Am Fam Physician. 2009;79:397-403.
Management of Common Childhood Poisonings Reviewed
Medscape Medical News
Clinical Context
In 2003, more than 2.4 million reports of toxin exposures were received by poison control centers in the United States. Children younger than 6 years accounted for 51% of exposures; of these, 38% involved children 3 years or younger. Most exposures involved oral ingestion (76%), occurred in the home (93%), and were unintentional (> 80%). In addition, most ingestions involved nontoxic substances and were managed at home.
The aim of this article was to review the evaluation and treatment of unintentional toxin ingestions in children younger than 12 years.
Study Highlights
The history of patients with suspected toxin ingestions should include age and sex, time and type of probable exposure, and all medications present in the home (evidence rating, C).
Initial evaluation involves determining whether the patient is symptomatic; any patient who has ingested a toxin and who has respiratory, circulatory, or neurologic symptoms should be transported by ambulance to the nearest emergency department (evidence rating, C).
If the ingestion was witnessed, a nontoxic substance was involved, and the patient appears asymptomatic, a prompt examination by the clinician in the office or a period of observation at home may be appropriate; otherwise, poison control should be consulted, and the patient should be evaluated in the clinician's office or in the emergency department.
In the emergency department, rapid triage is crucial, including airway, respiration, and circulation stabilization.
The most toxic substances to a child include iron, antidepressants, hypoglycemics, cardiovascular drugs, salicylates, anticonvulsants, and illicit drugs.
Iron poisoning is one of the most fatal in children younger than 6 years, especially because as few as 5 to 10 adult ferrous fumarate tablets can kill or seriously harm a child.
An asymptomatic child with suspected toxin ingestion may have ingested a delayed-action medication and should be monitored for a longer period (evidence rating, C).
Identifying toxidromes or symptoms that point to toxin exposure is crucial; therefore, the patient's mental status, vital signs, pupil reactivity, skin moisture and color, bowel sounds, powder or vomit around the mouth, and any unusual breath odors should be noted.
Useful laboratory tests usually include bicarbonate levels, blood glucose levels, electrocardiography, electrolytes, prothrombin time, pulse oximetry, serum acetaminophen levels, and urine human chorionic gonadotropin levels in women of childbearing age.
Appropriate supportive or toxin-specific treatment should be initiated with all childhood poisonings.
Gastric decontamination, such as activated charcoal and gastric lavage, is no longer routinely recommended. It is only recommended when performed by a clinician with experience placing orogastric tubes and when administered within 1 hour of the ingestion (evidence rating, C).
Activated charcoal decreases the absorption of toxins in the stomach and intestinal tract. It is most likely to help children who have ingested carbamazepine, dapsone, phenobarbital, quinine, theophylline, salicylates, phenytoin, or valproic acid.
The American Academy of Clinical Toxicology discourages the routine use of activated charcoal except within 1 hour of ingestion (evidence rating, C). If used, a charcoal-to-drug ratio of 10:1 is recommended or a dose of 1 to 2 g/kg is recommended for children with ingestions of an unknown quantity. Sorbitol is used to improve taste and transit through the intestinal tract.
Syrup of ipecac is no longer recommended (evidence rating, C).
Hemodialysis may be appropriate for lithium, salicylate, theophylline, methanol, atenolol, phenobarbital, or valproic acid toxicity.
Psychiatric consultation is appropriate in the setting of intentional ingestion.
Pearls for Practice
In 2003, reports of toxin exposure usually involved children younger than 6 years, were unintentional, involved oral ingestion, and occurred in the home.
Gastric decontamination, such as activated charcoal and gastric lavage, is no longer routinely recommended and should be reserved for the most severe cases, with poison control center support. Management options should consider the type and amount of substance ingested, potential toxicity, time elapsed since ingestion, and symptoms exhibited.
Saturday, March 14, 2009
Wednesday, January 14, 2009
ECG screening precompetition reduces sudden death in young athletes
Pre-participation Screening of Young Competitive Athletes for Prevention of Sudden Cardiac Death
Journal of the American College of Cardiology
Posted 01/07/2009
Domenico Corrado, MD, PhD; Cristina Basso, MD, PhD; Maurizio Schiavon, MD; Antonio Pelliccia, MD; Gaetano Thiene, MDAuthor Information
In 1982 a nationwide program of pre-participation screening including 12-lead electrocardiography (ECG) was launched in Italy. The aim of this article is to examine whether this 25-year screening program should be considered a valid and advisable public health
The analysis of data coming from the long-running Italian experience indicates that ECG screening has provided adequate sensitivity and specificity for detection of potentially lethal cardiomyopathy or arrhythmias and has led to substantial reduction of mortality of young competitive athletes by approximately 90%.
