Allison Bitonti-Brito, PharmD (Candidate)

Influenza A virus is a prominent cause of morbidity and mortality in children, even more so than in adults.

Last year’s flu season saw 146 pediatric deaths.

Overall, influenza has an annual prevalence rate estimated at 5% to 10% in adults and 20% to 30% in children, which is a stark difference.

Although the exact reason behind this phenomenon is unknown, a few theories were recently summed up in a review article published in

It has been speculated that the increased influenza severity and incidence in children may be due to increased viral replication, decreased ability to clear the virus, greater inflammatory response, more susceptibility to secondary bacterial infections, or a combination of all of these factors.

In a study on rhesus monkeys, increased viral replication and decreased secretion of interferon alpha (IFN-α), which is involved in the destruction of foreign pathogens, was found in infant monkeys, but not in their adult counterparts. In addition, studies in both mice and human infants suggest that there is also a decrease in the secretion of interferon gamma (IFN-γ), which is primarily secreted from natural killer (NK) cells.

IFN-γ has direct antiviral activity and aids in clearing pathogens. Non-functional NK cells may be the cause of the decrease in IFN-γ.

An emerging theory for the increased prevalence of influenza A virus in children is that they have an enhanced inflammatory response leading to increased morbidity and mortality. Several studies have found that increased pro-inflammatory cytokine interleukin-6 (IL-6) in the pediatric population has a direct effect on flu severity.

A recent prospective study also found that infants and young children had higher levels of inflammatory nasal cytokines and type I IFNs than adults—which coincides with the theory that inflammation, not innate immune deficiency, is to blame for the difference in morbidity and mortality.

Possibly due to a counter response of excessive inflammation, interleukin-10 (IL-10) seems to be elevated in children. Because IL-10 has anti-inflammatory properties, it is potentially detrimental to the host because it increases the risk for secondary bacterial infection.

Co-infection has been reported in 43% to 75% of fatal cases of influenza A virus in children.

These review findings provide a roadmap for future research to determine why the pediatric population is more prone to serious flu infection.

1. US Centers for Disease Control and Prevention. FluView: Influenza-Associated Pediatric Mortality. http://gis.cdc.gov/GRASP/Fluview/PedFluDeath.html. Accessed October 20, 2015.

2. World Health Organization. Influenza (seasonal). http://www.who.int/mediacentre/factsheets/fs211/en/. Published March 2014. Accessed October 20, 2015.

3. Coates BM, Staricha KL, Wiese KM, Ridge KM. Influenza A Virus Infection, Innate Immunity, and Childhood.

Articles

Why Are Children More Prone to Fatal Influenza?

Most medications are prescribed solely based on the professional opinion of the clinician. This leaves little to no room for input from the patient, who will ultimately decide whether or not to continue taking the prescribed medication.

A good portion of chronic disease states has drug classes with equivalent efficacy, so patient-specific factors play an important role in deciding which medication to prescribe. This is where patient decision aids can come into play.

Decision aids take the form of cards that detail information on treatment options for a given disease state, such as medication dosing, benefits, and side effects. These cards are shared with patients so that they may select the medication that they feel most comfortable with.

When decision aids are used, outcomes such as perceived involvement, agreement between values and choice, and decisional conflict move towards a desirable positive direction.

One recent study observed the use of decision aids that detail treatment options for depression, and it found that patients reported feeling more knowledgeable and comfortable with the medication that was chosen in comparison to those in the standard care group who were not shown decision aids.

According to the study authors, 79% of patients in the decision aid arm of the trial stated that they prefer to be the principal decision maker or be involved in medical decisions made by their clinician regarding their care. However, it remains unclear what effect decision aids can have on patient compliance.

Decision aids allow patients to take a proactive approach to their own care, which increases their satisfaction. With decision aids, patients are more comfortable with the therapy they receive and are content with their clinician’s care.

This atmosphere enhances the critical doctor-patient relationship. Because the downstream effect on persistence with decisions, health-related quality of life, and costs have not yet been established,

further research is needed to paint a full picture of the pros and cons of decision aids.

1. Stacey D, Entwistle V, Llewellyn-Thomas H, Rovner D, Holmes-Rovner M, et al. Decision aids for people facing health treatment or screening decisions.

2. LeBlanc A, Herrin J, Williams MD, et al. Shared Decision Making for Antidepressants in Primary Care: A Cluster Randomized Trial.

