Saturday, May 30, 2009

Red and Processed Meat Intake Linked to Mortality

News Author: Laurie Barclay, MD
CME Author: Charles Vega, MD, FAAFP
Arch Intern Med. 2009;169:543-545, 562-571

March 26, 2009 — Eating red and processed meat is associated with modest increases in total mortality, cancer mortality, and cardiovascular disease mortality rates, according to the results of a large, prospective study reported in the March 23 issue of the Archives of Internal Medicine.

"High intakes of red or processed meat may increase the risk of mortality," write Rashmi Sinha, PhD, from the National Cancer Institute, National Institutes of Health, Department of Health and Human Services in Rockville, Maryland, and colleagues. "Our objective was to determine the relations of red, white, and processed meat intakes to risk for total and cause-specific mortality."

The National Institutes of Health–AARP Diet and Health Study enrolled approximately half a million people aged 50 to 71 years at baseline. A food frequency questionnaire administered at baseline allowed estimation of meat intake, and Cox proportional hazards regression models allowed calculation of hazard ratios (HRs) and 95% confidence intervals (CIs) within quintiles of meat intake.

Red meat included all types of beef and pork such as bacon, beef, cold cuts, hamburgers, hotdogs, steak, and meats in pizza, lasagna, and stew. White meat included chicken, turkey, and fish along with poultry cold cuts, canned tuna, and low-fat hotdogs. Processed meats could include either red or white meats in the form of sandwich meats or cold cuts as well as bacon, red meat and poultry sausages, and regular hotdogs and low-fat hotdogs made from poultry. The authors note that some of the meats may overlap in the 3 categories, but they were not duplicated or used in the same models in the study analysis.

The models considered covariates of age, education, marital status, presence or absence of family history of cancer (for cancer mortality only), race, body mass index, smoking history, physical activity, energy intake, alcohol drinking, use of vitamin supplements, fruit consumption, vegetable consumption, and use of menopausal hormone therapy in women. Primary endpoints of the study were total mortality and deaths caused by cancer, cardiovascular disease, injury and sudden deaths, and all other causes.

During 10 years of follow-up, 47,976 men and 23,276 women died.
Overall mortality risks were increased for men and women in the highest vs the lowest quintile of red meat intake (HR, 1.31; 95% CI, 1.27 - 1.35; and HR, 1.36; 95% CI, 1.30-1.43, respectively) and processed meat intake (HR, 1.16; 95% CI, 1.12 - 1.20; and HR, 1.25; 95% CI, 1.20 - 1.31, respectively).
Men and women with higher intake also had increased risks for cancer mortality for red meat (HR, 1.22; 95% CI, 1.16 - 1.29; and HR, 1.20; 95% CI, 1.12 - 1.30, respectively) and processed meat (HR, 1.12; 95% CI, 1.06 - 1.19; and HR, 1.11; 95% CI 1.04 - 1.19, respectively).

Cardiovascular disease risk was increased for men and women in the highest quintile of intake of red meat (HR, 1.27; 95% CI, 1.20 - 1.35; and HR, 1.50; 95% CI, 1.37 - 1.65, respectively) and processed meat (HR, 1.09; 95% CI, 1.03 - 1.15; and HR, 1.38; 95% CI, 1.26 - 1.51, respectively).
For the highest vs the lowest quintile of white meat intake for both men and women, there was an inverse association for total mortality, cancer mortality, and mortality from all other causes.

"Red and processed meat intakes were associated with modest increases in total mortality, cancer mortality, and cardiovascular disease mortality," the study authors write. "In contrast, high white meat intake and a low-risk meat diet was associated with a small decrease in total and cancer mortality."

Limitations of this study include possible residual confounding by smoking; possible measurement error; and cohort predominantly non-Hispanic white, more educated, with less smoking, less fat and red meat intake, and more intake of fiber and fruit and vegetables than similarly aged adults in the US population, limiting generalizability.

"These results complement the recommendations by the American Institute for Cancer Research and the World Cancer Research Fund to reduce red and processed meat intake to decrease cancer incidence," the study authors write. "Future research should investigate the relation between subtypes of meat and specific causes of mortality."

In an accompanying editorial, Barry M. Popkin, PhD, from the University of North Carolina, Chapel Hill, discusses how the implications of reducing excessive meat intake would relate to several major global concerns.

"Of equal importance is the role of clinicians as public health advocates," Dr. Popkin writes. "Far too few clinicians speak out on topics such as this. What the public hears is the side of the profession that is preaching vegetarian diets and not the side of the profession that is discussing moderation as a healthy option."

