Concierge Medicine, Research Round-Up, Whooping Cough – PediaCast 207
Join Dr Mike this week in the PediaCast Studio as we add to our popular research round-up by shedding new light on old asthma and dehydration recommendations. Plus, tips for reducing the spread of MRSA in your home, concierge health care, and a new strain of whooping cough infecting thousands of kids in Australia.
- Concierge Medicine
- Inhaled Steroid Use for Asthmatics
- Rehydration Therapy in the Emergency Department
- MRSA – Risk Factors for Household Transmission
- Whhoping Cough – A New Strain Coming to Town?
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike!
Dr. Mike Patrick: Hello, everyone and welcome once again to PediaCast, a pediatric podcast from the folks at Nationwide Children's Hospital in Columbus, Ohio. I'd like to welcome everyone to the program. It's episode 2-0-7, 207 for April 18th, 2012 and we’re calling this one Concierge Medicine, Research Round-Up and Whooping Cough.
Research round-up, those of you who are regular listeners of the program know that once a quarter or so we take some time to sort of dissect some research articles and we're going to do that today. In fact, the topics are ones I think that a lot of parents will be interested in. Asthma, lots of you out there have kids who have reactive airway disease and have intermittent wheezing, so we do have a research study on the treatment of asthma in kids; also a lot of folks, especially this time of year, are dealing with vomiting and diarrhea illnesses and sometimes your kids get dehydrated and end up in the emergency department needing IV fluids.
So we're going to discuss a new study on IV fluids and kids with dehydration in emergency departments. Then finally in our research round-up, we're going to look at the study that talks about the transmission of MRSA in the home. MRSA of course being Methicillin-resistant Staphylococcus aureus, so it's a bacterial skin infection you get abscesses and I know lots of moms and dads know exactly what I'm talking about, because these infections are common and they sometimes will spread from one family member to another in the household; and so you're sort of constantly dealing with someone who has one of these infections.
So we're going to talk on a research article that looks at transmission of MRSA in the home and what you can do based on the results of this study to lessen your risk of getting MRSA from a family member at home.
Before we get started with the show though, a recent article in the Wall Street Journal and I'll open a link in the Show Notes for you, deals with concierge medicine. Basically, this is where a doctor takes on a relatively short panel of high income patients and the doctor charges a retainer fee directly to the family rather than taking health insurance. And it's kind of a pay once, at least once a year, get everything included kind of thing.
Sort of as an example of this, there are some doctors that charge up to $25,000 that's not only retainer fee, but it also is all-inclusive. So, for $25,000 a year, this is your doctor, you can go in whenever you want, there's not going to be a long wait in the waiting room and it's going to include not only your health maintenance exams but sick office visits. Anything that the doctor has direct control over the cost, so laboratory, simple laboratory things, simple x-rays, urinalysis, EKGs, that kind of thing. Anything your doctor can do in the office would be covered for this $25,000 a year.
And some of them have a poor man's special. So, for like $1,500, so much cheaper, you get the retainer, so this is just going to be your doctor, they're not going to be seeing lots of patients so you can get in easily to see them; and it includes one preventative care exam, sort of well check-up, so to speak, but sick office visits, any labs, x-rays, EKGs, urinalysis, those kind of things cost extra. So your $1,500 gets your health maintenance exam and gets you access to this concierge doctor.
So why would you pony up that kind of money? Well, you get to see the doctor when you want, on your terms, you don't have to wait. You actually going to see a doctor in the office, you don't see a nurse practitioner or a physician assistant or some other physician extender. And here's the key, the doctor has the time to spend a significant time with you in the exam room, explaining things, answering questions, so they're not in and out in 5-10 minutes.
So this sounds good in theory. I mean, the product certainly sounds good. It's a description of a primary care office back a few decades ago. And it would certainly make primary care more palatable for doctors who now have thousands of patients in their practice and are force to see, you know, upwards of 30-40 patients a day just to make ends meet.
But then the question sort of became in my mind as I read this article, how many doctors are actually doing this? This is just in New York City, in LA and Miami where they have these kinds of things or is this becoming a more of a common set-up. And you might be surprised to know that the numbers are increasing quite a bit. In fact, the American Academy of Private Physicians, which is a group representing these so called concierge docs, they say that 4,000 doctors across the country are offering these kind of services and the number is growing by another 1,000 doctors every year and it does include pediatricians in the ranks of these.
So this got me thinking are we heading toward a two-tiered system of medicine in this country where those who can afford it see private doctors in plush clinics with little wait time, in and out, quickly but at the same time when you're in the doctor being able to spend significant time with you and answering your questions; while those who can't afford this are forced into crowded clinics, staffed primarily by physician extenders, nurse practitioners and physician assistants.