Published online September 28, 2015. doi:10.1001/jamainternmed.2015.5214.

3. O'Connor AM, Fiset V, Degrasse C, Graham I, Evans W, Stacey D, et al. Decision aids for patients considering health care options: evidence of efficacy and policy implications.

Decision aids allow patients to take a proactive approach to their own care.

Are Patient Decision Aids Effective for Chronic Disease Management?

Most clinicians are programmed to believe that

is unprofessional. They tell themselves that they will create an unmanageable workload for their colleagues and are being dramatic for wanting to stay home.

But when clinicians don’t take a sick day, are they putting patients’ health at risk? An editorial published in

delves into the potential implications of health care professionals working while sick.

Most health care workers cite an obligation to help their patients and a responsibility to their colleagues as reasons for working while they’re under the weather. But the nature of the job entails close encounters with patients, which increases the risk of infection transmission.

Some communicable diseases are more contagious than others, as is the case with influenza. Due to this, the US Centers for Disease Control and Prevention (CDC) recommends that employees with influenza should not return to work until 24 hours after they are fever free or 7 days, whichever is longer.

concurs with this recommendation, as it found that 72% of transmitted illnesses was due to employees working while sick. The authors found that having a “flu day” policy consisting of 2 extra paid sick days reduced the incidence of workplace transmissions by nearly 40%.

For now, only 61% of private sector employees get any paid sick leave—a stark difference from their government-employed counterparts who fare much better at 90%.

More paid sick leave can dramatically reduce transmission of serious infections by health care workers. The line of what constitutes a serious infection and thus paid sick time is blurred, but it should be more concise.

A system that defines key parameters of a more serious illness such as vomiting, bloody diarrhea, or fever can be implemented by the workplace to ensure that those who need to take some days off can do so with little to no repercussions. Taking this action will lower patients’ risk of getting infected.

Kumar S, Grefenstette JJ, Galloway D, Albert SM, Burke DS. Policies to reduce influenza in the workplace: impact assessments using an agent-based model.

Employee Benefits in the United States. Bureau of Labor Statistics; 2015. Available at: http://www.bls.gov/news.release/pdf/ebs2.pdf. Accessed October 23, 2015.

Most clinicians are programmed to believe that calling in sick is unprofessional.

Why Clinicians Should Take Sick Days

Studies have shown that nurse practitioners (NPs) provide patients with the same level of care as primary care physicians (PCPs),

making these advanced practice nurses (APNs) aptly suited to fill the gaps left by a shrinking PCP population across the globe.

An international standard definition of an APN does not currently exist in global regulatory bodies and health care agencies, and so cross-border exchange of practitioners is difficult. A recent

discussed the importance of globalization in the realm of NPs.

The study authors found that differences in regulations between countries largely prevent APNs from treating patients at the top of their licenses. Since a standard requirement for licensure both nationally and abroad does not exist, an NP in one country or region may not be considered as such in another.

In addition, title protection only exists in the more economically developed countries such as the United States, meaning that there is no standardization of who is or who can become an NP in a vast number of countries. This leads to a lack of outcomes data and promotion. Different regulations within each US state can stunt an NP’s growth.

At the 2014 Global APN Symposium, 5 recommendations were made to help guide standardization of the field. Among the recommendations were removing policy barriers and having an agreed upon definition of what an APN is to allow for a smoother transition when changing jurisdictions.

With the ever-growing need to fill the patient-provider gap that leaves patients without primary care, these recommendations will provide APNs with the option to access patients in their home country or abroad. Collaborations between educational institutions as well as nursing regulatory bodies are needed to ensure the success of globalization within the nurse practitioner field.

Mundinger MO, Kane RI, Lenz ER, et al. Primary care outcomes in patients treated by nurse practitioners or physicians: A randomized trial.

Lambing AY, Adams DL, Fox DH, et al. Nurse practitioners and physicians’ care activities and clinical outcomes with an inpatient geriatric population.

Differences in regulations between countries largely prevent advanced practice nurses from treating patients at the top of their licenses. 

Making a Case for Advancing Primary Health Care Nurse Practitioner Practice

Diverticular disease affects 2.5 million people in the United States. Symptoms of diverticular disease include abdominal pain, bloating, and change in bowel habits.

Multiple factors are thought to contribute to the occurrence of the disease, including straining to defecate which raises the intraluminal pressure. The disease tends to recur most in male patients 40-50 years of age.

