age, sex, race, unit of admission, time, comorbid conditions, and admission white blood cell count, there was no significant difference between groups in the composite rate of infections (relative risk for chlorhexidine group 0.94; 95% confidence interval, 0.65-1.37; P = .83).

There was no difference in infection rates in any of the individual ICUs, and chlorhexidine made no difference in secondary outcomes, such as hospital-acquired bloodstream infections, blood culture contamination, in-hospital mortality, or multidrug-resistant cultures.

Vanderbilt’s ICU infection rates are similar to national benchmarks, “suggesting these findings are generalizable to other medical centers,” the investigators said.

Patient characteristics were well balanced in the study, with no significant differences in baseline lab values, comorbidities, and demographics. There were 4,488 patients in the chlorhexidine group and 4,852 in the control group. In both, 60% were men, the median age was almost 60 years old, and respiratory and cardiovascular complications were the most common reasons for ICU admission.

A previous study reported that chlorhexidine bathing significantly reduced ICU acquisition of multidrug-resistant organisms and health care–associated bloodstream infections. The study also included bone marrow transplant patients, who have a greater risk of infection, and the wipes were used for 6 months instead of periods of 10 weeks. The company that makes the wipes paid in part for the study (N. Engl. J. Med. 2013;368:533-542).

“It is possible that a longer intervention may have ecological consequences that reduce infectious outcomes,” but “the reduction in health care–associated bloodstream infections ... was driven primarily by a reduction in positive blood culture results caused by ... skin commensal coagulase-negative staphylococci, and it is not clear if this observation was a result of blood culture contamination or true infection,” Dr. Noto and his team said.

Dr. Noto reported no disclosures. One author reported that his spouse receives research funding from Gilead, MedImmune, and SanofiPasteur and is an advisor for Teva. The work was funded by the National Institutes of Health and Vanderbilt.

aotto@frontlinemedcom.com