Screening was feasible thanks to the Italian Health System, which is developed in terms of health care and prevention services, and because of the limited costs of cardiovascular evaluation in the setting of a mass program.
On the basis of current scientific evidence the implementation of a mass-screening program aimed to prevent athletic-field sudden cardiac death should be at least carefully considered by public health administrators worldwide.
Introduction
"He who saves a single life saves the whole world." --Talmud Sanhedrin 4:5[1]
Sudden death during sports is often the first and definitive manifestation of an underlying cardiovascular disease, which usually has a silent clinical course.[2-6] Medical evaluation before competition offers the potential to detect still asymptomatic athletes with life-threatening heart diseases and to protect them from sudden cardiac death (SCD).
http://www.medscape.com/viewarticle/585032?src=mp&spon=9&uac=71630FV
Journal of the American College of Cardiology
Posted 01/07/2009
Domenico Corrado, MD, PhD; Cristina Basso, MD, PhD; Maurizio Schiavon, MD; Antonio Pelliccia, MD; Gaetano Thiene, MDAuthor Information
In 1982 a nationwide program of pre-participation screening including 12-lead electrocardiography (ECG) was launched in Italy. The aim of this article is to examine whether this 25-year screening program should be considered a valid and advisable public health
The analysis of data coming from the long-running Italian experience indicates that ECG screening has provided adequate sensitivity and specificity for detection of potentially lethal cardiomyopathy or arrhythmias and has led to substantial reduction of mortality of young competitive athletes by approximately 90%.
Screening was feasible thanks to the Italian Health System, which is developed in terms of health care and prevention services, and because of the limited costs of cardiovascular evaluation in the setting of a mass program.
On the basis of current scientific evidence the implementation of a mass-screening program aimed to prevent athletic-field sudden cardiac death should be at least carefully considered by public health administrators worldwide.
Introduction
"He who saves a single life saves the whole world." --Talmud Sanhedrin 4:5[1]
Sudden death during sports is often the first and definitive manifestation of an underlying cardiovascular disease, which usually has a silent clinical course.[2-6] Medical evaluation before competition offers the potential to detect still asymptomatic athletes with life-threatening heart diseases and to protect them from sudden cardiac death (SCD).
http://www.medscape.com/viewarticle/585032?src=mp&spon=9&uac=71630FV
Sunday, November 23, 2008
Benefits of Probiotics Reviewed
Laurie Barclay, MD Medscape News
November 6, 2008 — Probiotics are microorganisms that may be helpful for conditions such as antibiotic-associated diarrhea, infectious diarrhea, irritable bowel syndrome, and atopic dermatitis in at-risk infants, according to a review published in the November 1 issue of American Family Physician.
"Probiotics are live microorganisms that benefit the health of the host when administered in adequate amounts," write Benjamin Kligler, MD, MPH, from Albert Einstein College of Medicine of Yeshiva University, and Andreas Cohrssen, MD, from the Beth Israel Residency Program in Urban Family Practice, both in New York, New York. "Several mechanisms have been proposed to explain the actions of probiotics. In most cases, it is likely that more than one mechanism is at work simultaneously."
Because of these multiple mechanisms of action, many different probiotics have potential applications to various diseases. Those in most widespread use, which have undergone the most clinical testing, include Lactobacillus species (such as L acidophilus, L rhamnosus, L bulgaricus, L reuteri, and L casei); Bifidobacterium species; and Saccharomyces boulardii, which is a nonpathogenic yeast.
Efficacy of a probiotic species taken orally requires that it be resistant to acid and bile so that it can pass through the upper gastrointestinal tract without loss of biological potency. However, even the hardiest microorganisms must be administered regularly to maintain colonization and typically can no longer be cultured from stool samples more than 1 to 2 weeks after ingestion of the probiotic.