The Intramural Research Program of the National Institute of Health, National Cancer Institute supported this study in part. The study authors have disclosed no relevant financial relationships. Dr. Popkin is not a vegetarian and has no financial conflict of interest related to any food product as it affects health.

Clinical Context

Dietary patterns are changing around the globe, and an editorial by Popkin, which accompanies the current article, describes these patterns. Individuals in higher-income countries continue to consume meat and dairy products at 2 to 3 times the rate of lower-income countries. However, meat and dairy products are becoming a more common dietary staple in some developing countries, particularly India, China, and Brazil.

In part, higher consumption of meat is the result of a lower cost of beef vs several decades ago. At the same time, the cost of grains and rice has increased significantly on the world market in the last 6 years. This has important environmental consequences, as the need for water and feedstock is much higher in raising animals vs raising basic crops.

Meat consumption can have significant effects on rates of obesity and overall health as well. The current study examines a large cohort of adults to determine the effect of meat intake on mortality rates.

Sunday, May 24, 2009

Melamine & kidney damage

Melamine Nephrotoxicity: An Emerging Epidemic in an Era of Globalization: Global Impact of the Milk Contamination in China

Vivek Bhalla,1 Paul C. Grimm,2 Glenn M. Chertow,1 Alan C. Pao 1
Division of Nephrology, Department of Medicine, Stanford University, Stanford, California

Global Impact of the Milk Contamination in China
Melamine contamination of foodstuffs produced in China is an international public health crisis, and the full repercussions of this scandal may not be known for many years. A recent report by the World Health Organization (WHO) estimated that 51,900 children in the People's Republic of China have been affected and six deaths have resulted due to melamine contamination.[1] After initial reports of nephrolithiasis among Chinese infants who drank milk-based formula surfaced in the summer of 2008, a systematic search by the Chinese Administration of Quality Supervision, Inspection, and Quarantine (AQSIQ) revealed 22 commercial brands of milk powder (69 batches out of 491 tested) with detectable levels of melamine.[2] Thirteen of the batches contained > 2.5 parts per million (p.p.m.) (2.5 mg/kg), the level of melamine above which the United States Food and Drug Agency (USFDA) had conservatively concluded would exceed the tolerable daily intake of 0.063 mg/kg of body weight/day in humans.[3] The culprit powder with the highest melamine concentration, produced by the Shijiazhuang-based San Lu company, the largest national distributor and exporter of milk powder, contained samples with 2563 p.p.m. of melamine, more than 1000-fold higher than the USFDA tolerable daily intake.[2] As of 12 September 2008, 66 of 175 infant formula manufacturers across China had halted production, and the remaining 109 manufacturers were undergoing investigation. This controversy required reaction from the highest levels of the Chinese government. The chief of the AQSIQ, Li Changjang, resigned, and Premier Wen Jiabao recently apologized publicly and promised reform of current safety regulations.[4]

Children outside of mainland China in Taiwan, Hong Kong, and Macau have also been affected.[1] Reports of detectable melamine in foodstuffs from around the globe continue to document the widespread nature of this epidemic. Sixty-eight countries (see Figure 1) have already taken decisive action to limit the dissemination of contaminated products,[4] which include Chinese-made milk-based infant formula and milk-based products, such as cookies and chocolates (see Table 1). Other nations are now monitoring the incidence of nephrolithiasis as a surrogate for melamine intoxication in their respective populations.[5] Several international agencies including the World Health Organization (WHO), the Food and Agriculture Organization (FAO), the European Food Safety Association (EFSA), and the International Food Safety Authorities Network (INFOSAN) are working together to characterize and control this outbreak.[1] The USFDA has twice amended its assessment of melamine toxicity for infants, and concluded that only foods with less than 1 p.p.m. of melamine are safe for infants.[3] The USFDA has also announced the establishment of an office in Beijing, China to oversee exports shipped to the United States.[3]

Additional Melamine Contamination in Animal Feed
Two international incidents in 2004 and 2007 showed that pet food containing a wheat gluten exported from China was responsible for kidney failure and death in domesticated cats and dogs in the United States and Europe.[3] Pet food scraps in the United States from the 2007 outbreak revealed similar levels of melamine as the infant formulas recently produced in China, ranging from 9.4 to 1952 p.p.m.[3] as well as another compound, cyanuric acid.[3] The 2004 pet food outbreak is presumed to have been due to melamine because autopsy reports from 2004 are comparable with those of animals that died in 2007. In October 2008, hundreds of raccoon dogs in China died from kidney failure after the ingestion of melamine-contaminated animal feed. Reports from Hong Kong and other nations state that chicken eggs and fish (fit for human consumption) recently imported from China contain melamine,[4] providing circumstantial evidence that the food supply is now contaminated and demonstrating that this epidemic is pervasive. The WHO has criticized the Chinese government for not effectively eliminating melamine from the animal feed supply despite a ban imposed in June 2007.[4] Milk-based products, animals, and animal by-products are all believed to be potential sources of melamine exposure for humans.

