Diarrhea and Death

Chances are good that even if you're not a healthcare provider you've heard of noroviruses.  That's because these nasty little beasties have been responsible for many a party boat, a.k.a cruise ship, limping into port with hundreds of passengers aboard confined to their cabins with vomiting and diarrhea. Such stories make the news perhaps because they give us landlubbers a reason to feel smug.  In any case, noroviruses are again in the news, as Rick and I discuss on PodMed this week.  That's because they're associated with increased mortality among older people who live in long term care facilities, in this week's JAMA.  In fact, infection with a norovirus is an important cause of death, and according to one expert at Johns Hopkins, William Greenough, one that's largely avoidable.

On to the study.  Medicare-certified nursing homes in Oregon, Pennsylvania and Wisconsin that reported at least one norovirus outbreak to the National Outbreak Reporting System between January 2009 and December 2010 were included in the dataset. Deaths and hospitalizations during this period were tallied and correlated with the norovirus outbreak. Both hospitalizations and deaths were increased during outbreaks, especially in the initial week and the first two weeks. One very important observation was that those facilities with a lower RN to resident ratio experienced higher rates of both hospitalizations and deaths relative to norovirus infection, suggesting, as Rick points out, that family members could perhaps weigh this factor when it comes to selection of long term care facilities.

Rick and I both find it astonishing that until this study, we've never really talked about diarrheal illnesses and mortality on PodMed, yet CDC data are compelling: of the 800 or so norovirus-associated deaths annually, 90% occur in people 65 and older. While Clostridium difficile remains the more problematic bug, these are still numbers that deserve attention and are likely to increase as the numbers of older people grow larger.  So what can be done?  As I mentioned before, William Greenough, an expert in oral hydration therapy at Johns Hopkins, says quite a lot.

Oral hydration therapy is so very simple and has been proven effective in developing world countries such as Bangladesh, Greenough says.  Very simple formulations such as Pedialyte or a rice-based concoction Greenough has helped develop and has a proprietary interest in can stave off death in the majority of cases of norovirus infection.  Turns out that even when someone continues vomiting or has severe diarrhea, they still retain the vast majority of what they drink and don't develop dangerous dehydration, which then can lead to infarcts and death.  For the elderly population, this means having someone help push fluids since they may not feel dehydrated or want to drink anything.  Greenough reveals that even a homemade preparation of a rice-based instant breakfast cereal and a small pinch of salt will serve quite well, diluted to a drinkable consistency.

Other topics this week on PodMed include peripheral arterial disease in men and the treatment effects of large studies, also in JAMA, and rates of bystander-initiated CPR in different neighborhoods in NEJM.  Until next week, y'all live well.

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