Probiotics are considered to be both safe and effective for preventing and treating antibiotic-associated diarrhea and infectious diarrhea. The probable mechanism of action may be a combination of direct competition between pathogenic bacteria in the gut and immune modulation and enhancement.
Other specific applications supported to some degree by available studies include relief of gastrointestinal tract symptoms in irritable bowel syndrome and therapy for pediatric atopic dermatitis.
Although probiotics are sometimes used for other conditions, evidence is lacking to support these indications, and they were therefore not discussed in this review. These conditions include vaginal candidiasis, stomach infection with Helicobacter pylori, inflammatory bowel disease, and upper respiratory tract infections.
On the basis of dosages used in clinical studies documenting efficacy, frequently used dosages range from 5 to 10 billion colony-forming units per day for children and from 10 to 20 billion colony-forming units per day for adults, although these vary based on the specific microorganism or combination used. In most studies, the dosages of S boulardii range from 250 to 500 mg/day.
Probiotics have no reported drug interactions. Common adverse effects are mild and self-limited, including flatulence and mild abdominal discomfort. Septicemia and other severe adverse effects may rarely occur, and these have only been reported in severely ill or immunocompromised hosts or in children with short-gut syndrome. Therefore, probiotics should be used only with caution in patients with short-gut syndrome, and they are contraindicated in patients with conditions that severely compromise the immune system.
Available formulations of probiotics include capsules, powder, tablets, liquid, or incorporated into food.
November 6, 2008 — Probiotics are microorganisms that may be helpful for conditions such as antibiotic-associated diarrhea, infectious diarrhea, irritable bowel syndrome, and atopic dermatitis in at-risk infants, according to a review published in the November 1 issue of American Family Physician.
"Probiotics are live microorganisms that benefit the health of the host when administered in adequate amounts," write Benjamin Kligler, MD, MPH, from Albert Einstein College of Medicine of Yeshiva University, and Andreas Cohrssen, MD, from the Beth Israel Residency Program in Urban Family Practice, both in New York, New York. "Several mechanisms have been proposed to explain the actions of probiotics. In most cases, it is likely that more than one mechanism is at work simultaneously."
Because of these multiple mechanisms of action, many different probiotics have potential applications to various diseases. Those in most widespread use, which have undergone the most clinical testing, include Lactobacillus species (such as L acidophilus, L rhamnosus, L bulgaricus, L reuteri, and L casei); Bifidobacterium species; and Saccharomyces boulardii, which is a nonpathogenic yeast.
Efficacy of a probiotic species taken orally requires that it be resistant to acid and bile so that it can pass through the upper gastrointestinal tract without loss of biological potency. However, even the hardiest microorganisms must be administered regularly to maintain colonization and typically can no longer be cultured from stool samples more than 1 to 2 weeks after ingestion of the probiotic.
Probiotics are considered to be both safe and effective for preventing and treating antibiotic-associated diarrhea and infectious diarrhea. The probable mechanism of action may be a combination of direct competition between pathogenic bacteria in the gut and immune modulation and enhancement.
Other specific applications supported to some degree by available studies include relief of gastrointestinal tract symptoms in irritable bowel syndrome and therapy for pediatric atopic dermatitis.
Although probiotics are sometimes used for other conditions, evidence is lacking to support these indications, and they were therefore not discussed in this review. These conditions include vaginal candidiasis, stomach infection with Helicobacter pylori, inflammatory bowel disease, and upper respiratory tract infections.
On the basis of dosages used in clinical studies documenting efficacy, frequently used dosages range from 5 to 10 billion colony-forming units per day for children and from 10 to 20 billion colony-forming units per day for adults, although these vary based on the specific microorganism or combination used. In most studies, the dosages of S boulardii range from 250 to 500 mg/day.
Probiotics have no reported drug interactions. Common adverse effects are mild and self-limited, including flatulence and mild abdominal discomfort. Septicemia and other severe adverse effects may rarely occur, and these have only been reported in severely ill or immunocompromised hosts or in children with short-gut syndrome. Therefore, probiotics should be used only with caution in patients with short-gut syndrome, and they are contraindicated in patients with conditions that severely compromise the immune system.
Available formulations of probiotics include capsules, powder, tablets, liquid, or incorporated into food.