Environmental Exposures and Kidney Disease
This Chinese milk controversy and emerging cases of kidney disease in infants is another reminder of how nephrology and the environment are intertwined. Many environmental and/or occupational kidney diseases have been described since the industrial revolution of the nineteenth century. Various toxins have been associated with AKI, CKD, and ESRD, whereas others have caused non-renal complications in persons with pre-existing kidney disease. Similar to melamine nephrotoxicity, most of these diseases have a known etiologic agent and yet, despite years of national and international safety regulations, are still with us today.

As organs responsible for much of the body's waste management, with extensive exposure to blood-borne toxins, the kidneys often bear the burden of clearing the bloodstream of materials to which humans are parenterally or enterally exposed. The recent recognition of acute phosphate nephropathy following exposure to phosphate-containing bowel preparations is a good example of this vulnerability.[14]

Just as melamine has emerged in the past few months, in an era of free trade and globalization, new toxins will certainly surface, and tools designed to rapidly identify cases and their etiology will be necessary. The prospect of earlier detection of AKI with novel biomarkers has gained traction over the past several years. Newer biomarkers could facilitate diagnosis of AKI in hospitalized patients and may also identify potentially nephrotoxic pharmaceuticals or food additives in preclinical studies.[15]

Several CKDs have been ascribed to occupational or environmental exposures. Occupational kidney diseases, including chronic lead nephropathy, cadmium nephrotoxicity, and nephropathy due to other heavy metals or solvents, have been described for decades,[13] but lead, for example, is still encountered today as a progression factor for CKD.[16] Analgesic nephropathy is caused by well-recognized, over-the-counter 'toxins,' particularly in Europe and Australia.[17] Aristolochic acid, which has been used as a component of weight loss regimens and is probably the etiologic agent of endemic Balkan nephropathy,[18] is an example of a toxin that was used therapeutically and/or was present in the environment and caused kidney disease for many years before being identified as such.

Several other toxic exposures have affected patients with pre-existing kidney disease by virtue of poor solute clearance. Itai-itai byo or 'ouch-ouch' disease in post-World War II Japan caused by cadmium contamination of rice fields downstream of metal mining operations - caused Fanconi syndrome and osteomalacia in many individuals, but those with decreased glomerular filtration rate were among the most severely affected.[13] Infants with CKD whose organ systems are still developing may be most sensitive and therefore act as 'sentinel canaries' for the detection of environmental toxins, where the effects may be amplified compared with those effects in adults. In pediatric patients with CKD, aluminum binders were often prescribed at the same time as citrate-containing base supplements to treat metabolic acidosis in CKD. This combination markedly increased the absorption of aluminum by the gastrointestinal tract further aggravating the neurotoxic effects of aluminum in the developing brain.[19] It is an important lesson that this interaction had been recognized in the early 1980s, but these therapies continued to be used by physicians for many years after. More recent concerns have centered on the use of gadolinium-chelating agents for contrast enhancement on magnetic resonance imaging. While epidemiologists eventually identified gadolinium as the culprit etiologic agent of nephrogenic systemic fibrosis, the insidious onset and relatively low incidence rate delayed recognition of the association for many years.[20]

These examples highlight the challenges facing nephrologists and other health providers in establishing links between hazardous environmental exposures, the development or progression of kidney disease, and/or complications of CKD. Particularly in view of the high prevalence of CKD, with a large fraction of the disease burden unexplained by known risk factors, we should probably adopt a high index of suspicion for environmental and/or occupational exposures as potential contributing causes.

for complete article:

Friday, May 22, 2009

Vaccination Order for Pneumococcal Conjugate Vaccine May Affect Infant Pain Response

From Medscape Medical News
Laurie Barclay, MD

May 5, 2009 — Infants who receive the pneumococcal conjugate vaccine (PCV) after the combination vaccine for diphtheria, polio, tetanus, pertussis, and Haemophilus influenzae type b (DPTaP-Hib vaccine) appear to experience less pain than those who are immunized in the reverse order, according to the results of a double-blind, randomized clinical trial reported in the May issue of the Archives of Pediatric & Adolescent Medicine.

