A lot of patients who think they can't receive H1N1, seasonal influenza, or other vaccines; can. That's the kicker of new practice parameters on adverse reactions to vaccines released by a joint task force of the American College of Allergy, Asthma, and Immunology and the American Academy of Allergy, Asthma, and Immunology at the ACAAI's annual meeting in Miami Beach.

The new parameters aim to correct common misconceptions among patients and healthcare providers about who can't receive vaccinations, including pregnant women and those with food allergies.

Most commonly, patients objecting to receiving vaccinations have experienced fever, achiness, or rashes that do not prevent them from receiving future vaccines. Of the roughly 235 million vaccines doses administered annually in the United States, only one in one million causes anaphylactic reactions.

"(But) even patients who are allergic (to eggs), the vast majority can be vaccinated," said Jonathon M. Kelso, MD, one of the chief editors on the practice parameters.

First, patients with suspected allergies to vaccines or vaccine components should be evaluated by an allergist, who can use intradermal skin tests to confirm whether or not the patient is reacting to the vaccine or vaccine components, said Dr. Kelso, of the division of allergy, asthma, and immonology at Scripps Clinic in San Diego, Calif.

For those who do test positive for egg allergies, graded doses of vaccines containing less than 1 microgram of egg protein may allow patients with to safely recieve the vaccine.

The full practice parameters were published in the October 2009 supplement to the Annals of Allergy, Asthma & Immunology and will be available at the website of the joint task force on practice parameters.

In the future, therapists might also want to evaluate the patient for neurotic tendencies or exposure to high stress. German researchers, led by Adrian Loerbroks, MD, of Heidelberg University, have found chronic stress in animals alters hormone levels, which can inflame airways. The researchers further argue stress and neurotic character traits exert similar effects in humans. If so, helping people chill out might theoretically reduce their risk of asthma.

Surveying 5,114 men and women over an eight-year time span, researchers found from the get-go there was a link between asthma and neuroticism in men and between asthma and the trauma of unemployment in both sexes. Women who broke off life relationships were associated with asthma as well.

This study, reported in the October edition of the journal Allergy, found about 2 percent of the sample population developed asthma during the course of the data collection. Researchers found highly neurotic men and women were more than three times as likely to develop asthma as were their calmer counterparts. Breaking off a life partnership increased the risk of asthma by more than twofold in women, but not in males.

Although unemployment is a stressor, it did not significantly raise an association level with development of asthma, researchers reported.

"The physical mechanisms by which personality, stress, and emotions might influence the development of asthma," researchers wrote, "are still not well known."

Nonetheless, therapists who clue in to the everyday stress levels of their patients may find they need to provide TLC beyond the norm for stressed out asthmatics. A few calming words may be just as important as the MDI in some instances. And doesn't that assessment skill, which can benefit the healing process, belong in the realm of respiratory care?

Asthma educators in respiratory care ranks in particular can certainly counsel their patients to try to remain calm to ward off asthma exacerbations.

Recession has done some serious damage to the industry, causing patients to put off  treatments leading to layoffs of staff in some locations and creating credit crunches that have forced some facilities to close their doors, according to a recent U.S. News report.

Still, the key phrase among workforce experts is these trends seem to be "short term." Some aspects of the industry have been improving, especially in residential services, ambulatory health, home health and physician offices.

California reports indicate that state's population will grow by 10.2 million in the next 20 years and the number of its residents age 65 and older will more than double. Projections note that state needs 1.2 million health care workers now and will need 2 million by 2030.

The California study focused on an increased demand for allied health care workers (think respiratory therapists,  polysomnographers, lab techs and dental hygienists) rather than nurses, however.

States with small populations still will find increased needs for health care workers.

On  a national level, government projections say overall health care employment will grow by a whopping 22 percent through 2016. On a positive note, the industry added more than a half million jobs since the recession started.

Last year's nursing and health care worker shortages have dissipated pretty much because of the recession with medically qualified workers spun off from jobs in other industries returning to the fold, especially some of the workers in the older ranks. Potentially that trend holds some threats, because these same workers can back out of the employment picture if other aspects of the job market improve.

One positive force in the marketplace remains aging baby boomers. They will continue to grow in number, placing greater demands on the nation's health care services, creating what Brad Kemp, who headed the California study, called a "recession resistant" population.

Currently the U.S. population stands at about 305 million. That number is expected to grow by nearly 70 million (just under 30 percent) within the next 20 years, creating a far larger patient population than we now have.

Obviously more hands will be needed to provide for the demand for care.

If ethnic factors are considered, white children have the best showing, with a third using inhaled corticosteroids in a three-month study. The data for black children is not as good. About 22 percent were using their drugs; among Hispanic children, the figure is 21 percent.