Wednesday, September 24, 2008
Prevention of Vulvar and Vaginal cancer
Gardasil Approval Expanded to Prevention of HPV-Related Vulvar, Vaginal Cancer
News Author: Laurie Barclay,
CME Author: Yael Waknine
September 18, 2008 — The US Food and Drug Administration (FDA) announced yesterday that approval for the vaccine Gardasil (HPV quadrivalent [types 6, 11, 16, and 18] recombinant vaccine) has been expanded to include the indication of preventing vaginal and vulvar cancer caused by human papillomavirus (HPV) types 16 and 18 in girls and women aged 9 to 26 years.
"There is now strong evidence showing that this vaccine can help prevent vulvar and vaginal cancers due to the same viruses for which it also helps protect against cervical cancer," Jesse L. Goodman, MD, MPH, director of the FDA's Center for Biologics Evaluation and Research, said in a news release. "While vulvar and vaginal cancers are rare, the opportunity to help prevent them is potentially an important additional benefit from immunization against HPV."
In 2006, the original FDA approval for Gardasil was for the prevention of cervical cancer caused by HPV types 16 and 18, which cause 70% of cervical cancers and which are implicated in unknown percentages of vulvar and vaginal cancers. The original approval, which was for girls and women aged 9 to 26 years, was also for the indications of preventing precancerous genital lesions caused by HPV types 6, 11, 16, and 18 and genital warts caused by HPV types 6 and 11.
In the United States, HPV is the most prevalent sexually transmitted disease, with an annual incidence of 6.2 million new infections, according to the US Centers for Disease Control and Prevention.
Merck & Co Inc, the manufacturer of Gardasil, followed up on more than 15,000 participants from the original cervical cancer prevention studies for 2 more years to determine the effects of Gardasil on the risk for vulvar and vaginal cancer compared with control participants who had not received Gardasil.
This follow-up showed that Gardasil was highly effective in preventing HPV-related precancerous vulvar and vaginal lesions in women who tested negative for HPV types 16 or 18 at study enrollment. None of the participants in the Gardasil group developed HPV type 16- or 18-related precancerous lesions compared with control group findings of 10 precancerous vulvar lesions and 9 precancerous vaginal lesions related to HPV types 16 or 18.
Women previously infected with HPV types 16 or 18 before immunization had no evidence of benefit. To optimize the preventive effects of Gardasil, the investigators therefore recommend vaccination before potential exposure to HPV types 16 or 18.
Caveats from the FDA represented in the label are that presently available information is insufficient to support use in women older than age 26 years and that Gardasil does not protect against diseases caused by other HPV types. Because Gardasil does not protect against preexisting HPV infections and because no vaccine is 100% effective, all women should continue to be monitored with Papanicolaou tests, even after vaccination.
Most adverse events of Gardasil reported since FDA approval in 2006 have not been serious. The most frequently reported adverse events have included syncope, injection site pain, headache, nausea, and fever. Observation is recommended after vaccination in case of syncope or severe allergic reactions.
A short- and long-term safety surveillance study is underway of 44,000 individuals in a managed care organization who received Gardasil for all its approved uses.
Source :Gardasil Prescribing Information
Study Highlights
The FDA has approved an expanded indication for a quadrivalent recombinant vaccine, allowing its use for the prophylaxis of vaginal and vulvar cancer caused by HPV types 16 and 18 in girls and women aged 9 to 26 years.
The HPV vaccine is administered as an intramuscular injection at 0, 2, and 6 months.
Previously, the FDA approved use of the vaccine for the prevention of cervical cancer caused by HPV types 16 and 18; precancerous genital lesions caused by HPV types 6, 11, 16, and 18; and genital warts caused by HPV types 6 and 11.
The current approval was based on data from 3 placebo-controlled, randomized studies that followed up on 18,714 participants for a mean of 3 years; approximately 50% had been vaccinated.
Results showed that the vaccine was 100% effective for preventing precancerous high-grade vulval intraepithelial neoplasia and vaginal intraepithelial neoplasia caused by HPV types 16 and 18 in girls and women who tested negative for infection up to 1 month after the last dose.
In the intent-to-treat population, which included all participants, the vaccine was 71% effective against vulvar intraepithelial neoplasia or vaginal intraepithelial neoplasia associated with HPV 16 or 18.