"Vaccine injections are the most common painful iatrogenic procedures performed in childhood," write Moshe Ipp, MBBCh, from the University of Toronto in Toronto, Ontario, Canada, and colleagues. "Multiple injections are routinely administered during a single visit to a physician....The objective of this study was to determine if acute pain response after administration of 2 separate vaccines was affected by the order in which they were administered."

At an outpatient pediatric clinic in Toronto, Ontario, Canada, healthy infants aged 2 to 6 months who were undergoing routine immunization received either their primary DPTaP-Hib vaccine or the PCV first, followed by the other vaccine. The main endpoint of the study was infant pain during vaccine injection as measured by a validated measure, the Modified Behavioral Pain Scale (MBPS), with use of videotaped recordings of the vaccination. Other outcomes were parent-rated pain with use of a 10-cm visual analog scale (VAS) and the presence or absence of crying.

Between July 21, 2006, and June 21, 2007, a total of 120 infants participated, of whom 60 received the DPTaP-Hib vaccine first and 60 received the PCV first. The groups did not differ significantly in infant characteristics.

When DPTaP-Hib was given first, overall mean pain scores per infant after receiving both vaccine injections were significantly lower than when PCV was given first (MBPS score, 7.6 ± 1.5 vs 8.2 ± 1.5; P = .037; parent VAS score, 4.2 ± 2.3 vs 5.6 ± 2.6; P = .003). Based on the MBPS, VAS, and crying, the DPTaP-Hib vaccine caused significantly less pain when given first (P < .001).

"Pain was reduced when the DPTaP-Hib vaccine was administered before the PCV in infants undergoing routine vaccination," the study authors write. "We recommend that the order of vaccine injections be the DPTaP-Hib vaccine followed by the PCV."

Limitations of this study include relatively small sample size and difficulty in assessing pain in infants.

Swine Flu Less Severe for Over-50s?

Daniel J. DeNoon
from WebMD — a health information Web site for patients

May 20, 2009 — People born before 1957 may be less susceptible than younger people to the H1N1 swine flu.

CDC researchers have detected antibodies in the blood of older people that neutralize the new flu bug now sweeping the nation, Daniel Jernigan, MD, MPH, deputy director of the CDC's flu division, said today in a news conference.

"We infer from that, there is some level of protection," Jernigan said. "But to prove protection, we look at the effect [the virus has] on the population, and at this point we don't have that information."

Why is 1957 a key year? Every flu season after it first appeared, the deadly 1918 pandemic H1N1 flu bug circled the globe. Each year, the virus acquired changes that made it different from the original virus. But in 1957 there was a new pandemic, this time with an H2N2 virus. The new virus took the place of the old H1N1 bug.

"And so when we talk about the pre-1957 exposures, we are referring to those exposed to the past H1N1 virus that went away in 1957," Jernigan said. "The farther back you go in time, the more likely you are to have been exposed to an H1N1 virus before 1957 -- and exposure to that virus many years ago may allow you to have some reaction to the new H1N1."

The new H1N1 swine flu bug is much different from the 1918 H1N1 virus. It's also much different from the H1N1 seasonal flu virus that still circulates. But something about that pre-1957 bug seems to have left older people with antibodies that neutralize the new flu -- and might offer some protection against it.

Swine Flu Hits Youths Hardest

Whether or not ancient antibodies are protective, many older people are getting sick from the new flu. Some of these illnesses are severe: 13% of people hospitalized with swine flu are 50 or older. And the number of H1N1 cases among older people is increasing.

But H1N1 swine flu is hitting young people hardest. More than 60% of cases are in 5- to 24-year-olds.

Remarkably -- since this is usually the healthiest age group -- 37% of people hospitalized with swine flu are 19 to 49 years old. The median age of a person hospitalized with the new flu is 19.

Those aged 5 to 18 make up 29% of swine flu hospitalizations. Because so many cases of H1N1 swine flu have been transmitted in schools, it's possible that older people only seem to be protected because they've had less contact with younger people.

In past flu pandemics, however, the same pattern has emerged: the illness tended to strike young people hardest.

Jernigan said that the CDC will soon release a detailed report on the neutralizing antibody study.

Meanwhile, the new flu continues its spread while the seasonal flu wanes. Jernigan said that nearly 80% of people who test positive for flu now turn out to have the new H1N1 bug.


Daniel Jernigan, MD, PhD, deputy director, influenza division, CDC, Atlanta.