The disparities really start to show in trips to the emergency room. Overall, 39 percent of the black children in the study had visited the ER recently, compared to 18 percent of white children, and 24 percent of Hispanic youngsters.

Researchers reported that minority children were more likely to be overusing quick-acting drugs designed to treat an asthma attack in progress. Data indicate 26 percent of black children used rescue inhalers on a daily basis, as did 19 percent of Hispanic children and 12 percent of white children.

It is not definitely clear why the racial disparities exist, according a team led by Deidre Crocker, MD, of the U.S. Centers for Disease Control and Prevention. Even after researchers weighed factors like family income, insurance coverage, household smoking and children's weight, race itself was still a factor in asthma control and medication use.

One potential reason for the differences, according to the CDC group, is black and Hispanic children are more likely than white children to get their medical care in an ER where prescriptions for preventive asthma medication are less likely to be written. Other possible reasons may center on parental distrust in the medications or the failure of doctors to prescribe the corticosteroids to minority children.

The study of 1,485 children appeared recently in the medical journal Chest.

But the results underscore the amount of work therapists still have before them when trying to get their young charges to take their drugs as ordered.

How often do therapists hear the phrase: "It's all in the genes"?  It's used to explain everything from brainpower to muscle power and points in between. Now that same uttering might be used to apply to asthma attacks.

British researchers are currently reporting youngsters carrying a gene variant called Arg 16 are more prone to attacks than are other asthmatics, even though they use drugs to control asthma properly.

Scientists studying the issue reported the data suggest clinicians should give genetic tests to children before treatment is started, and this practice may produce a more cost-effective way of treating them.

"This is a global question that needs to be addressed," noted lead researcher Somnath Mukhopadhyay of Brighton and Sussex Medical School.

Popular drugs like salbutamol (albuterol) and salmeterol are less effective in treating asthmatic children with Arg 16 and may, in fact, make their asthma worse, scientists told Reuters news service.

U.S. drug regulators have cautioned in the past that these asthma drugs may actually increase the asthma risk in some patients, but drug manufacturers report they have not found a gene variant risk in their own studies.

British researchers, who looked at patients between the ages of 3 and 22 years and using an inhaler, said their studies found a 30 percent greater risk of asthma if the children carried the Arg 16 gene. Those children with two copies of the gene had a 70 percent greater risk of drug-related woes. Scientists noted children taking daily doses of the drugs were typically those with the most severe chronic presentations of the illness.

More than 1 million British children have asthma and it is estimated 100,00 youngsters carry the Arg 16 variant, noted Coin Palmer of Dundee University, a fellow researcher.

This study is due to be published by the American Academy of Allergy, Asthma and Immunology.

"This is possibly a good time to ask the question whether it is cost effective to prescribe all children with the same or very similar types of medicine, or whether we should look at the question of genetics," added Mukhopadhyay.

Researchers said such tests could be simple and relatively cheap by using cheek swabs or saliva tests.

Findings may impact the therapy and advice given in the future.

Therapists looking for discussion topics for young asthma patients and their parents might look at the results of a study published in the September edition of Annals of Allergy, Asthma and Immunology.

Could atmospheric conditions play a part?

That actually may be the case, according to Alan Baptist, MD, director of the University of Michigan asthma program in Ann Arbor and the senior study author. His group reported temperature changes of more than 10 degrees and humidity change factors of 10 percent could be factors in asthma exacerbations.

In the study, researchers looked at the records of youngsters hospitalized for asthma exacerbations at the Children's Hospital of Michigan in Detroit. The facility recorded more than 25,000 asthma admissions in a two-year span from Jan. 1, 2004, to Dec. 31, 2005.

The hospitalization records were then mapped against weather data during this time frame along with data on airborne allergens and air pollution. Their statistical model was designed to control for those factors, Baptist noted.

An increase of 10 percent in humidity two days before the admission date was associated with one additional visit to the emergency department, noted Baptist. "For temperature, an interday change of 10 degrees one day before the admission resulted in two additional visits." The facility averaged 35 asthma visits per day.

But wait! Doesn't the daily temperature change vary generally by 10 degrees or more? And how frequently do the relative humidity levels change? Aren't these sometimes by the hour?

"It's really unknown why temperature and humidity changes exacerbate asthma, and it should be looked at further," noted Baptist. "Asthma at its core is inflammation of the airways, and maybe these changes could be triggering more inflammation."

The results are not enough to encourage major changes in clinical practice, suggested Shean Aujla, MD, a pediatric pulmonologist at the Children's Hospital of Pittsburgh.