Results also showed the vaccine to be 49% effective against all vulvar intraepithelial neoplasia or vaginal intraepithelial neoplasia irrespective of whether HPV DNA was detected in the lesion.
No evidence of vaccination benefit was observed in girls and women previously infected with the HPV subtypes contained in the vaccine.
There is insufficient evidence to support use of the vaccine in women older than 26 years.
Adverse events most commonly include syncope, pain at the injection site, headache, nausea, and fever. Because of the potential for allergic reactions and syncope, a 15-minute postvaccination observation period is recommended.
Pearls for Practice
The FDA has approved an expanded indication for HPV quadrivalent (types 6, 11, 16, and 18) recombinant vaccine, allowing its use for the prevention of grades 2 and 3 vulvar and vaginal intraepithelial neoplasia caused by HPV types 16 and 18 in girls and women aged 9 to 26 years. Clinical data showed 100% efficacy in women who were infection naive at baseline. Intent-to-treat efficacy was 71%.
No evidence of benefit was observed in girls previously infected with the HPV subtypes contained in the vaccine, and there is insufficient evidence to support its use in women older than 26 years. Because of the potential for allergic reactions and syncope, patients should be observed for 15 minutes after vaccination.
News Author: Laurie Barclay,
CME Author: Yael Waknine
September 18, 2008 — The US Food and Drug Administration (FDA) announced yesterday that approval for the vaccine Gardasil (HPV quadrivalent [types 6, 11, 16, and 18] recombinant vaccine) has been expanded to include the indication of preventing vaginal and vulvar cancer caused by human papillomavirus (HPV) types 16 and 18 in girls and women aged 9 to 26 years.
"There is now strong evidence showing that this vaccine can help prevent vulvar and vaginal cancers due to the same viruses for which it also helps protect against cervical cancer," Jesse L. Goodman, MD, MPH, director of the FDA's Center for Biologics Evaluation and Research, said in a news release. "While vulvar and vaginal cancers are rare, the opportunity to help prevent them is potentially an important additional benefit from immunization against HPV."
In 2006, the original FDA approval for Gardasil was for the prevention of cervical cancer caused by HPV types 16 and 18, which cause 70% of cervical cancers and which are implicated in unknown percentages of vulvar and vaginal cancers. The original approval, which was for girls and women aged 9 to 26 years, was also for the indications of preventing precancerous genital lesions caused by HPV types 6, 11, 16, and 18 and genital warts caused by HPV types 6 and 11.
In the United States, HPV is the most prevalent sexually transmitted disease, with an annual incidence of 6.2 million new infections, according to the US Centers for Disease Control and Prevention.
Merck & Co Inc, the manufacturer of Gardasil, followed up on more than 15,000 participants from the original cervical cancer prevention studies for 2 more years to determine the effects of Gardasil on the risk for vulvar and vaginal cancer compared with control participants who had not received Gardasil.
This follow-up showed that Gardasil was highly effective in preventing HPV-related precancerous vulvar and vaginal lesions in women who tested negative for HPV types 16 or 18 at study enrollment. None of the participants in the Gardasil group developed HPV type 16- or 18-related precancerous lesions compared with control group findings of 10 precancerous vulvar lesions and 9 precancerous vaginal lesions related to HPV types 16 or 18.
Women previously infected with HPV types 16 or 18 before immunization had no evidence of benefit. To optimize the preventive effects of Gardasil, the investigators therefore recommend vaccination before potential exposure to HPV types 16 or 18.
Caveats from the FDA represented in the label are that presently available information is insufficient to support use in women older than age 26 years and that Gardasil does not protect against diseases caused by other HPV types. Because Gardasil does not protect against preexisting HPV infections and because no vaccine is 100% effective, all women should continue to be monitored with Papanicolaou tests, even after vaccination.
Most adverse events of Gardasil reported since FDA approval in 2006 have not been serious. The most frequently reported adverse events have included syncope, injection site pain, headache, nausea, and fever. Observation is recommended after vaccination in case of syncope or severe allergic reactions.
A short- and long-term safety surveillance study is underway of 44,000 individuals in a managed care organization who received Gardasil for all its approved uses.
Source :Gardasil Prescribing Information
Study Highlights
The FDA has approved an expanded indication for a quadrivalent recombinant vaccine, allowing its use for the prophylaxis of vaginal and vulvar cancer caused by HPV types 16 and 18 in girls and women aged 9 to 26 years.