So it gives you something definitely to think about. I'm certainly not advocating this kind of system, but look, if you're fresh out of medical school and you want to go into primary care and you have $200,000 of medical school loans to pay back and you want to work 40 hours a week instead of 60 or 80 and you want to see 15 patients a day instead of 30-40 so you can go home unfrazzled and spend quality time with your family and if you don't have to fight and argue with the "I don't have a clue because I don't have a background in medicine insurance company decision makers," are you going to pass up this kind of gig, especially if it becomes more common place.
So look out America, this could be the future of primary care. Again, something definitely to think about. Now, if you're thinking about jumping on the bandwagon as a patient of a so-called concierge doctor, there are some questions you might want to ask your perspective physician and you can find those questions in the Wall Street Journal article I eluded to and as always, we'll have a link to the story for you over the Show Notes at pediacast.org.
All right. So, we have a research round-up coming your way. We're going to talk about inhaled steroid use in asthma patients, is this something that should be done daily or is it better to use inhaled steroid intermittently, we're going to discuss that. Also IV fluid rehydration in the emergency department, a couple of different ways you can go with how you rehydrate kids and we'll discuss that. And then as I mentioned, MRSA risk factors associated with household transmission and what you can do to stop the spread.
And then we're going to wrap things up after our research round-up with the new story about whooping cough. There may be a new strain of whooping cough or pertosis coming to town and your vaccinated children might not be protected against it. So we're going to discuss that.
I want to remind you if there's a topic you'd like us to talk about or if you have a question for us here at PediaCast, it's easy to get a hold of me. Just go to pediacast.org and click on the Contact link. You can also email email@example.com or call the voice line at 347-404-KIDS. That's 347-404-K-I-D-S.
Also I want to remind you the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment7 plans for specific individuals. If you have a concern about your child's health, make sure you call your doctor and arrange a face-to-face interview and hands-on physical examination.
All right, with all that in mind, stick around for our research round-up, it's coming your way right after this.
All right. We are back and we're going to cover a research round-up now. For those of you who have not heard one of our research round-ups in the past, basically we just take three recent research studies and we kind of break them down, analyze it and then talk about what it means for you, the parent.
And the first one is on intermittent Beudesonide in young with recurrent wheezing. OK. So let's break that up. Let's break that down a little bit, make it a bit understandable. Beudesonide is an inhaled steroid medicine used as a maintenance therapy for kids with asthma. So it's something that they generally use every day and it helps to prevent asthma flare-up, so to speak. Also known as Pulmicort, that's one of the brand names of this particular chemical. So if you've heard of Pulmicort before, you know someone who's taking it or your own kid is taking it, that's what we're talking about.
So this particular study is going to look at to see if intermittent use rather than daily use would be a better thing and this actually comes from multiple institutions across the country. It was published in the New England Journal of Medicine last November. And with all of these articles we will in the Show Notes over at pediacast.org the Show Notes for episode 2-0-7 we will have links to these articles on PubMed. So if you want to see the articles for yourself, there'll be a way for you to do that.
OK. For this one, the question before the researchers was among preschool age children with recurrent wheezing is intermittent Beudesonide inhalation suspension or Pulmicort superior to daily use in reducing exacerbations. So what they do here, well children 12-53 months of age, so one year to 4 1/2 years of age where looked at in this study and there were some guidelines for which kids that they could use.
Each child had to have had at least four episodes of wheezing in the previous year, they also had to have a positive value on the Modified Asthma Prediction Index. So that just spent that they had to have certain criteria that made each child likely to have future problems with their asthma. And then at least one of their four exacerbations in the previous year where their flare-ups had to require oral steroids, so Prednisolone or Orapred, or it had to involve an emergency room visit or hospitalization for the asthma flare-ups.
So these are kids with pretty bad asthma. These kids had to have at least four episodes of flare-ups in the past that required either a trip to the ER or hospitalization or the prescription of an oral steroid.
All together 278 children were enrolled and of those 213 or 77% completed the study. So once they enrolled these kids, they randomized them into two groups. Group one would get a daily low dose regimen of inhaled Beudesonide solution, so this is the control group. This is what generally is already done. They would get 0.5 mg every day.
So for those of you who have kids with asthma who are young and so they are not using an inhaler, they're using a nebulizer, that's what we're talking about here. They would have the Pulmicort nebulized and it is the 0.5 mg dose. It also comes in a 0.25 mg that sometimes is used, but the standard dose that most kids get is of low dose Beudesonide is 0.5 mg respule given once a day. So that's what group one, the control group, did in the study.
The experimental group would use intermittent high doses of inhaled Beudesonide and what they would basically do with this is early on during a respiratory illness, so as soon as the kid got a little sniffle, the parents would start this. So they didn't do it every day but as soon as the kid showed signs of a viral illness, they would start using their inhaled steroid. But they wouldn't use the 0.5 mg once a day; they would use 1 mg twice a day. So they're actually using four times as much, but intermittently.