Monday, May 18, 2009

Lack of Sleep in Children Linked to ADHD Symptoms

News Author: Caroline Cassels
CME Author: Désirée Lie, MD, MSEd

May 6, 2009 — Inadequate sleep in children appears to be an independent risk factor for behavioral symptoms of attention-deficit/hyperactivity disorder (ADHD), new research suggests.

In a cross-sectional study of 7- to 8-year-old children, investigators at the University of Helsinki, Finland, found that short sleepers — those who got less than 7.7 hours of sleep per night — were significantly more likely to be hyperactive/inattentive compared with children who were moderate or longer sleepers.

"There is a large amount of literature linking sleeping difficulties to behavioral symptoms. However, this study shows short sleep duration itself is related to behavioral symptoms, independent of sleeping difficulties," principal investigator E. Juulia Paavonen, MD, PhD, told Medscape Psychiatry.

The study is published online April 27 in Pediatrics.

National Problem

It is estimated that up to one-third of children in the United States suffer from inadequate sleep, suggesting it may be a "nationally significant problem," said Dr. Paavonen. This is true not only in the United States, she added, but also in Finland, where research has shown that Finnish children sleep less than children elsewhere in Europe, suggesting inadequate sleep may be a particular problem in this country.

Previous studies have shown that ADHD is often associated with sleep

for rest of article refer source -

Thursday, May 14, 2009

Testosterone Gels - Warning

New Boxed Warning for Testosterone Gels to Protect Against Secondary Exposure
Martha Kerr
From Medscape Medical News Published: 05/07/2009

The US Food and Drug Administration (FDA) held a press conference today to announce a change in the labeling of the testosterone gel products AndroGel 1% (Solvay Pharmaceuticals) and Testim 1% (Auxilium Pharmaceuticals). The label is now required to include a boxed warning about the dangers of secondary exposure to children.

The decision to add the boxed warning was a result of reports of adverse events in 8 children as of December 1, 2008, who had been in close contact with users of the products.

The children, ranging in age from 9 months to 5 years, developed "inappropriate enlargement of the genitalia (penis or clitoris), premature development of pubic hair, advanced bone age, increased libido, and aggressive behavior,"

"In most cases, the signs and symptoms regressed when the child no longer was exposed to the product. However, in a few cases, enlarged genitalia did not fully return to age-appropriate size and bone age remained modestly greater than the child's chronological age," Diane Murphy, MD, from the Office of Pediatric Therapeutics, Office of the Commissioner, FDA, told Medscape Diabetes & Endocrinology.

"In some cases, children had to undergo invasive diagnostic procedures and, in at least one case, a child was hospitalized and underwent surgery due to a delay in recognizing the underlying cause of the signs and symptoms," FDA officials reported.

Mark Hirsch, MD, medical team leader of urology in the Division of Reproductive and Urologic Products, Center for Drug Evaluation and Research, FDA, said that "the case review has been incomplete, but some of these children were less than a year old...[and] they had rather high levels of testosterone," which were likely a result of direct skin-to-skin contact with areas to which the gel had been applied.

The labeling states that treated areas should be covered with clothing and that hands should be thoroughly washed with soap and water after application. The new warning will highlight these directions.

The boxed warning will include the following:

1.Adults who use testosterone gels should wash their hands with soap and warm water after every application;
2.Adults should cover the application site with clothing once the gel has dried;
3.Adults should wash the application site thoroughly with soap and warm water before any situation where skin-to-skin contact with another person is anticipated;
4.Children and women should avoid contact with testosterone application sites on the skin of men who use these products; and
5.Adults should note that use of any similar, but unapproved, products from the marketplace — including from the Internet — that can result in the same serious adverse effects should be avoided.

Screening for H1N1 Influenza A

Screening for H1N1 Influenza A (Swine Flu) in Regions With Few or No Cases: Guidance for Clinicians
Deborah Brauser
From Medscape Infectious Diseases Published: 05/05/2009

Their interim screening guidelines for areas with few or no reported cases include how to determine which patients should be specifically evaluated for possible infection, how to test, and important steps to take afterwards.

What Is an Influenza-like Illness?
The CDC defines influenza-like illness (ILI) as one that includes fever with a temperature of 100° F (37.8° C) or greater, accompanied by cough and/or sore throat, in the absence of a known cause other than influenza.

