Influenza vaccination is safe and immunogenic when administered to hospitalized patients.

CONTEXT: Very few high-risk persons receive influenza vaccine while hospitalized. Health care providers may be reluctant to administer the influenza vaccine to hospitalized patients because of insufficient data related to the safety and immunogenicity of vaccinating this population. OBJECTIVE: To evaluate the safety and immunogenicity of the influenza vaccine administered to hospitalized patients compared to ambulatory clinic patients. DESIGN: Prospective cohort study. SETTING: A 711-bed, acute-care, private tertiary hospital and two private internal medicine clinics from October 1 to December 25, 1999. PARTICIPANTS: 51 inpatients; 177 outpatients. INTERVENTION: All study participants received influenza vaccine. Serum samples for antibody assays were collected at baseline and at 3 weeks after vaccination. Study participants were mailed a questionnaire to elicit information about adverse effects of vaccination. MAIN OUTCOME MEASURE: Seroconversion rates (4-fold increase in hemagglutination-inhibiting antibodies) and seroprotection rates (titers > or = 1:40) to the influenza vaccine in hospitalized and ambulatory patients. RESULTS: The seroconversion and post-vaccination seroprotection rates in the inpatient group were 65% (33/51) and 88% (45/51) compared to 55% (98/177) and 94% (167/177) in the ambulatory clinic patients. Soreness at the site of injection was the most common adverse effect, reported by 12% of both the inpatients (5/42) and ambulatory clinic patients (20/171). Seventy-four percent of patients (31/41 inpatients and 127/174 outpatients) reported no significant side effect to vaccination. CONCLUSIONS: Influenza vaccine is at least as safe and immunogenic in hospitalized patients as it is in ambulatory patients. These data can be used to help convince health care providers to order the influenza vaccine for their hospitalized patients.

Variation among cardiologists in the utilization of right heart catheterization at time of coronary angiography.

To describe how often a right heart catheterization was performed at the time of coronary angiography, the patient characteristics that predicted the use of this procedure, and the variation among cardiologists in the use of this test, we reviewed all cases of coronary angiography (n = 1,282) during the first 2 mo of 1993 at two large community hospitals. Fifty-two percent of the cases received a right heart catheterization at the time of their coronary angiography. The following characteristics were associated with the receipt of a right heart catheterization in a logistic regression analysis: cardiomyopathy (odds ratio = 2.59, 95% CI = 1.01, 6.62), congestive heart failure (odds ratio = 2.07, 95% CI = 1.42, 3.01), valvular heart disease (odds ratio = 2.54, 95% CI = 1.44, 4.49), no coronary angioplasty performed at the procedure (odds ratio = 2.71, 95% CI = 2.12, 3.45), and increased age (odds ratio = 1.13 per decade, 95% CI = 1.03, 1.25). Of 37 cardiologists who performed > 10 coronary angiography procedures, the use of right heart catheterization varied from 10-90%. The cardiologists' practice variation persisted after adjustment for patient clinical characteristics. Because of the high utilization of right heart catheterization at the time of coronary angiography and the variation in use among cardiologists, even when controlling for patient characteristics, the issue of appropriate indications for this procedure needs to be addressed in a rigorous fashion.

Age-related differences in the utilization of therapies post acute myocardial infarction.

