New research may lead to understanding of sepsis, NEC in children
STANFORD, Calif. New research from Lucile Packard Children’s Hospital and the Stanford University School of Medicine is helping physicians unravel the cause of a deadly and mysterious bowel disease that strikes medically fragile newborn babies.
The findings could lead to a better understanding of the disease and its medical management, and also shed light on the causes of sepsis, a major killer of children and young adults.
The bowel disorder, necrotizing enterocolitis, or NEC, is seen mainly among premature infants, affecting about one-in-every 2,000 births. A similar constellation of symptoms, also labeled NEC, is also seen in children born with congenital heart defects. The disease causes intestinal inflammation and impairs nutrient uptake. Complications can include perforation of the intestine and widespread infection of the abdominal cavity or blood — sepsis — as well as lasting consequences such as the need for bowel transplant or chronic intravenous feeding.
The findings, which will appear in the May issue of the journal Pediatrics, suggest that the diagnosis of NEC in premature infants versus those with heart disease may actually encompass two distinct disease processes with different origins.
“If we start accepting that we are looking at two different diseases, further research may be able to elucidate some differences in the disease process and help us tailor management,” stated senior study author Sanjeev Dutta, assistant professor of surgery and pediatrics at Packard Children’s and the School of Medicine.
Right now, because physicians have such a poor understanding of what causes the disease, they can’t tell which infants will be hardest hit, Dutta said. “At present, we’re managing all cases the same way without addressing the concept that the child with heart disease may have a different underlying cause of NEC than the child with prematurity alone. We’re giving support, but not really curing the disease.”
To gain insight into how necrotizing enterocolitis starts, Dutta and his collaborators investigated whether a pre-existing medical problem—congenital heart defects—affected the course of the disease. They reviewed medical records from 76 infants who had a congenital heart defect together with necrotizing enterocolitis and 126 infants who had necrotizing enterocolitis alone. All study subjects were patients at Packard Children’s between May 1999 and August 2007.
The researchers found that babies who had both necrotizing enterocolitis and a congenital heart defect fared better than those who had necrotizing enterocolitis alone. Even premature babies with heart defects did better than those who were premature alone. Babies who had heart defects were less likely than other affected infants to suffer intestinal perforation or abnormal narrowing of the bowel. They also were less likely to need surgery to resolve infection, to require an artificial drain through the abdominal wall for managing bowel perforation or to require removal of portions of diseased intestine.
The findings suggest that infants with heart defects may be getting the disorder because of reduced blood flow to the bowel, while those with normal hearts may get the disease for other reasons, such as a bad reaction to oral feeding in premature infants with an underdeveloped gut. Both poor blood flow and gut immaturity have been blamed for NEC before, but the relative importance of each factor has been unclear.
Another possibility suggested by the researchers is that the close medical monitoring given to infants with heart defects helps physicians detect the intestinal problem early and thus institute therapy more quickly.
Although necrotizing enterocolitis is relatively rare, “it’s a disease that has a huge impact on society,” Dutta said. “These kids can get very sick and die, or suffer permanent injury to the bowel.”
Infants who survive often require repeat hospitalizations and expensive treatments throughout their lives.
CDC confirms swine flu outbreak
ATLANTA The Centers for Disease Control and Prevention on Thursday confirmed seven human cases of swine flu, including five in southeast California and two in San Antonio, Texas.
The agency is currently working with local and state health agencies to investigate these cases and has determined that the virus is contagious and is spreading from human to human.
“However, at this time, we have not determined how easily the virus spreads between people,” the agency noted.
There is no vaccine available at this time, so it is important for people living in these areas to take steps to prevent spreading the virus to others, CDC noted. If people are ill, they should attempt to stay at home and limit contact with others. Healthy residents living in these areas should take everyday preventive actions.
People who live in these areas who develop an illness with fever and respiratory symptoms, such as cough and runny nose, and possibly other symptoms, such as body aches, nausea, or vomiting or diarrhea, should contact their health care provider. Their health care provider will determine whether influenza testing is needed.
Clinicians should consider the possibility of swine influenza virus infections in patients presenting with febrile respiratory illness who:
- Live in San Diego County or Imperial County, California or San Antonio, Texas; or
- Have traveled to San Diego and/or Imperial County, California or San Antonio, Texas; or
- Have been in contact with ill persons from these areas in the 7 days prior to their illness onset.
If swine flu is suspected, clinicians should obtain a respiratory swab for swine influenza testing and place it in a refrigerator, not a freezer, the agency advised. Once collected, the clinician should contact their state or local health department to facilitate transport and timely diagnosis at a state public health laboratory.
None of the infected individuals, who range in age from 9 to 54, have had direct contact with pigs, suggested Anne Schuchat, director of the CDC’s National Center for Immunization and Respiratory Diseases, during a conference call with journalists Thursday. “Investigations to identify the source of infection and to determine whether additional persons have been ill from infection with similar swine influenza viruses are ongoing,” the CDC stated.
Schuchat identified the virus as “unusual,” in that it contains fragments from four different influenza sources: a North American swine flu, a North American avian flu, a human flu, and a swine virus typically found in Asia and Europe.
The virus is resistant to amantadine and rimantadine, but susceptible to the newer flu drugs Tamiflu (oseltamivir) and Relenza (zanamivir).
Schuchat reported that the flu strain did not seem very severe, with onset accompanied by typical flu symptoms in addition to nausea, vomiting and diarrhea in some.
Paperless prescribing hits milestone
NEW YORK Surescripts’ announcement that more than 100,000 physicians have jumped aboard the e-prescribing bandwagon is an important milestone for the industry as one of the major hurdles for e-prescribing has been physician adoption.
As stated in the article, by the end of 2008, there were 74,000 doctors actively prescribing electronically, compared with 36,000 at the end of 2007. This means that physician adoption has increased more than 100% between 2008 and 2007.
What’s even more important is that these numbers will likely ramp up quickly in light of incentives created under the Medicare reform and HIT stimulus.
In fact, a recent Pharmaceutical Care Management Association study found that financial incentives for physicians to adopt health information technology included in the recent economic stimulus bill will increase the number of prescribers using electronic prescribing to more than 75% over the next five years — nearly double the rate of use anticipated after passage of last year’s e-prescribing legislation.
The study also found that e-prescribing will help prevent 3.5 million medication errors and save the federal government $22 billion in drug and medical costs over the next 10 years.
“E-prescribing saves lives, lowers costs and will substantially finance the government?s overall HIT investment in the new stimulus law,” stated PCMA president and CEO Mark Merritt in announcing the study findings.
It should also be noted that a ramp up in e-prescribing could have an impact on top-line pharmacy sales as more scripts reach the pharmacy counter.