CHICAGO—Although medical rehabilitation patients are spending less time as inpatients at facilities, their functional outcomes have not declined. However, the death rate following discharge has increased nearly 4 percent from 1994 to 2001, according to a study in the October 13 issue of JAMA.

Changes in reimbursement have reduced length of stay (LOS) for patients receiving inpatient medical rehabilitation, according to background information in the article. The impact that reduced LOS has had on rehabilitation outcomes including functional status, living setting, and death has not been known.

Kenneth J. Ottenbacher, PhD, O.T.R., of the University of Texas Medical Branch, Galveston, Texas, and colleagues examined changes in LOS for persons receiving inpatient medical rehabilitation from 1994 through 2001. The researchers analyzed information from the Uniform Data System for Medical Rehabilitation. In addition to exploring trends in LOS for 5 major impairment groups (stroke, brain dysfunction, other neurologic conditions, spinal cord dysfunction [traumatic and nontraumatic], and orthopedic conditions), the researchers also examined changes in rehabilitation effectiveness, efficiency, discharge to home, living setting at 3- to 6-month follow-up, and death. The authors hypothesized that decreasing LOS would be associated with reduced functional status and decreased community living at follow-up.

The study included 744 inpatient medical rehabilitation hospitals and centers located in 48 U.S. states. A total of 148,807 patient records were examined. The patients' average age was 67.8, the sample was 59 percent female and 81 percent non-Hispanic white.

The researchers found that the LOS decreased from 20 to 12 days from 1994 to 2001. The proportional decrease in average LOS was greatest (42 percent) for patients with orthopedic conditions. Functional status was clinically stable, while efficiency (functional status change divided by LOS) increased significantly. Rates of discharge to home and living at home at follow-up remained stable, ranging from 81 percent to 93 percent. However, mortality at 80- to 180-day follow-up increased from less than 1 percent in 1994 to 4.7 percent in 2001.

CHICAGO—A change in the national polio vaccination policy has led to the elimination of vaccine-associated paralytic poliomyelitis (VAPP), according to a study in the October 13 issue of JAMA.

According to background information in the article, the last case of poliomyelitis (polio) in the United States caused by a naturally occurring virus occurred in 1979; however, as a consequence of oral poliovirus vaccine (OPV) use that began in 1961, an average of 9 cases of VAPP were confirmed each year from 1961 through 1989. To reduce the VAPP burden, national vaccination policy changed in 1997 from reliance on OPV to options for a schedule of inactivated poliovirus vaccine (IPV) followed by OPV. In 2000, an exclusive IPV schedule was adopted.

Lorraine Nino Alexander, M.P.H., of the Centers for Disease Control and Prevention, Atlanta, and colleagues reviewed national polio surveillance data in the United States from 1990 through 2003, examining the epidemiology of polio and assessing the association between the vaccine schedule changes and VAPP in the United States.

The researchers found that from 1990 through 1999, 61 cases of paralytic polio were reported; 59 (97 percent) of these were VAPP (1 case per 2.9 million OPV doses distributed), 1 case was imported, and 1 case was indeterminate. Thirteen cases occurred during the 1997-1999 transitional policy period and were associated with the all-OPV schedule; none occurred with the IPV-OPV schedule. No cases occurred after the U. S. implemented the all-IPV policy in 2000. The last imported polio case occurred in 1993 and the last case of VAPP occurred in 1999.

"Following this change, all forms of poliomyelitis have been eliminated in the United States...," the authors write. "The only threats from polio in the United States are from laboratories and the few remaining polio-endemic areas in Africa and Asia."

CHICAGO—Examination of reports from the first two years after licensure of a new vaccine against pneumococcal infections indicates that the majority of adverse effects are minor, but that continued surveillance is warranted, according to a study in the October 13 issue of JAMA.

The Food and Drug Administration (FDA) licensed the 7-valent pneumococcal conjugate vaccine (PCV, trade name Prevnar) on February 17, 2000, according to background information in the article. The recommended vaccination series includes doses at ages 2, 4, 6, and 12 to 15 months, with catch-up doses through 9 years of age. Pneumococcal conjugate vaccine has been rapidly adopted into routine pediatric practice, reflecting concern for the gravity of serious pneumococcal infections (such as meningitis or pneumonia) and confidence in the efficacy and safety of PCV.