The HPV vaccine is administered as an intramuscular injection at 0, 2, and 6 months.
Previously, the FDA approved use of the vaccine for the prevention of cervical cancer caused by HPV types 16 and 18; precancerous genital lesions caused by HPV types 6, 11, 16, and 18; and genital warts caused by HPV types 6 and 11.
The current approval was based on data from 3 placebo-controlled, randomized studies that followed up on 18,714 participants for a mean of 3 years; approximately 50% had been vaccinated.
Results showed that the vaccine was 100% effective for preventing precancerous high-grade vulval intraepithelial neoplasia and vaginal intraepithelial neoplasia caused by HPV types 16 and 18 in girls and women who tested negative for infection up to 1 month after the last dose.
In the intent-to-treat population, which included all participants, the vaccine was 71% effective against vulvar intraepithelial neoplasia or vaginal intraepithelial neoplasia associated with HPV 16 or 18.
Results also showed the vaccine to be 49% effective against all vulvar intraepithelial neoplasia or vaginal intraepithelial neoplasia irrespective of whether HPV DNA was detected in the lesion.
No evidence of vaccination benefit was observed in girls and women previously infected with the HPV subtypes contained in the vaccine.
There is insufficient evidence to support use of the vaccine in women older than 26 years.
Adverse events most commonly include syncope, pain at the injection site, headache, nausea, and fever. Because of the potential for allergic reactions and syncope, a 15-minute postvaccination observation period is recommended.
Pearls for Practice
The FDA has approved an expanded indication for HPV quadrivalent (types 6, 11, 16, and 18) recombinant vaccine, allowing its use for the prevention of grades 2 and 3 vulvar and vaginal intraepithelial neoplasia caused by HPV types 16 and 18 in girls and women aged 9 to 26 years. Clinical data showed 100% efficacy in women who were infection naive at baseline. Intent-to-treat efficacy was 71%.
No evidence of benefit was observed in girls previously infected with the HPV subtypes contained in the vaccine, and there is insufficient evidence to support its use in women older than 26 years. Because of the potential for allergic reactions and syncope, patients should be observed for 15 minutes after vaccination.
Sunday, September 14, 2008
Thermerosal No link with Autism
California Data Do Not Support a Link Between Thimerosal in Vaccines and
Continuing Increases in Autism Reported to California's Developmental Services System: Mercury in Retrograde
Schechter R, Grether JK
Arch Gen Psychiatry. 2008;65:19-24
Summary
This study was a retrospective review of autism spectrum disorder (ASD) cases referred to the California Department of Developmental Services (DDS) from 1995 through 2007. Children enter the DDS system at 3 years old; therefore, this referral represents the prevalence of a diagnosis of ASD in this population at the age of 3 years.
The authors plotted the prevalence of ASD referrals against critical time points in US vaccine history relative to the use of thimerosal. Critical dates relative to thimerosal are:
|
The authors' hypothesis was that if thimerosal were a contributor to ASD then children born and vaccinated after 2002 should have decreased rates of ASD diagnosis, and this would be reflected in decreased numbers of referrals (ie, decreased prevalence) to California DDS.
The authors did not find a dip in referral rates; their data did not reflect a change in ASD prevalence. In fact, the prevalence of ASD was increasing before 1991 and continued on roughly the same slope throughout the 1990s and 2000s, regardless of age group evaluated.
Only one year's cohort of children was born after thimerosal was largely eliminated from vaccines and were not at risk for receiving old vaccine -- the children born in 2003. These children also had a higher prevalence of ASD than children born in previous years, and the slope was increasing along a very similar trajectory to prior years. The increase over the time period 1993 through 2003 was from 0.3 cases per 1000 births to 1.3 cases per 1000 births.
The authors conclude that the California DDS data do not support a link between thimerosal in childhood vaccines and development of ASD.
Viewpoint
This study was published in January 2008 but only recently came to my attention. The findings here mirror those of a Danish study that demonstrated ongoing increases in ASD diagnosis despite removal of thimerosal from vaccines,[1] as well as Canadian data demonstrating no decrease in ASD diagnosis for children vaccinated with non-thimerosal-containing vaccines.[2] The figure from the Canadian study is particularly interesting and is worth viewing separately.
