Margo Schilling

The potential to use PspA and other pneumococcal proteins to elicit protection against pneumococcal infection.

Pneumococcal proteins, alone, in combination with each other, or in combination with capsular polysaccharide-protein conjugates may be useful pneumococcal vaccine components. Four proteins with a potential for use in vaccines are PspA, pneumolysin, PsaA, and PspC. In a mouse model of carriage, PsaA and PspC were the most efficacious vaccine proteins. Of these, PsaA was the best at eliciting protection against carriage. However, a combination of PspA and pneumolysin may elicit stronger immunity to pulmonary infection and possibly sepsis than either protein alone. Recently, a phase one trial of a recombinant family 1 PspA was completed in man. PspA was observed to be safe and immunogenic. Injection of 0.1 ml of immune serum diluted to 1/400 was able to protect mice from fatal infection with S. pneumoniae. Under these conditions, pre-immune serum was not protective. The immune human serum protected mice from infections with pneumococci expressing either of the major PspA families (1 and 2) and both of the pneumococcal capsular types tested: 3 and 6.

Evidence-based assessment of acute pain in older adults: Current nursing practices and perceived barriers

Objectives:To report data on current nurse practice behaviors related to evidence-based assessment of acute pain in older adults, perceived stage of adoption of pain assessment practices, and perceptions of barriers to optimal assessment in this population. Methods:Medical records from 709 older adult patients hospitalized with hip fractures from 12 acute care settings were abstracted for nurse assessment practices during the first 72 hours after admission. Questionnaires sent to nurses on study units regarding perceived stage of adoption and barriers to assessment in older adults. Results:Data revealed several areas in which pain assessment practices were not optimal. Pain was not routinely assessed every 4 hours, and pain location was assessed even less frequently. Pain behaviors were assessed more in patients with a diagnosis of dementia compared to those without dementia, but the frequency of pain behavior assessments was low. Pain was not routinely assessed within 60 minutes of administering an analgesic. Nurses reported not using optimal pain assessment practices even when they were aware of and persuaded that those practices were desirable. In addition, nurses reported that difficulty communicating with patients created the greatest challenge in managing pain. Conclusions:Our data suggest that pain is not being assessed and reassessed in a manner that is consistent with current practice recommendations in older adult patients with pathologic processes that highly suggest the presence of acute pain.

Elevated Plasma Levels of Interleukin-6 in Postmenopausal Women Do Not Correlate with Bone Density

Elevated Plasma Levels of Interleukin‐6 in Postmenopausal Women Do Not Correlate with Bone Density

Efficacy of zanamivir for chemoprophylaxis of nursing home influenza outbreaks

Despite vaccination, influenza remains a common of morbidity in nursing homes. Chemoprophylaxis of residents with currently available antivirals is not always effective and new agents effective against both influenza A and B are needed. In a randomized, unblinded pilot study, we compared 14 day chemoprophylaxis with zanamivir, an antiviral which inhibits influenza neuraminidase, to standard of care during sequential influenza A and influenza B outbreaks in a 735 bed nursing home. Influenza A outbreaks were declared on 6/14 epidemic units. Sixty-five volunteers on four epidemic units were randomized to zanamivir and on two epidemic units, 23 volunteers were randomized to rimantadine. During the 14 days of prophylaxis, only four new febrile respiratory illnesses were detected. One volunteer receiving rimantadine prophylaxis developed laboratory-confirmed influenza. Influenza B outbreaks were declared on 3/14 epidemic units. Thirty-five volunteers on two epidemic units were randomized to zanamivir and 18 volunteers on one epidemic unit were randomized to no drug. During the 14 days of prophylaxis, only one new febrile respiratory illness was detected. One volunteer randomized to receive no drug developed laboratory-confirmed influenza. Zanamivir appears comparably effective to standard of care in preventing influenza-like illness and laboratory-confirmed influenza in nursing homes, but requires further testing.