The take-home lesson for discussion: Most parents watch the weather forecasts daily so they know how their children should be dressed for school. Perhaps parents of school-age children with asthma should make it a point of stressing the importance of peak-flow tests and taking asthma medications, especially on those days when rapid climate changes can be expected. In addition, outdoor activities may need to be tailored to accommodate changes in temperature and humidity.

Kids are told to come in out of the rain. Further advice to asthma patients may be: on rainy days, be sure to check your peak flows when you come in out of the rain.

At least these are points that might be discussed in asthma management sessions.

One new blood test, measuring the level of omega-3 fatty acids in red blood cells, is broadly available for the first time to the public as a fast, consumer-friendly, at-home finger stick test.

Recent health care research shows omega-3 levels may be among the best predictors of future coronary heard diseases, providing much stronger correlations for the risk of sudden cardiac death than traditional indicators, including HDL and LDL cholesterol levels.

The test, Gene Smart Omega-3 Index, records data on a sliding scale and results are represented as a score from 4 percent or less indicating a high risk and a score of 8 percent or more, indicating a relatively low risk.

Recent tests also suggest individuals have varying capacities to metabolize omega-3, "so even if a person eats fish or takes fish oil supplements, they may not be getting enough," noted Floyd "Ski" Chilton, Ph D, a pioneer in omega-3 research and professor of physiology and pharmacy at Wake Forest University School of Medicine. He noted the test is convenient, affordable and convenient.

The test was developed by Gene Smart in conjunction with work by William S. Harris, PhD, of Sanford School of Medicine at the University of South Dakota. The test uses Dr. Harris's HS-Omega-3 Index methodology.

Conditions are worse than average in the top-tier 28 communities, according to the report. The data are scored on high pollen scores, medicine utilization and board certified allergists per patient.

In order, here are the cities destined to bring tears to the eyes and wheezes to the lung:

1. McAllen, Texas

2. Wichita, Kan.

3. Louisville, Ky.

4. Oklahoma City

5. Jackson, Miss.

6. Dayton, Ohio

7. Augusta, Ga.

8. Tulsa, Okla.

9. Knoxville, Tenn.

10. Little Rock, Ark.

11. Madison, Wis.

12. San Antonio

13. Dallas

14. New Orleans

15. Baton Rouge, La.

16. Charlotte, N.C.

17. St. Louis, Mo.

18. Birmingham, Ala.

19. El Paso, Texas

20. Virginia Beach, Va.

21. Memphis, Tenn.

22. Chattanooga, Tenn.

23. Des Moines, Iowa

24. Austin, Texas

25. Greensboro, N.C.

26. Omaha, Neb.

27. Columbia, S.C.

28. Philadelphia

Cities occupying the last five of 100 slots are Portland at 100; Albany, N.Y., at 99; Seattle, 98; San Diego, 97; and Greenville, S.C., 96.

View a full list of communities. 

Results of two recent studies may provide respiratory therapists with some flexibility in treating their acute respiratory distress syndrome patients, according to Timothy A. Mullen, RRT, in an article titled "Beyond ARDS Net: A Two-Study Review Shows a Reduction in Mortality."

Behind the scenes, he shows how the debate over use of low tidal volumes for ventilated ARDS patient went on for years and eventually confirmed that low tidal volume is the preferred method for treating these patients. In this method, peep and FiO2 are adjusted in a step-by-step fashion to reach the best levels.

Mullen said two studies raise several questions however: Are lower tidal volumes and peep and FiO2 adjustments enough, or should more be done? He questions whether the ARDS NET protocol strategy is enough to prevent alveoli from recollapse and whether oxygenation and mortality can be improved in this patient population.

Study results were surprising. In the first study published in JAMA last year, researchers put a control group on the ARDS protocol and a study group went on a protocol that maintains plateau pressures of 28 to 32 cmH2O. In this latter group, volume was reduced to 6 ml per Kg and peep was adjusted to achieve plateau pressure of 30 cmH2O. Results yielded a decrease in mortality at 28 days and an increase in ventilator-free days as well.

The study shows that keeping plateau pressures at 30 cmH2O will improve alveoli recruitment and possibly prevent alveolar relapse. Mullens notes the technology is equipped on most ventilators today to monitor and provide that pressure range.

A second study published in the New England Journal of Medicine monitored transpulmonary  pressures via esophageal balloon. The study took pressure measurements at the end of inspiratory airway and transpulmonary pressure cycles of study patients along with end-expiratory airway and transpulmonary pressures of ARDS patients.