So, much higher doses but only when the kids start to show sign that they have a respiratory illness. OK. So they randomized them into these two groups, the daily low dose and the intermittent high dose, and then following randomization they did look at the two groups to make sure that the clinical and demographic characteristics of the two groups were similar, because they didn't want any confounding variables to be in play, so they made sure that the overall severity of the kids' asthma, their social economic levels, how well that they were adherent to their therapy, those kind of things was equal between the two groups.
And then they did a one year prospective study. So they took both of these groups and said, OK, we're going to watch you moving forward for a year. And the primary outcome for this study is what is the frequency of exacerbations or flare-ups as defined by the number of physician consultations for acute wheezing resulting in a course of oral steroids. So, as we move forward with each of these groups we want to know how many time a year does each kid have to go in and see a doctor for an asthma flare-up and that flare-up was bad enough that they were prescribed an oral steroid for the flare-up.
Now secondary outcomes, so the other outcomes that were just observed along with the study, the number of episode-free days, so these are the number of days that the kid did not have any asthma symptoms and in the case of the experimental group the number of days that they didn't have any respiratory symptoms at all. So these are the number of days they were not using their inhaled Beudesonide.
Also the time it took to get to the first and second exacerbations from the go time, how long did it for them to have that first flare-up, the frequency of albuterol use, the rate of treatment failure, the rate of wheezing-related health care utilization, quality of life measures and change in height over the study period. That's one of the things that parents say we're concerned about if a kid is on an inhaled steroid everyday could it affect their growth. So they wanted to see if there was any growth difference between using it every day and using intermittently.
OK. So what did they find?
Well, the primary outcome, so the frequency of flare-ups, in the daily low dose control group there were 0.97 exacerbations per patient a year. So if you took the total number and divided it by the total number of patients over that year, the average is 0.97. So each kid had about one major flare-up of their asthma during the course of that year in the control group, the daily low dose group.
In the intermittent high dose or experimental group, that number was 0.95, some say 0.97, it was 0.95 exacerbations per patient a year. So again, each kid in the intermittent high dose experimental group also had about one significant flare-up of their asthma during the course of that year.
So, this of course is not statistically significant so there was no difference between the two groups. So no difference in terms of frequency of exacerbations between daily low dose and intermittent high dose inhaled Beudesonide.
OK. What about the secondary outcomes?
The number of episode-free days was 78% for both groups, no difference at all; 78% of the time they were symptom-free, 22% of the time they were dealing with upper respiratory symptoms or wheezing and in the intermittent group that's the amount of time that they were using their inhaled steroid. There was no significant difference in time to first and second exacerbations, how long it took to get to that first flare-up, no difference there.
Frequency of albuterol use, 6% of days the kids used albuterol and 6% of all days of the year for the intermittent group and 5% for the daily group. So again, pretty similar there, no significant difference in terms of frequency of albuterol use.
What about the rate of treatment failure? No significant difference there. The rate of wheezing-related health care utilization, there were 2.4 visits per year per child to their doctor that was unscheduled because of their asthma for both groups. So these kids in both groups on average they'd go to their doctor 2 1/2 times a year for wheezing and one of those times they would end up on an oral steroid and there was a time they wouldn't.
Then again we're just talking averages and the important thing here though is no difference between the two groups. With regard the quality of life measures and change in height over the study period, again no significant differences between the two groups.
So, the authors conclude that a daily low dose regimen of Beudesonide inhaled is not superior to an intermittent high dose regimen.
So the two regimens are pretty much the same. Some discussion points here, most of you out there who have kids with asthma who are on a daily inhaled steroid, that's what you do. I mean, that's still really the standard of care, at least here in the United States to do daily inhaled steroid, not the intermittent high dose as was described here.
So why talk about this, especially since we didn't get a statistically significant result, what's the big deal?
Well, some parents would say the daily group, at least on the surface it would seem, the daily group has a much higher steroid exposure over the course of the year and the intermittent group, since they only use the steroid when they need it, they have a lower total steroid exposure. And so from a parent's standpoint maybe I'd rather do the intermittent type so that my kid doesn't get as much steroid.
So at first look, you'd think that will be the case, but it's really not as true as you'd think, does the intermittent group really have less steroid exposure. And the authors didn't make a point of this but I do think it's the question on most parents' mind, in this intermittent group, was their steroid exposure less?
Let's look at this. If you take the intermittent group on 22% of days they use their high dose Beudesonide, so they were fine 78% of the time but 22% of the time when they started to have the runny nose and congestion, they started their inhaled steroid. If you calculate that out, 22%, that's about 80 days and on those 80 days, remember the kids are getting four times of the dose compared to the daily dose with the low dose group. So instead of getting 0.5 mg once a day, they're getting 1 mg twice a day. So four times the amount at 80 days that equals the equivalent steroid exposure of 320 days versus 365 days for the daily low dose group
So really, over the course of a year the intermittent group only has 45 less days of exposure. Now you might say, yeah, but that adds up over years of use, I mean it's only 45 days in one year but what if my kid's taken an inhaled steroid for 20 years, then what?