Diverticular disease includes conditions such as diverticulosis and diverticulitis. Diverticulosis is characterized by chronic inflammation. It is thought to occur because of alterations in pro and anti-inflammatory cytokines in the gut. In symptomatic diverticulosis, hypertrophy and higher motility occurs in the affected areas.

An increase of interleukin-1 (IL-1) and tumor necrosis factor-alpha, and a decrease in anti-inflammatory cytokines IL-1 receptor antagonist, IL-4, IL-10, and IL-11 are associated with the development of diverticulitis.

Diverticulitis is an acute inflammation or infection of the diverticula. Data shows that most people with diverticulosis will not develop diverticulitis.

indicates that the management of diverticular disease in the primary care setting should consist of a more active approach.

Risk factors for the development of the disease include: diets low in fiber; >7 bowel movements/week; high intake of red or processed meat; lack of vitamin D; alcohol use; obesity; positive first-degree family history; smoking; and sedimentary lifestyle. Management of the disease focuses on eliminating symptoms, preventing infection, and controlling chronic inflammation.

Treatment recommendations include diet modification and the use of antibiotics during acute diverticulitis. Patients with uncomplicated diverticulitis should be on a clear liquid diet. Patients with nausea, vomiting, and dehydration should be admitted to the hospital for intravenous therapy and pain management (with the use of morphine sulfate being contraindicated due to colon spasm).

Differentiation of uncomplicated and complicated diverticulitis can be made by evaluating CBC, C-reactive protein, and sedimentation rate. The most commonly isolated bacteria found in acute diverticulitis are E-coli, Bacteroides fragilis, and Clostridia species.

The most common antibiotic combination used in diverticulitis is ciprofloxacin and metronidazole to cover both gram-negative and anaerobic bacteria, as well as Augmentin, in the outpatient setting. Probiotics show a decrease in symptoms due to restoration of normal gut flora.

The use of antispasmodics may relieve pain and bloating. Mesalamine or rifamixin can be considered in treatment-resistant disease or incomplete resection.

The authors state that it is imperative for nurse practitioners to recognize the symptoms of diverticular disease and to investigate them further as they can mimic other diseases. If diverticular disease is diagnosed, the patient must be educated on proper diet and lifestyle modifications.

Probiotics and vitamin D supplements can be recommended to appropriate patients as well as avoidance of NSAIDS, which can cause GI bleeding. The prescribing of non-OTC medications should be tailored to each patient.

Patients who present with diverticulitis should be referred to a specialty provider for chronic treatment.

Recent research indicates that the management of diverticular disease in the primary care setting should consist of a more active approach.

Update on Diverticular Disease Management

out of The Netherlands looked to determine if sun exposure in adolescence could delay the onset of MS.

Multiple sclerosis (MS) is an auto-immune disease that affects the myelin sheath of nerves in the central nervous system. Symptoms include muscle weakness, numbness, vision problems and difficulty with balance and coordination.

has shown that a relationship exists between Vitamin D and MS in that individuals with higher blood levels of vitamin D had reduced MS activity and slower progression of the disease during 5 years of follow-up. Since our bodies synthesize vitamin D upon exposure to sunlight, researchers from The Netherlands wanted to determine if sun exposure in adolescence could delay the onset of MS.

A total of 1,161 patients with MS participated in the study. Lifestyle questionnaires on the amount of sun exposure the patients acquired in their teens, as well as blood samples for genotyping were collected from all participants between 2009 and 2012. The results indicated that those individuals who admitted to daily sun exposure in their teens experienced the onset of symptoms 2 years later, on average, than those who did not. The Danish researchers found no relationship between study participant’s use of vitamin D supplementation in their teens and disease onset, suggesting that sunlight has its own positive effect on the immune system.

The results also showed that patients who had been overweight at age 20 developed MS almost two years earlier, on average, than those who had been at a normal weight at age 20. This finding may or may not be related to vitamin D, as a higher percentage of body fat can be associated with lower vitamin D levels.

Although these findings on vitamin D’s effect on MS do not indicate a cause and effect relationship, they do seem to indicate that adolescence is a critical time for disease development. Further research is needed to determine exactly out how sun exposure, vitamin D, and weight affect the disease.

Recent research out of The Netherlands looked to determine if sun exposure in adolescence could delay the onset of MS.