Which Patients With ILI Should Be Tested?
For clinicians in areas that currently have very low numbers of S-OIV outbreaks or none at all, the CDC recommends testing for infection in the following:

1.Patients who meet the case definition of ILI and present to providers who participate in the US Outpatient Influenza-like Illness Surveillance Network (ILINet; an organization of approximately 2400 healthcare providers in 50 states who provide weekly reports to the CDC of patient visits for ILI as a way to regularly track influenza)
2.Patients with an ILI who have traveled within 7 days to an area either within the United States or internationally with 1 or more confirmed swine influenza A (H1N1) cases (To find the most up-to-date information on these areas, see
3.Patients admitted to the hospital with an ILI
These patients should be segregated promptly as they await assessment, and all healthcare personnel interacting with them should follow infection-control guidelines as shown at

How Should Tests Be Administered?
In patients who meet the criteria listed above, clinicians should obtain an upper respiratory specimen to test for the influenza A (H1N1) virus. This means:

Collecting a nasopharyngeal swab/aspirate or nasal wash/aspirate
If these specimens cannot be collected, a combined nasal/oropharyngeal swab is acceptable
For patients who are intubated, an endotracheal aspirate should also be collected

Clinicians should pay special attention to the type of swab used, keeping the following in mind:
Ideally, specimens should be collected using swabs with a synthetic tip and an aluminum or plastic shaft
Swabs with cotton tips and wooden shafts are not recommended
Specimens collected with swabs made of calcium alginate are not acceptable

The specimens should then be placed in a sterile refrigerator (not a freezer), and clinicians should immediately contact their state or local health department to find out the quickest way to submit and transport the sample to a state public health laboratory.

These labs will then perform subtype testing on all influenza A (H1N1)-positive samples identified; specimens that cannot be subtyped as human influenza A (H1N1) or (H3N2) will be sent to CDC for identification.

What Precautions Should Be Taken by Healthcare Workers?
To prevent the transmission of all respiratory infections in healthcare settings, respiratory hygiene/cough etiquette infection-control measures (located at should be implemented at the first point of contact with a potentially infected person.

In addition, all healthcare personnel:
1.Who work in areas where there are patients being assessed or isolated for H1N1 (including those in an outpatient setting or emergency department) should be monitored daily for signs and symptoms of febrile respiratory infection
2.Who develop symptoms should be instructed not to report to work; if they are already at work, they should cease patient-care activities and notify their supervisor and infection-control personnel
3.Who are asymptomatic but have had an unprotected exposure to H1N1 may continue to work if they are started on antiviral prophylaxis

Interim guidance on antiviral recommendations for those who have had close contact with patients who have confirmed or suspected swine influenza A (H1N1) virus infection can be found at

Where Can I Find the Latest Information?
The CDC Website offers additional guidance recommendations, case definitions, and more on screening at
The World Health Organization is coordinating a global response to human cases of influenza A (H1N1), monitoring the current outbreaks and providing access to technical guidelines and useful information; see
Information is updated throughout the day at

Tuesday, May 12, 2009

Risk factors in Adolescent Suicide

Suicidal Behavior in Adolescents: Risk Factor Identification, Screening, and Prevention

Jaspal S. Ahluwalia, MD, MPH

Suicide is the third leading cause of death, following unintentional injuries and homicide, among adolescents in the United States.[1] There have been approximately 2000 adolescent suicides per year during the past decade, accounting for some 10% of all deaths in adolescents. Further, in an alarming trend, adolescent suicide rates have doubled in the United States over the past 50 years.[2] This increase may be attributed at least in part to increased rates of depression, alcohol and substance abuse, family disintegration, and access to deadly weapons during this time.

With the exception of suicidal ideation, most types of suicidal behavior are rare before the onset of adolescence. After the onset of adolescence, there is a very clear increasing risk for both suicidal attempts and completions. Recent survey data[3] have shown that nearly 15% of all US high school students have seriously considered attempting suicide; more than 11% have made a plan for suicide; and almost 7% have attempted suicide in the past year. Although girls are more likely to engage in suicidal ideations, planning, and attempts, boys are more likely to complete a suicide due to boys using more violent and dangerous means. White male adolescents have the highest rate of suicide.[4] With such high rates of contemplated, attempted, and successful suicide among adolescents, it is particularly important to understand the risk factors for suicide, as well as ways to screen for it and effectively prevent it.

Risk Factors for Suicide

Suicide risk is greatly increased with the presence of both depression and an anxiety or disruptive disorder.[5] Concerns over an association between selective serotonin reuptake inhibitor (SSRI) therapy and suicide risk in adolescents led to the US Food and Administration (FDA) issuing a warning in 2004.[6] Since then, however, observational studies[7,8] have found that a broader extent of SSRI prescriptions in the population are associated with lower suicide rates in children. These findings may reflect on antidepressant efficacy, adherence, the quality of mental healthcare, and the lower toxicity of these medications in the event of an overdose or suicide attempt. Several organizations have issued specific prescribing recommendations for SSRIs.[9-11] The American College of Neuropsychopharmacology (ACNP), the American Academy of Child and Adolescent Psychiatry (AACAP), and the Society for Adolescent Medicine (SAM) all recommend the use of fluoxetine in the treatment of depression in adolescents. Their findings suggested that use of SSRIs, such as fluoxetine, may have a slightly higher risk of increasing suicidal ideation but do not increase the risk for completed suicides.