Well before you hop on that bandwagon, you should also know that daily inhaled steroids already have a very low total body exposure profile. So when you compare inhaled steroids to oral steroids, we're basically by using inhaled steroids trying to prevent the number of acute flare-ups that require oral steroids, and the reason for that is because a five-day course of oral steroids is about the same as two years of low dose daily inhaled steroid in terms of total body exposure.
So when you inhaled the steroid, the amount of steroid that gets to the whole body it would take two years of being on a daily low dose inhaled steroid to get the same amount of total steroid exposure on your whole body as it does in the five-day course of oral steroids.
And the studies have consistently shown that in large well-done studies that daily inhaled steroids are at low doses are safe and effective. So, do we argue that we need to make this change from daily to intermittent based on that kids are going to get less steroid exposure? Maybe, but it's a weak argument.
How about cost?
And again this was not addressed by the research team and I think it should have been. In fact, I think this would have been a more convincing argument for changing the standard of care. Again, I did a little research, myself, and if you take 30 days of once daily low dose Beudesonide, what's the cost of that? So what's the monthly cost of a kid in the control group, so sort of what's the standard of care right now?
Well, that's about $50. So inhaled Beudesonide costs about $50. Now I know not all parents are paying for it, their insurance may be paying for it, but someone is paying for it. So, there's still a burden of healthcare cost here and it's about $50 for 30 days. So in a year it's about $600 a year. Now, if we compare that to the intermittent group, remember about 80 days of use but using four times as much during those 80 days, if you do the math that comes out to about $533 per year. So that's a saving of about $67 per year.
But again, over a lifetime of use that's going to add up and when you consider the very, very large number of people who use daily inhaled steroids and that you consider that over the course of all of their lifetimes, that figure is definitely going to add up. Unlike total body steroid exposure, which really isn't much even when you add it up, the money does add up and it adds up on a very real way. And when you consider our overall healthcare cost burden these days, I do think that's significant.
So I think future studies really need to consider cost as one of their secondary outcomes, because cost does matter more than total steroid exposure, in my opinion.
All right. What about efficacy? Since the two groups are so similar, the next question in your mind might be are inhaled steroids doing anything at all? I mean, maybe the groups are similar because inhaled steroids are ineffective to begin with. So why didn't the authors include a placebo group to see if the placebo kids did have a higher exacerbation or flare-up rate?
But, previously well-done and large prospective studies have shown that daily low dose inhaled steroids are effective at reducing asthma exacerbations. And remember, asthma flare-ups can be deadly and the authors didn't want to put the kids at unnecessary risk by adding a placebo arm to the study because this is really already been shown to be effective in very well-done studies.
There have actually been those who criticized this study for not including a placebo group, but I'm with the authors on this one. As I already mentioned there's already plea of evidence out there to support the safety and efficacy of inhaled steroids. So in the end, daily low dose inhaled steroids is still the standard of care for the maintenance and prevention of exacerbations or flare-ups in children with asthma.
And I'll caution parents out there who are listening, don't change from daily low dose inhaled steroid to intermittent high dose treatment on your own. Talk to your doctor, let them make the call along with you in collaboration, but I wouldn't expect your doctor to be supportive of this change. Again, asthma exacerbations can kill children and we know that daily low dose inhaled steroids prevent deadly exacerbations.
And one study of 200 some kids isn't going to turn the ship on daily inhaled steroid use. So we'll keep our eyes on the journals and if larger study shows similar results and if the cost advantage is pointed out, we'll let you know. I think if those things happen, if further studies do show, larger well-done studies show similar results and the cost comes more to the forefront here, then the folks who make recommendations and guidelines might be swayed to change their mind on this one.
In the mean time, stick with what you're doing and as always when it comes to making healthcare decisions for your child make sure you talk to your doctor. One final point and I'd be remissed if I didn't take this opportunity to stress something really important here, daily inhaled steroids and the intermittent higher dose inhaled steroids do help. But the most important immediate treatment for anyone having an asthma exacerbation is the bronco dilator, not the steroids.
So it's important to know which medicines your child has and you need to know the names of those medicines and their functions. Your rescue medicine is always a bronco dilator, something like albuterol or Proventol or Xopenex. And I see too many parents when I worked in the ED who don't know the difference between their child's maintenance treatment and the rescue treatment. It's called rescue for a reason, so make sure you know which medicines your kids are taking and when to give each one.
OK. So let's move on. The next study, this one is a particular interest to me since I do see kids in the emergency department. I hate to be self-indulgent here, but I think it would be of an interest t many of you as well since this is another aspect of medicine that many parents face every day. And this one deals with the IV fluids.
I'm sorry there's not an individual parent out there who faces this everyday but as a parent this is something that you do face from time to time in a very real way and that's when your kid has vomiting and diarrhea and end up dehydrated and you take them into the emergency department because you think they might need IV fluids. So that's what this one is going to deal with.
This comes out of the hospital for sick children in Toronto and was published in the British Medical Journal also last November. And again, as with the other studies we'll have a link to this particular article in PubMed if you head over to pediacast.org, click on the Show Notes for episode 207.