OBJECTIVE: To describe the effect of age on the care of patients hospitalized with acute myocardial infarction (MI). DESIGN: Retrospective chart review of all cases with a primary or secondary discharge diagnosis of acute MI. SETTING: Two large community hospitals in Milwaukee, Wisconsin, from July 1, 1990 to June 30, 1991. PATIENTS: There were 771 charts reviewed, of which, 149 cases were aged 54 years or younger, 203 were 55 to 64 years, 224 were 65 to 74 years, and 195 were aged 75 years or older. MEASUREMENTS: Hospital charts were examined for use of diagnostic and therapeutic interventions, including medications and procedures, as well as length of stay and in-hospital mortality. RESULTS: Older patients were more likely to be female (18%, 20%, 38%, and 56% for the four age groups, respectively, P < .001 chi-square for linear trend), more likely to present with congestive heart failure (31%, 39%, 51%, and 72%, P < .001), and had a higher in-hospital mortality rate (5%, 7%, 10%, and 18%, P < .001). Older patients had a longer length of stay in the hospital. The use of cardiac catheterization in these post-MI patients was high and did not decrease until after age 75 (85%, 88%, 88%, and 47%, P < .001). The percentage of patients receiving balloon angioplasty decreased with age (51%, 51%, 43%, and 20%, P < .001), whereas the percentage of patients receiving myocardial revascularization did not significantly differ with age (15%, 22%, 25%, and 19%, P = .46). Aspirin was less likely to be prescribed to older patients at discharge (79%, 82%, 70%, and 62%, P < .001). CONCLUSION: A surprisingly high percentage of those older than age 65 received invasive tests and interventions. This high utilization rate coexists with our continued ignorance about the efficacy of these tests and interventions in older adults.

Beta blocker use in the treatment of community hospital patients discharged after myocardial infarction.

OBJECTIVE: To explore the reasons for underutilization of beta blocker treatment after acute myocardial infarction. DESIGN: A retrospective chart review. SETTING: Two large community hospitals in Milwaukee, Wisconsin. PATIENTS/PARTICIPANTS: All subjects (n = 694) discharged alive from July 1, 1990, to June 30, 1991, who had a diagnosis of acute myocardial infarction were eligible. Of these, 250 had missing data, resulting in a final sample of 444. RESULTS: Twenty-nine percent of the 444 patients were prescribed beta blocker therapy on discharge. Characteristics of the patients and their treatment associated with receipt of beta blocker therapy were identified with a logistic regression model. The adjusted odds ratios were 0.52 for female gender, 0.34 for no health insurance, 0.21 for chronic obstructive pulmonary disease, 0.46 for congestive heart failure, 0.28 for atrioventricular block, 1.86 for hypertension, 1.93 for chest pain during acute myocardial infarction, and 4.65 for prehospital beta blocker use. Prescription of beta blocker therapy was also influenced by receipt of other treatment modalities. The adjusted odds ratios were 0.23 for receipt of beta blocker therapy associated with myocardial revascularization, 0.18 for prescription on discharge of calcium channel blockers, and 0.22 for receipt of angiotensin-converting enzyme inhibitors. CONCLUSION: A minority of patients discharged after acute myocardial infarction receive beta blocker therapy, and women are only half as likely as men to receive it, after controlling for other factors. Though there are no data relating to whether calcium channel blockers or angiotensin-converting enzyme inhibitors lessen the protective effect of beta blocker therapy post-acute myocardial infarction, it would appear that these agents are frequently being used in lieu of beta blocker therapy for post-acute myocardial infarction patients.

Duration of response to intramuscular versus low dose intradermal hepatitis B booster immunization.

OBJECTIVE: To determine the duration of the immune response to plasma-derived hepatitis B vaccine among healthcare workers responding to booster doses of intradermal (ID) or intramuscular (IM) vaccine in 1986 and those with protective levels of antibody to hepatitis B surface antigen (anti-HBs) in 1986 without booster vaccine. Both groups received a primary hepatitis B vaccine series 24 to 36 months earlier. DESIGN: Cross-sectional follow-up study two years later of an inception cohort defined in 1986. SETTING: An academically affiliated metropolitan county hospital. PARTICIPANTS: Group 1: Hospital employees responding to booster doses of hepatitis B vaccine given ID or IM in 1986 due to low anti-HBs levels. Forty-one (82%) of 50 eligible persons were evaluated. Group 2: Persons not receiving booster vaccine in 1986 due to protective levels of anti-HBs. A random sample of 95 persons was drawn from a pool of 152 participants with protective levels in 1986. Sixty-five (68%) of 95 contacted persons were restudied. RESULTS: In 1988, 14 (64%) of 22 previous ID responders had anti-HBs levels greater than or equal to 10 milli-international units (mIU)/mL, compared with 17 (89%) of 19 IM responders (p = .055). The 1988 geometric mean titer of IM recipients was 66.4 +/- 4.5 mIU/mL and of ID recipients was 20.7 +/- 7.4 (p = .04). None of 65 Group 2 subjects' anti-HBs titers dropped below 10 mIU/mL by 1988. CONCLUSIONS: Plasma-derived hepatitis B vaccine recipients with anti-HBs levels greater than or equal to 10 mIU/mL at 24 to 36 months after primary immunization are likely to maintain these levels two years later. The diminished durability of the antibody response together with the increased rate of local side effects associated with the ID injection route may limit its applicability as an alternative to using IM booster doses of hepatitis B vaccine.