Translating Research into Practice Intervention Improves Management of Acute Pain in Older Hip Fracture Patients

OBJECTIVE To test an interdisciplinary, multifaceted, translating research into practice (TRIP) intervention to (a) promote adoption, by physicians and nurses, of evidence-based (EB) acute pain management practices in hospitalized older adults, (b) decrease barriers to use of EB acute pain management practices, and (c) decrease pain intensity of older hospitalized adults. STUDY DESIGN Experimental design with the hospital as the unit of randomization. STUDY SETTING Twelve acute care hospitals in the Midwest. DATA SOURCES (a) Medical records (MRs) of patients > or =65 years or older with a hip fracture admitted before and following implementation of the TRIP intervention and (b) physicians and nurses who care for those patients. DATA COLLECTION Data were abstracted from MRs and questions distributed to nurses and physicians. PRINCIPAL FINDINGS The Summative Index for Quality of Acute Pain Care (0-18 scale) was significantly higher for the experimental (10.1) than comparison group (8.4) at the end of the TRIP implementation phase. At the end of the TRIP implementation phase, patients in the experimental group had a lower mean pain intensity rating than those in the comparison group ( p<.0001). CONCLUSION The TRIP intervention improved quality of acute pain management of older adults hospitalized with a hip fracture.

Non-influenza respiratory viruses may overlap and obscure influenza activity

OBJECTIVE: To report the number and timing of influenza A isolates, as well as overlapping respiratory viruses. Co‐circulating respiratory viruses may obscure the determination of influenza activity.

Emergence and Transmission of Amantadine‐Resistant Influenza A in a Nursing Home

Objectives: To prospectively detect amantadine‐resistant influenza when amantadine was used for influenza A outbreak control.

Hypervitaminosis D Associated with a Vitamin D Dispensing Error

OBJECTIVE To report a case of hypervitaminosis D resulting in hypercalcemia and acute kidney injury in a 70-year-old female who was prescribed a standard dose of vitamin D but given a toxic dose of vitamin D 50,000 IU (1.25 mg) daily resulting from a dispensing error. CASE SUMMARY A 70-year-old female in her usual state of health was instructed to begin supplementation with vitamin D 1000 IU daily. Three months later she developed confusion, slurred speech, unstable gait, and increased fatigue. She was hospitalized for hypercalcemia and acute kidney injury secondary to hypervitaminosis D. All vitamin D supplementation was discontinued and 5 months after discharge, the patients serum calcium and vitamin D concentrations, as well as renal function, had returned to baseline values. Upon review of the patients records, it was discovered that she had been taking vitamin D 50,000 IU daily. DISCUSSION There is an increased interest in vitamin D, resulting in more health care providers recommending--and patients taking--supplemental vitamin D. Hypervitaminosis D is rarely reported and generally only in the setting of gross excess of vitamin D. This report highlights a case of hypervitaminosis D in the setting of a prescribed standard dose of vitamin D that resulted in toxic ingestion of vitamin D 50,000 IU daily due to a dispensing error. As more and more people use vitamin D supplements, it is important to recognize that, while rare, hypervitaminosis D is a possibility and dosage conversion of vitamin D units can result in errors. CONCLUSIONS Health care providers and patients should be educated on the advantages and risks associated with vitamin D supplementation and be informed of safety measures to avoid hypervitaminosis D. In addition, health care providers should understand dosage conversion regarding vitamin D and electronic prescribing and dispensing software should be designed to detect such errors.

Summative index: Acute pain management in older adults

One of the challenges in measuring adoption of complex evidence-based practices (EBPs) such as acute pain management is determining what constitutes adherence to an EBP guideline. Traditionally, individual process indicators extrapolated from an EBP guideline are selected as dependent measures of guideline adoption. When using multiple indicators, the challenge is determining the number of indicators that must be met to define adherence to the EBP guideline. The primary goal of the study reported herein was to develop and test a summative index (SI) of guideline adherence for acute pain management of hospitalized older adults. Steps in formulating the initial index are described as well as refinement of this metric. Techniques used included factor analysis, discriminate validity, and split-half reliability. The resulting SI is composed of 18 indicators each scored as 0 (not present) or 1 (present), with a total SI score of 0 to 18.