OK. So the question before the researchers among children with dehydration treated in an emergency department does rapid intravenous rehydration compared to standard rehydration improve the clinical outcome at two hours or reduce the length of stay in the emergency department?
So what they did here is they look it from December 2006 to April 2010 children who are three months of age to 11 years of age and they all had gastroenteritis, so a stomach virus, that was causing vomiting and diarrhea and so the kids were dehydrated. And the way that they defined dehydration, they used a validated dehydration scale and they used parameters that we use to measure clinical dehydration, things like heart rate, what are the mucous membranes like, are they moist, are they dry, are they tacky, also skin trigger, capillary refill.
They also used an electrolyte panel and glucose to determine eligibility and then based on these things they decided whether a kid could be included in the study or not. Some of the exclusion criterions include underlying chronic illness, history of bilious or bloody vomiting with this illness, suspected surgical conditions, low blood pressure or hypotension, severe electrolyte disturbances when they got the blood work or low blood sugar or too high blood sugar.
And the reasons are that those kids need a specifically tailored work-up and management. So these aren't your standard kid with a stomach bug that gets dehydrated that comes into the ER. So anything more complicated than that it was not for this study.
Now, all of the kids that they identified as being eligible, the first thing they did is just they tried some oral rehydration therapy, although not with medication. They just have them sipped on some fluids see if they could hold it down. If they were able to hold it down they'd let them keep sip in and try to rehydrate them orally. But if they failed oral rehydration, so they started to drink but they continue to vomit or they weren't drinking enough to change their clinical state so that they weren't dehydrated anymore, then they were entered into the study.
Once they were entered, they were divided into two groups — the control and an experimental group. In this case, the control group would get standard rehydration, we'll talk about what that is in a minute and the experimental group would get rapid rehydration to see if that would make a difference in terms of how fast they were able to get rehydrated and how long they had to stay in the emergency department.
OK. So the standard rehydration group would get a fluid bowl list, a standard fluid bowl list of 20 cc/kg of normal saline over an hour. And then subsequent fluid was given per protocol and that protocol basically just looked at the kid's age and weight and would determine what their maintenance fluids ought to be. So they would give them a big bowl of 20 cc/kg and then slower IV fluid infusion right after that based on the kid's age and there's pretty standard on how we go about doing that. So that would be the standard rehydration group.
The rapid rehydration group would get 60 cc/kl of normal saline over an hour and then subsequent fluids according to that same protocol. So in other words, what we're doing here is just saying and so I've given him 20 cc/kl and then a slower rate, let's give them more up front. Let's give them 60 cc/kl, so bigger volume and see if can get them rehydrated faster by doing that.
And the primary outcome is was the child successfully rehydrated at the two-hour mark and then secondary outcomes, what is the time until discharge, what is the hospitalization rate and what is the prolonged treatment rate and prolonged treatment was considered in emergency department stay of greater than six hours or admission to the hospital following their ED stay; or if within 72 hours of discharge they bounced back and got admitted to the hospital, that was also considered a prolonged treatment.
All right. So 226 children were enrolled and like our last study we talked about the baseline characteristics were similar for the two groups, so there was good randomization so we don't have a lot of confounding type variables. For both groups, 60% of the kids were mildly dehydrated per their dehydration score and 40% were moderate to severe dehydration and that was equal for both groups.
All right. So what did they find? Well, one-third of all children in both groups were well-hydrated at the two-hour mark, but two-thirds of them did take longer than two hours; but it's in equal number on both groups. And there was no statistically significant difference between the two groups with regard to hydration status four hours time until discharge, hospitalization rate or prolonged treatment rate.
So the authors conclude that rapid intravenous rehydration has no advantage over standard intravenous rehydration among children requiring IV fluids because of uncomplicated gastroenteritis and dehydration.
So again, sort of the point here and again I apologize for being a bit self-indulgent and I know this going to be more interesting to the clinicians out there than to the parents, but the point here is that rapid rehydration, if you give the more fluid at the front-end even though it seems like you might rehydrate faster and get them out of the emergency room faster, it really and according to this study does not appear to be the case.
Now that leads into an interesting point, we have two studies that we're talked about today that fail to show statistically significant findings. And you might be saying what's up with this, why do you even bring these studies up?
Well, keep in mind every investigator brings bias to the table, then they have a hypothesis, they think they know what might happen based on their own knowledge and experience and they set out to prove a point. They think they have a better idea and they want statistically significant results to prove their hypothesis, right?
Well these two studies are different. Rather than trying to prove a new idea is a great idea, these investigators are coming in with the hypothesis that maybe a new idea isn't all that great. If it's not broken why fix it? Just because an idea is new doesn't mean it's better. Is the new idea of intermittent inhaled steroids really better than the daily low dose standard? And in this one, is the new idea of rapid rehydration really better than the tried and true standard rehydration?