Suicidal behavior risk factors have been classified into 2 separate categories: predisposing factors and precipitating factors.[12] Predisposing factors are those that directly increase an adolescent's risk for suicide. They include the following.

1.Previous Suicide Attempt
Adolescents who have had a previous suicide attempt are much more likely to try again, with an even more marked increase in those with multiple previous attempts. Between one quarter and one third of adolescents who attempt suicide will go on to try again, with the greatest risk for recurrence falling between 6 months and 1 year after their first attempt.[13]

2.History of a Prior or Ongoing Psychiatric Disorder
A prior or ongoing psychiatric disorder is a major risk factor for suicide, with studies showing that adolescents who commit suicide have a higher rate of depression, substance abuse disorders, eating disorders, anxiety disorders, and antisocial disorders.[14-16]

3.History of Sexual or Physical Abuse
Studies have shown that adolescents who are victims of sexual or physical abuse are up to 3 times more likely to commit suicide and up to 8 times more likely to have repeated suicide attempts.[17]

4.History or Exposure to Violent Behavior
Adolescents who have been exposed to high levels of violence are twice as likely to attempt suicide as those who have not.[18]

5.Family History of Suicidal Behavior or Mood Disorders
A family history of suicidal behavior plays both a genetic and environmental role in increasing the risk for an adolescent's likelihood to attempt or commit suicide.[19]

6.Biological Factors, Including Male Sex and Gay or Lesbian Sexual Orientation
Boys are about 5-6 times more likely to complete suicide than girls.[4] Gay and lesbian teens are much more likely to have suicidal ideations and attempt suicide than heterosexual teens.[20,21] There is some evidence to suggest that those adolescents with smaller concentrations of serotonin and all of its metabolites and receptors and neurons are at a greater risk of attempting and committing suicide.[22]

In addition to these 6 direct risk factors, 4 main precipitating, or potentiating, factors play a role in adolescent suicide. Although they are not sufficient in and of themselves to increase suicide risk, they can synergistically increase the likelihood of some form of suicidal behavior when they are present. They include:

Substance abuse[23];

Access to firearms or other means[24];

Social stress, such as interpersonal conflicts with friends, family, or law enforcement[25];

Emotional factors, such as feelings of despair or hopelessness.[2]

for rest of article see:

Saturday, May 2, 2009

Over-the-counter Cough & Cold Medications

Several Factors Contribute to Child Deaths Due to Nonprescription Cough, Cold Meds

From Reuters Health Information

Health) Apr 29 - Pediatric fatalities associated with over-the-counter cough and cold medications are uncommon, generally involve overdose with or without therapeutic intent, and mainly affect children younger than 2 years, according to findings reported in the April issue of the Annals of Emergency Medicine.

"Cough and cold products have been sporadically associated with severe toxicity and death in children," Dr. Richard C. Dart, of the University of Colorado School of Medicine, Aurora, and colleagues write. In 2005 in the US, 28 of 64,658 cases of poisonings in children due to these products resulted a major adverse effect or death

An expert panel was convened to examine factors contributing to fatalities involving child younger than 12 years related to a cough or cold remedies.

A total of 189 cases were identified. Eleven of these were excluded, leaving 178 cases. Of these, the panel concluded that a relationship between the cough and cold ingredient and the fatality was at least possible in 118 cases. Overall, 82 cases involved a nonprescription medication alone, 21 cases involved exposure to both a nonprescription and prescription medication, and 15 cases involved only a prescription medication.

The team reports that in the 103 cases that involved nonprescription medications, ingredients most often mentioned were pseudoephedrine (n = 45), diphenhydramine (n = 38), and dextromethorphan (n = 36).

Of these cases, 88 were judged to have involved an overdose. Insufficient information was available for the remaining 15 cases to estimate the dose.

"The intent of caregivers appears to be therapeutic to relieve symptoms in some cases and nontherapeutic to induce sedation or to facilitate child maltreatment in other cases," the investigators report.

A number of contributing factors were identified, including age younger than 2 years, use of the medication for sedation, use in a daycare setting or babysitter home, use of two medicines with the same ingredient, failure to use a measuring device, product misidentification, and use of a product intended for adults.