Prior to licensure, almost 19,000 infants and children received PCV in randomized clinical trials that demonstrated good efficacy against invasive infections and a favorable safety profile. However, rare vaccine complications may not emerge before licensure for a variety of reasons, particularly the relatively limited sample sizes of trials.

Robert P. Wise, M.D., M.P.H., of the Food and Drug Administration, Rockville, Md., and colleagues analyzed the summary of data from the Vaccine Adverse Event Reporting System (VAERS), a national passive surveillance database, in the first 2 years after PCV licensure. Reports studied were for children younger than 18 years and vaccinated with PCV.

The researchers found that a total of 4,154 reports of events following PCV were submitted to VAERS, for a rate of 13.2 reports per 100,000 doses distributed. Multiple vaccines were given in 74.3 percent of reports. The most frequently reported symptoms and signs included fever, injection site reactions, fussiness and rashes. Serious events were described in 14.6 percent of reports (a rate similar to that for other vaccines), including 117 deaths and 34 cases of invasive pneumococcal infections possibly representing vaccine failure. Neurological symptoms occurred in 38 percent of reports. Seizures were described in 393 reports.

CHICAGO—A summary of data from numerous studies suggests that the majority of morbidly obese patients who underwent bariatric (obesity) surgery experienced effective weight loss and improvement in diabetes, hyperlipidemia, hypertension, and obstructive sleep apnea, according to an article in the October 13 issue of JAMA.

According to background information in the article, an estimated 1.7 billion people worldwide are overweight or obese. Overweight is defined as having a body mass index (BMI) of 25 or higher; obesity is defined as a BMI of 30 or higher; and morbid obesity as 40 or higher. Being obese is associated with a greater risk for type 2 diabetes, hypertension, heart disease, stroke and asthma. The loss of life expectancy due to morbid obesity is significant: in comparison with a normal-weight individual, a 25-year-old morbidly obese man has a 22 percent reduction in expected remaining lifespan, representing an approximately loss of 12 years of life. For treating obesity long term, diet therapy has been found to be relatively ineffective.

Henry Buchwald, M.D., Ph.D., of the University of Minnesota, Minneapolis, and colleagues conducted a review of 136 studies published between 1990 and 2003, which included 22,094 patients who underwent bariatric surgery, to determine the impact of bariatric surgery on weight loss, operative mortality outcome, and four obesity related disorders (diabetes, hyperlipidemia, hypertension and obstructive sleep apnea). The bariatric surgery procedures included gastric banding, gastric bypass, gastroplasty, biliopancreatic diversion or duodenal (part of small intestine) switch, and others (such as jejunoileal bypass, a bypass of a section of the small intestine). Nineteen percent of patients were men and 72.6 percent were women, with an average age of 39 years. The average body mass index for 16,944 patients was 46.9 before surgery.

The researchers found that the average percentage of excess weight loss was 61.2 percent for all patients; 47.5 percent for patients who underwent gastric banding; 61.6 percent, gastric bypass; 68.2 percent, gastroplasty; and 70.1 percent, biliopancreatic diversion or duodenal switch. Death due to surgery within 30 days of the procedure was 0.1 percent for purely restrictive procedures (gastric banding and gastroplasty), 0.5 percent for gastric bypass, and 1.1 percent for biliopancreatic diversion or duodenal switch.

Diabetes was completely resolved in 76.8 percent and resolved or improved in 86 percent of patients. Hyperlipidemia (i.e., elevated levels of cholesterol and triglycerides in the blood), improved in 70 percent or more of patients. Hypertension was resolved in 61.7 percent, and resolved or improved in 78.5 percent of patients. Obstructive sleep apnea was resolved or improved in 83.6 percent of patients.

SHORTER INPATIENT MEDICAL REHABILITATION LEADS TO EFFICIENT AND EFFECTIVE RESULTS, BUT AFTER DISCHARGE, HIGHER RATES OF HOSPITAL READMISSION AND DEATH