In both of these studies, the investigators' sort of worldview was they didn't think that these new things really were better ideas. So that was their bias. So these guys were looking for statistically insignificant results. That's what they wanted, to prove their point that these new things really aren't better. And that's exactly what they got.
So sometimes, statistical insignificance is a good thing. So if you hear, ahh, that article wasn't statistically significant, well maybe if you really look at the study because maybe the fact it was not statistically significant is actually significant. OK.
As with the previous study too, I'd be remised if I didn't point something out here. Not all kids failed their oral rehydration and because of a drug called Ondansetron or Zofran is the brand name of Ondansetron there is a medicine that helps to take away nausea. And so a lot of times now in the emergency department we'll give kids a dose of this medicine that really just sort of magically makes the nausea feeling go away and kids are able to tolerate oral hydration much better.
And so one criticism of this study is that they didn't use Zofran and so the kids that failed oral rehydration, could they've had a better shot of being able to be successfully orally rehydrated if they've had this medicine. So the study didn't use that. And I will say this, since we've started Zofran in a wide spread fashion, lots of kids have been able to avoid getting IV fluids and that's a good thing because IVs cause some pain, cause anxiety, there's the risk of over hydrating, there's the risk of creating electrolyte disturbances through over hydrating or using improper fluids.
So, being able to rehydrate orally is a good thing and the authors of this study didn't really point that out. But I wanted to point out to you that if you do have a kid with vomiting and diarrhea just because we're been talking about IV rehydration, chances are when you do go in they'll get a dose of Zofran and be able to orally rehydrate.
Now, of course Zofran is not without its own consequences. Headache and diarrhea are common side effects of Zofran. Diarrhea is not necessarily good thing when you already have vomiting and diarrhea. And so as with all things medicine, we have to look at the benefit versus the risk or the benefit versus the side effect profile and that's why it's important to talk to your doctor about these things because they'll have some insight based on their own knowledge and past experiences.
All right. Let's move on to our final study in this week's research round-up and this one is from investigators in Minnesota and the Centers for Disease Control and Prevention. It was published in the Journal of Pediatric Infectious Diseases also last November 2011. And as always, we'll put a link to the article in PubMed and you can find that at pediacast.org in the Show Notes for show 207.
All right. So the question before the researchers for this one is among households with children previously infected with MRSA or Methicillin-resistant Staphylococcus aureus, what risk factors were associated with MRSA colonization months later in the same patient or household contacts compared to those households without MRSA colonization?
So in other words, if a kid has MRSA, what sort of risk factors make it more likely that they will continue to be colonized with MRSA and at risk for future infection and what risk factors are associated with other people in the household becoming colonized from the bacteria?
So, patients were initially identified based on culture results at 12 Minnesota hospital laboratories. So there were 12 hospitals involved, if they got a positive MRSA in a kid then the person was deemed, at least, and identified for this study. Then they looked at some exclusion criteria, so if the kid was in the hospital for their MRSA infection, as long as they'd only been in the hospital for 48 hours or less, that was great, that was fine.
But if they had been in the hospital for a longer period of time than 48 hours prior to the diagnosis of the skin infection then they weren't eligible. And the reason for this is we're looking at community acquired MRSA. We don't want to know about MRSA that you might have caught while you're in the hospital because that's a different bug all together.
They also were excluded if they had previously been hospitalized in the past year or if they've had surgery. Dialysis patients were excluded, residents of long-term care facilities at any point during the past year were excluded, as were patients with entholic catheters, percutaneous medical devices, so any tube through the skin, G-tubes, that sort of thing, they were not eligible for this.
So basically, we want healthy kids who don't have chronic illnesses, they have not been in long-term facilities or hospitalized or have surgeries. They're not at risk for being colonize with MRSA. They're healthy kids as we were talking about here, with skin infections, abscesses from MRSA, that's what we were looking at.
So, when a patient was deemed eligible, the parents were contacted, asked to participate and then a study team after the child had recovered a study team would go to the child's home to interview all the household contacts and obtain nasal swabs on all of the household contacts to culture them to see if they had colonization or MRSA growing in their noses. And then they would look at some behaviors, hygiene behaviors, to see if there were any risk factors that might make it more likely that household contacts would become colonized after a kid came back home who had a MRSA infection.
So they identified 784 potentially eligible children but then when they read them out with their eligibility, their exclusion criteria, only 30% met eligibility requirements. So now they're down to 236 participants. Of those 236, there were 818 household contacts that were identified and 87% of them agreed to participate, so they had 712 household contacts all together. 77% of the households had complete household member enrollment. So, pretty good recruitment and response out there.
In terms of timing of the home visit after the infection was resolved, the range was 16 to 178 days after the onset of the child's infection with the median of 69 days. So, on average, it was a couple months after the infection that researchers went out to see what was going on in the home.