Code teams and the review of cardiac arrests.

A new system for responding to Codes, or resuscitations of patients with cardiopulmonary arrest, was implemented at St Luke's Medical Center, Milwaukee. A teaching program was begun to establish the Advanced Cardiac Life Support (ACLS) guidelines as the standard of care. A task force defined the composition of the Code team and was then designated the Code Review Committee, meeting monthly to review all Codes. Indicators for review were established. Code review is followed by a letter to the physician Code team leader and/or registered nurse. Data for 18 months, still preliminary, show improved compliance with indicators for documentation and for adherence to ACLS guidelines.

Susceptibility of hospital-based health care personnel to varicella-zoster virus infections.

Varicella-zoster virus (VZV) transmission poses a major infection risk for health care workers in the hospital environment. Immunologically normal adults who contract varicella have 9 to 25 times the risk of major morbidity or death from infection compared with healthy children. Moreover, varicella infection during pregnancy is associated with a high rate of complications and the risk of the congenital varicella syndrome. To evaluate susceptibility to VZV infection among hospital workers, the employee health service screened 241 personnel for VZV antibody by the indirect fluorescent antibody technique. Overall, 7 (2.9%) of 241 personnel lacked VZV antibody and were therefore presumed susceptible to infection. Susceptibility varied dramatically by age and was significantly higher among persons 35 years of age and younger (7/93 = 7.5%) than among those aged 36 years and older (0/148 = 0%, p = 0.001). Persons 35 years old or younger with a clinical history of chickenpox or herpes zoster were much less likely to lack immunity (3/71 = 4.2%) than those stating they had no history of either (4/11 = 36.4%, p = 0.005). Screening strategies for VZV immunity in hospital employees could be made more efficient by performing serologic tests only on those persons aged 35 years or younger with a negative or uncertain history of the disease. Persons who lack antibody may be considered for preexposure immunization with live attenuated varicella vaccine as an alternative to varicella-zoster immune globulin or enforced absence from patient care after exposure to a VZV-infected patient.

Duration of immunity after hepatitis B vaccination: efficacy of low-dose booster vaccine.

Although the efficacy of hepatitis vaccine is well documented, the duration of immunity of healthy adults after vaccination is unknown. We studied 245 hospital employees 3 years after primary vaccination with hepatitis B vaccine to determine the prevalence of immunity indicated by levels of antibody to hepatitis B surface antigen of 10 mIU/mL or greater; and to compare the immunogenicity of low-dose intradermal vaccine with standard-dose intramuscular vaccine in persons found to be seronegative. Thirty-eight percent of employees studied had antibody levels less than 10 mIU/mL. Low levels were associated with smoking, older age, and higher body-mass index. Seventy-eight percent of persons with low antibody levels responded to a single booster vaccine. Two micrograms of intradermal vaccine was as effective as 20 micrograms of intramuscular vaccine in inducing an antibody response; however, intradermal vaccine was associated with more local reactions (42% compared with 17%). Many healthy adults will need periodic boosters of hepatitis B vaccine to maintain production of antibody to hepatitis B surface antigen; low-dose intradermal booster schedules may be feasible.