This study found patients placed on the ARDS Net protocol had negative thoracic pressures, and peep was adjusted to reach an end-expiratory rate of 0 to 10 cmH2O with an end-inspiratory pressures less than 25 cmH2O, preventing alveolar recollapse and overdistention of the lungs.

As in the study above, researchers showed that by monitoring transpulmonary pressures, they could lower the mortality rate at 28 days compared to the control group which strictly followed the ARDS protocol. Oxygenation and compliance were improved.

This method, Mullens notes, requires extra monitor equipment that some health care systems may not have or cannot afford.

He noted the second study does take into account the rigidity of the chest wall and may give RCPs an improved method to tailor their care to patient needs.

Decisions! Decisions! Decisions! That's the status quo in many healthcare departments today as clinicians ponder the many choices they confront on the flu vaccine front.

The hard part is deciding whether to get the flu shot or not, and according to a current  ADVANCE survey, many are opting not to get one. Even in states like New York which require flu shots, staff are not 100 percent behind the push.

It is not just the flu shot itself under consideration today but multiple flu shots. One is needed for general flu; a second is used specifically against the swine flu strains.

Deciding for or against one or two shots is now the option.

But there is more to the decision-making. The New England Journal of Medicine recently compared the effectiveness of two different types of vaccines currently  being offered. One version is a live attenuated vaccine in which the virus is weakened through a chemical or physical progress to yield an immune response that is not as severe as you would normally get with exposure to a full virus strain.

The second is an inactivated vaccine made from viruses which have been killed and are unable to cause the disease.

Which type is best?

According to the NEJM, the inactivated flu vaccine is more effective and has been for the past three years.

Lining up for a flu shot then is just one part of the formula. Once the decision has been made to get this year's flu shot, you must still decide if you will opt for a general flu shot, a swine flu shot or two separate shots. Then you need to consider the composition of the vaccines themselves: inactivated or live attenuated.

It's still a bit early perhaps to make a final decision on the subject, but as each payday period comes along, we all move closer to the day we must roll up our sleeves and get the shot or opt out of participating.

Decisions! Decisions! Decisions!

A small number of tubes were manufactured with internal diameters slightly smaller than indicated on the labeling, which may create the potential for the clinician to experience difficulty passing through or withdrawing the suction catheter.

The health consequences that may result from use of the defective device include the inability to remove secretions from the device and from the patient's airway, which may result in partial or complete obstruction of the airway and an inability to ventilate the patient.

In addition, this defect may increase airway resistance and compromise the ability to ventilate the patient. There is a reasonable probability of serious injury and/or death.

Smiths Medical is instructing customers to return all unused Tracheal Tubes and in their press release has provided recommendations for management of recalled product that is currently in use.

Click here to get more information about this recall, including complete details and recommendations.

An elderly bank robber had his portable oxygen system conveniently slung over his shoulder when he arrived at the San Diego National Bank, and also when he left with an unspecified amount of cash, the L.A. Times reported on Sept. 12.

The suspect, who had an oxygen tube leading to his nose, stood 6-feet 6-inches tall with white hair, a gray mustache, and glasses. Investigators estimate he's in his 70s or 80s.

Clad in a white beret, argyle sweater, and brown sports jacket, he allegedly gave the teller a hold-up note, took the loot, and got away from police on foot.

All I have to say is his six-minute walk time must be incredible...

The study involved 3,600 Dutch children studied from birth through 8 years and tallied daycare experiences and health indicators like wheezing. By age 5, the daycare children who started daycare from birth to age 2 had less wheezing than the kids who did not go, researchers noted. But three years later, any discrepancies disappeared.

"We found no evidence for any protection against asthma, allergy and airway hyper-responsiveness at 8 years," reported Dr. Johan C. de Jongste, of Erasmus University Medical Center in the Netherlands.

Researchers used a combination of annual parent reports and health assessments like blood tests used to measure IgE antibodies typically elevated in youngsters with allergies. They likewise tested lung function and airway hyper-responsiveness and used maternal allergies as control factors.

Overall, the Dutch study used a reasonable reflection of the general population, including rural and urban area participants, de Jonste wrote in an e-mail interview to Health Day's Kathleen Doheny.

The bottom line: Early exposure to germs and other organisms does cause more symptoms early in a child's life but...and here's the real kicker...without a counterbalancing health benefit later in life as was previously believed.

Children had an increase in airway symptoms until age 4, an overall decrease from age 4 to 8 but no protection at age 8 compared to those youngsters who were not in daycare.

John Heffner, MD, past president of the American Thoracic Society, termed the study a landmark investigation, "the first to follow children prospectively from birth to 8 years and assess the effect of daycare enrollment on both asthma symptoms and immunologic evidence of allergic disease."