So what did they find? Well, 25% of case patients, so the kid with the original patients, 25% at the follow-up visit had nasal colonization with generic staph aureus and 13% with MRSA, with Methicillin-resistant Staphylococcus aureus, so one that's more difficult to treat. And the 29% of household contacts had nasal colonization with regular staph, 12% with MRSA. So, 12-13% of all of the kids with the MRSA to begin with and the same amount, 12-13% of their household contacts all had MRSA colonization at the follow-up; 25% of households had at least one colonized household contact and 9% of households had more than one colonized household contact.
This is interesting. Is it the same MRSA or is it a new case of MRSA? So in other words, did the kid really take it home and spread it or is this just the kid went to school and caught it from someone else. So what they did is they actually genetically identified the MRSA in the initial culture and then compared the genetics of the new swabs when they did the follow-up visit to see is it likely that the MRSA is really the same MRSA or could it be different.
76% of MRSA isolates in the case patients were genetically related to the original infection and 87% of the MRSA isolates in household contacts were genetically related to the original infection. So, the vast majority of this it really was the same MRSA even though the kid had been treated it's still in the nose colonized ready to cause another acute skin infection in the future and that's the one that had been spread to the household contacts.
So, what about the risk factors for a nasal colonization in the household contacts, that's what we want to know about, because if there are some things that you can do, if there's a kid in the house with a MRSA infection they get treated, they come back into the house, what can you do to keep from getting colonized yourself?
So risk factors were eczema or a dry, cracked skin and particularly on the hands, so there was definitely a higher risk if you had eczema. So that means if there's a case of MRSA in the house and you have eczema, make sure you're using lots of your moisturizing cream and keeping your eczema under good control, because that was definitely a risk factor for getting colonized yourself.
Also, assisting the case patient, the kid with the original infection, when they get home assisting them with bathing or showering was a risk factor. Also sharing a wash cloth and sharing balms, lotions and ointments with the case patient, so with the kid that was originally infected. So, you don't want to assist them with bathing or showering, although you may have to, depending on the age of the child. But just no, that's a risk factor. And sharing a wash cloth is a no-no and sharing balms, lotions and ointments.
Factors that decrease colonization with the use of antibacterial soap in the household and that held true for the case patient and the household contact. So, if you regularly use antibacterial soap in the home, there was less chance that it would then spread once the kid got home after treatment.
So, the authors conclude that following community-acquired MRSA infection in a child substantial portion of household members are colonized with the MRSA and modifiable behaviors, such as the sharing of personal items may contribute to MRSA transmission within the household.
So there you have it and you've heard it said, never share what touches your hair, but I tell you when it comes to balms, lotions, ointments and wash cloths, never touch again what touches the skin; at least of those things were previously touched or used by someone with a recent MRSA infection. Sorry folks, I couldn't resist that one.
All right. Let's take a quick break and we'll be back and wrap up the show right after this.
All right. We are back and as I mentioned in the introduction to the program today, we're going to talk about a new strain of whooping cough that's being seen in Australia. And it's in Australia where a prolong pertussis epidemic has entered a disturbing phase with the study showing a new strain capable of evading the current vaccine. And it is maybe responsible for the sharp rise in the number of whooping cough cases doctors are seeing down under.
A team of Australian scientists led by the University of New South Wales believe this emerging new genotype called prn2-ptxP3 of the Bordetella pertussis bacterium maybe evading the protective effects of the current A-cellular vaccine and increasing the incidents of this potentially fatal respiratory illness. That's according to a study published in the Journal of Infectious Diseases.
Scientists have discovered the genotype in other countries suggesting it has the potential to spark epidemics around the globe and they say should be monitored closely. Dr. Ruiting Lan, an Associate Professor at the University of New South Wales School of Biotechnology and Biomolecular Sciences and one of the study authors, says this prolong whooping cough epidemic in Australia began in 2008 and has been predominantly caused by this new genotype of Bordetella pertussis.
The genotype was responsible for 31% of cases in the 10 years before the epidemic and that's now jumped to 84% a nearly three-fold increase, indicating it has gained a selective advantage under the current vaccine protocol. The current immunization is still the best way to reduce transmission of the disease in reduced cases but it appears to be less effective against this new strain and immunity wanes more rapidly.
He says, "We need to look at changes to the vaccine itself or increase the number of boosters.” Last year nearly 38,000 cases of life-threatening disease were reported in Australia, despite Australians having a relatively high vaccination rate.
The authors point out the increase in the number of whooping cough cases may be partly due to recent improvements in diagnostic tests, which means that mild or atypical cases in older children or adults are now more likely to be correctly identified. But, this has not explain the marked increase in hospital admissions, especially of very young children who are not yet fully immunized and in whom the diagnosis is much easier and the disease is more severe.
The team's findings suggest that while the current vaccine remains effective against most forms of whooping cough, its use could be contributing to the emergence of new and potentially more dangerous strains. Acellular pertussis vaccine introduced worldwide in the 1990s replaced whole-cell vaccine (WCV), due to concern with whole-cell’s side-effects.