"Many of the factors related to inadvertent overdose identified by the expert panel are preventable and interventions could potentially reduce the deaths associated with cough and cold products substantially," Dr. Dart's team explains. "A successful public health intervention requires clear identification of contributing factors, implementation of effective tools to address each factor, and ongoing active surveillance to document the effect of interventions and to detect new developments."

Ann Emerg Med 2009;53:411-417.

Friday, May 1, 2009

Exclusive Prolonged Breastfeeding improves IQ

Prolonged, Exclusive Breast-Feeding Linked to Improved Cognitive Development

News Author: Laurie Barclay, MD
CME Author: Désirée Lie, MD, MSEd

Observational studies of breast-feeding have consistently demonstrated a positive effect of breast-feeding on infant cognitive development using IQ measures compared with formula-feeding and a dose-response association with larger differences for longer duration of breast-feeding. Randomization to breast-feeding vs formula-feeding is unfeasible, but randomization to a strategy to promote breast-feeding among mothers who have already decided to initiate breast-feeding can be performed.

PROBIT is the largest randomized trial of human lactation ever conducted and used a cluster randomization design to randomize hospitals and clinics in Belarus to an intervention to promote breast-feeding using the Baby-Friendly Hospital Initiative of WHO and UNICEF. In this study, the WASI IQ measures and teacher evaluations of academic performance in children at 6.5 years were linked to breast-feeding in infancy.

Study Highlights

Included were participants in the PROBIT study consisting of 17,046 healthy term infants weighing at least 2500 g at birth, from 31 maternity hospitals and their associated polyclinics in 1 country.
Sites were randomized to either an intervention to promote breast-feeding or usual policy.
The 2 types of cluster groups were matched for maternal age, education, previous breast-feeding, and number of other children.
The experimental intervention led to a significant increase in duration of any breast-feeding up to 12 months and also of exclusive breast-feeding up to 6 months.
Follow-up interviews and examinations were conducted at 6.5 years by pediatricians, 1 to 2 for each site, using the WASI scale.
The WASI consisted of 4 subsets testing vocabulary, similarities, block design, and matrices and took 30 minutes to administer.
It was translated to Russian and back translated to ensure comparability of the Russian version.

Children who had begun school by the 6.5 year follow-up were evaluated by their teachers in 4 components: reading, writing, mathematics, and other subjects.
The child was rated using a 5-point scale as "far below," "somewhat below," "at somewhat above," or "far above" his or her grade level.
5 children were randomly selected for audit for each pediatrician to assess inter-rater reliability and consistency of WASI testing.
More than 80% of mothers were aged 20 to 34 years, half had completed secondary education, more than half had no other children at home, and fewer than 3% smoked during pregnancy.
Mean birth weight was 3440 g.
The 2 randomized groups were similar in demographics.
Follow-up at 6.5 years was 81.5% with similar rates in the 2 groups.
The cluster-adjusted mean difference in IQ was greatest for verbal IQ.
The verbal IQ was +7.5 points higher; the performance IQ, +2.9 points higher; and the full-scale IQ, +5.9 points higher in the breast-feeding intervention vs the no intervention group.
The results of the WASI demonstrated a high degree of clustering and large confidence intervals.

After adjusting for the cluster randomization, differences in mean scores for the WASI were +2.8 for verbal IQ, +2.9 for performance IQ, and +3.1 for full-scale IQ.
After carrying out sensitivity analyses to account for the large site variations, the differences were +4.7, +4.0, and +4.9, respectively.
There was a slightly greater mean difference in verbal IQ for boys (8 points higher for boys and 7 points higher for girls) in the breast-feeding vs the control group.
Higher WASI scores were seen with greater duration of breast-feeding and of exclusive breast-feeding.

Exclusive breast-feeding for 6 months or more was associated with an increase in verbal IQ score of +5.2 points vs exclusive breast-feeding for less than 3 months.
Similar dose-response associations were seen for teacher ratings for all 4 subject areas, but the increases were not significant for breast-feeding duration of 6 months or more.
The findings were robust in the direction of benefit for breast-feeding.
The authors concluded that breast-feeding improved children’s cognitive development.

Pearls for Practice

A breast-feeding intervention vs no intervention is associated with higher WASI IQ scores, which are greater for verbal IQ but also indicated for the performance and overall IQ scores, in children age 6.5 years old.
Improved IQ scores and teacher evaluations for 6.5-year-old children associated with increased breast-feeding are greater with longer duration of exclusive breast-feeding.