There is no strong evidence that enrollment in a daycare center will provide protection against asthma; and as such, that type of strategy cannot be promoted as a public policy, Heffner added.

Does that mean daycare does not work? Not really. But it may serve mostly by providing social contacts for children and enabling both parents to work as opposed to building up a long-term immunity against prevalent childhood diseases. And the study may open a firestorm of protests from daycare operators who advertise their services as a way to build children's immunity against subsequent diseases. For those operators, it will be back to the drawing board for recruitment strategies.

CDC's Advisory Committee on Immunization Practices (ACIP) has released recommendations for use of vaccine against novel influenza A (H1N1) or swine flu.  

ACIP met to develop recommendations on who should receive vaccine against H1N1 when it becomes available, and to determine which groups of the population should be prioritized if the vaccine is initially available in extremely limited quantities.

The key populations include those who are at higher risk of disease or complications, those who are likely to come in contact with H1N1, and those who could infect young infants. The committee recommended the vaccination efforts focus on five key populations. 

• pregnant women;
• people who live with or care for children younger than 6 months of age;
• healthcare and emergency services personnel;
• persons between the ages of 6 months to 24 years of age; and
• people aged 25-64 years, with chronic disorders or compromised immune systems.

The groups listed above total approximately 159 million people in the U.S.

ACIP does not anticipate a shortage of novel H1N1 vaccine, but availability and demand can be unpredictable. There is some possibility the vaccine initially will be available in limited quantities. 

In this setting, the committee recommended that the following groups receive the vaccine before others:

• pregnant women;
• people who live with or care for children younger than 6 months of age;
• healthcare and emergency services personnel with direct patient contact;
• children 6 months through 4 years; and
• children 5-18 with chronic medical conditions.

ACIP further recommended that once the demand for vaccine for these prioritized groups has been met at the local level, programs and providers should begin vaccinating everyone from ages 25 through 64 years. 

Current studies indicate the risk for infection among persons age 65 or older is less than the risk for younger age groups. Therefore, as vaccine supply and demand for vaccine among younger age groups is being met, programs and providers should offer vaccination to people over 65.

The committee also stressed people over 65 receive the seasonal vaccine as soon as it is available. Even if H1N1 vaccine is initially only available in limited quantities, supply and availability will continue, so the committee stressed that programs and providers continue to vaccinate patients who have not been immunized and not keep vaccine in reserve for later administration of the second dose.

The novel H1N1 vaccine is not intended to replace the seasonal flu vaccine. It is intended to be used alongside seasonal flu vaccine to protect people. Seasonal flu and novel H1N1 vaccines may be administered on the same day, according to the CDC.

-from ADVANCE for Nurses

For continuing coverage of H1N1, visit our swine flu resource center.

There is no single "best" answer available. Some caregivers object to vaccinations on the basis that new shots available may not be effective or may even could trigger flu or flu symptoms; others argue it will be impossible almost to track vaccination use among millions of health care workers, leaving potential gaps in health care protection overall.

Respiratory therapists certainly are a vital component in the health care arena. They provide direct care to the sickest of the sick in the nation's clinics. The decisions they make as to endure the minor pain of the working end of a vaccination needle will have a major impact on the overall health of their patients. If they opt out, they run the risk of passing on the flu to their patients; on another important level, if they fail to get the vaccine, they can succumb to the disease and be unavailable to care for their patients at all.

If the past years are any example, roughly one of two caregivers opted out of the vaccine for the season. Will the scare of swine flu change the formula? That remains to be seen.

So far, nobody from either the respiratory care or the sleep medicine communities has started a drum roll for a PR campaign for getting an arm ready for the needle. And some caregivers are taking a low-key approach for the time being.

Results of a current ADVANCE poll indicate 43 percent of our audience think swine flu is media hype. Only 14 percent are getting ready for a swine flu epidemic.

Deborah Burger, of the California Nurses Association, said safety concerns persist over the new vaccine. Her union, with 86,000 members in 50 states, is weighing whether or not to support required flu shots for nurses. She said her union believes patients should be protected but also wants to protect nurses from any potential vaccine-related problems.

Some clinicians fear a repeat of repercussions of diseases like Guillain-Barre syndrome which surfaced as a potential side-effect during the 1976 swine flu vaccination effort 33 years ago.

Just as important an issue is what might happen to the therapists and nurses who refuse to get the one or two shots needed in today's health care vaccination blitz. Hospital officials may have few options to enforce compliance other than firing staff for insubordination. That would be an extreme measure that would do nobody any good in the long run. It would deprive hospitals of the very helpers they would need in a crisis.

What are your own feelings on the issue? Are you for the vaccinations or against them? Why?