Dr. Lan says, “The whole cell vaccine contained hundreds of antigens, which gave broad protection against many strains of Bordetella pertussis, but the acellular vaccine only contains three to five antigens. If the acellular vaccine (ACV) is less effective against these new strains, we need to ask what other strategies can be used to combat the epidemic, which is ongoing."
There has been growing concern among public health officials about the rising incidence of whooping cough in Australia. The death rate for babies under the age of six months who have pertussis infection is one in every 200 babies infected and adults and adolescents won the risk of passing the disease to these young infants.
So those certainly been more news related to this story, especially if the Australian strain of whooping cough becomes an international traveler on a larger scale and this will keep tabs on the wires and you'll be the first to know of any warnings or changes in vaccine recommendations coming out from the CDC or the American Academy of Pediatrics.
I do want to pause real quick. Some of you might be reeling a little bit. We used a lot of science terms in that story. So whooping cough, you've heard of whooping cough, it's something that babies get vaccinated against and the medical name for whooping cough is pertussis and the bacteria that causes pertussis or whooping cough is the Bordetella pertussis, a bacterium.
Now, it used to be, really not that long ago, back in the 80s and early 90s and prior to that, that the DTP vaccine that kids got it would have diphtheria, tetanus and pertussis. And the pertussis, basically was the bacteria that was killed and that's why it was called whole-cell pertussis because they would just take the pertussis, the bacteria, and kill it and put that in the vaccine.
So it couldn't infect you but the whole cell was there and cells, a bacterial cell has lots of proteins that are antigens on the outside of the cell and it's these that your body's immune system says hey, this isn't suppose to be here, I'm going to make an antibody against it, so when the real pertussis bacteria that's living comes along, you have antibodies against those proteins that'll attack the cell and kill it and keep you from getting infected; that's how it works.
Well, the problem with the whole-cell vaccine is that it contains some chemicals, one of which was cyclic AMP that had the effect of causing a high fever and it also makes kids just fell miserable, I mean you'd be achy and just feel bad for a few days. And you can have this high fever that lasted for a few days too and the high fever was high enough with the rapid of enough change in body temperature that it could bring on a feberal seizure.
And of course, that freaks moms and dads out even though feberal seizures aren't particularly dangerous but you don't want to see your kids having suddenly a high fever and they're sneezing and right after they got their vaccine, even though the outcome is fine, they're fine, they're protected now but it's stressful and traumatic for the family
And so what they've discovered is that since it was the contents inside the cell that cause this problem, what we could do instead is just take some of those proteins that are on the outside of the bacteria cell wall and put that, or the cell membrane I should say, we're not plants, and put those in the vaccine so your body would still make antibodies against these proteins but you didn't have to have the whole dead pertussis cell inside of the vaccine.
And we found that this really cut down on those side effects with the fever and feberal seizures and such. So, we came out with an Acellular, meaning the whole cell's not there just the proteins, Acellular pertussis vaccine. Well the problem is you just pick a handful of those proteins, three to five of them, and those are the only ones that you are going to be protected against. But if a new strain of pertussis comes along that doesn't have those particular proteins but has been naturally selected to have other proteins on the cell membrane, it can evade the vaccine, because the proteins that you made the antibodies against aren't on that cell membrane of this particular strain.
So, as the bacteria sort of evades this, the vaccine may have to have antigens or proteins added to it, of course that means that teenagers and adults who have not had the newer vaccine might have to get boosters with this new pertussis component in it, in order to protect babies from getting whooping cough.
It's easy for all of us to forget that back in my grandmother's day, I mean kids died all the time, right and left, if you had a family you had nine kids so that six of them would live,. I mean, really, kids died very frequently back in the early decades of the 20th century. Polio was rampant, measles was rampant.
That's just a part of life that kids died and I think we forget that and we've just grown accustomed to what life is like post-vaccines and then because of bad information out there about vaccine possible complications and is it associated with autism and other things; people are scared and don't want to get their kids vaccinated. But we forget that these disease that we vaccinate against killed kids.
And as we get larger populations that aren't vaccinated this becomes a threat again as we're seeing. In this particular case, it's not so much a problem with people not being vaccinated, it's because of the side effects of the vaccine, people didn't want it. So we come out with a newer, kinder, gentler vaccine that doesn't cause the same types of side effects in order to get people to actually get their kids vaccinated and so that's coming back to bite us a little bit.
So like I said we'll keep an eye on the story and let you know if there's any new vaccine or new advice coming out from the Centers Disease Control and Prevention or the American Academy of Pediatrics.
All right. Well that puts this episode of PediaCast in the proverbial can. I'd like to thank all of you for taking time out of your day, to listening and participating with the program. I want to remind you iTunes reviews are definitely helpful to us. So if you have not done that before it really doesn't take much of your time. Just head over to iTunes and write a little review for us, that would be most helpful in helping us recruit more moms and dads to the audience.
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All right. That wraps things up for this time and until next time, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids. So long everybody. [Music]
Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.