Sunday, June 29, 2008
Obese and Overweight Teens at Higher Risk for Chronic Diseases
News Author: Laurie Barclay, MD
CME Author: Penny Murata, MD
CME Author: Penny Murata, MD
June 2, 2008 — Teens who were obese and overweight had a higher risk for chronic diseases such as type 2 diabetes, cardiovascular disease, and fatty liver disease, according to the results of an Australian cross-sectional study reported in the June issue of the Archives of Pediatrics & Adolescent Medicine.
"Several studies have shown that obese children and adolescents have an increased prevalence of metabolic risk factors for cardiovascular disease, type 2 diabetes, and, more recently, fatty liver disease," write Elizabeth Denney-Wilson, PhD, MPH, BN, from the University of Sydney in Sydney, Australia, and colleagues. "Although morbidity could be expected to increase in parallel with the prevalence of obesity, little is known about chronic disease risk factors in the general adolescent population. Most studies of comorbidities either have been conducted in clinic-based groups of severely obese adolescents or have not studied the full range of metabolic complications."
The goal of this study was to evaluate the association between measures of adiposity (body mass index [BMI] and waist circumference) and risk factors for heart disease, type 2 diabetes, and fatty liver disease as well as the clustering of risk factors in middle adolescence.
At secondary schools in Sydney, 496 grade 10 students were categorized as overweight or obese by the International Obesity Task Force cutoff points and the UK waist circumference cutoff points. Mean age was 15.4 ± 0.4 years; 58.4% were boys. Blood samples were tested for high-density lipoprotein (HDL) and low-density lipoprotein (HDL) cholesterol, triglycerides, insulin, glucose, alanine aminotransferase (ALT), gamma-glutamyltransferase (GGT), and high-sensitivity C-reactive protein (CRP) levels. Published guidelines were used to categorize these results as normal or abnormal. Logistic regression helped define associations between overweight and obesity and risk factors, and clustering of risk factors within individuals was also examined.
In adolescent boys, factors significantly associated with overweight and obesity were insulin levels (P <.001), ALT (P <.001), GGT (P = .005), HDL cholesterol levels (P < .001), high-sensitivity CRP levels (P <.001), and blood pressure (P <.001). Factors significantly associated with overweight and obesity in adolescent girls were insulin, HDL cholesterol (P <.001) and high-sensitivity CRP levels (P < .001).
Compared with adolescents who were not overweight, obese adolescent boys and girls were significantly more likely to have 2 or more risk factors (boys: 73.5% vs 7.6%; girls: 44.4% vs 5.4%; P < .001 for both).
"Overweight and obese adolescents, especially boys, are at substantial risk for chronic conditions," the study authors write. "Waist circumference is not a better predictor of metabolic risk factors than is . . . BMI."
Limitations of this study include lack of data on family history of cardiovascular disease and lack of reporting of the consumption of alcohol and other drugs.
"The propensity of adiposity, behaviors, and risk factors to track from adolescence through adulthood would suggest that health care systems can expect a greater burden of disease from obesity-related conditions when today's young people achieve adulthood," the study authors conclude.
Pearls for Practice
- In adolescent boys, overweight and obesity are linked with abnormal values of insulin, ALT, GGT, HDL cholesterol, high sensitivity CRP, and blood pressure. In adolescent girls, overweight and obesity are linked with abnormal values of insulin, HDL cholesterol, and high sensitivity CRP.
- Obese adolescents, especially boys, are more likely to have at least 2 risk factors for heart disease, type 2 diabetes, and fatty liver disease than nonobese adolescents.
The New South Wales Department of Health supported this study. The study authors have disclosed no relevant financial relationships.
Arch Pediatr Adolesc Med. 2008;162:566-573.
Wednesday, June 25, 2008
Sucrose before Vaccination can Reduce pain
How to Stop the Hurt -- Sucrose Prior to Infant Vaccinations:
A Best Evidence Review Posted 06/16/2008
A Best Evidence Review Posted 06/16/2008
Charles P. Vega, MD
Vaccination is the most common procedure performed in infancy, although parents might have significant concerns regarding the pain associated with routine vaccinations. Moreover, painful experiences very early in life can promote somatization later in life. Oral sucrose has been demonstrated to reduce pain reactions among neonates, and the current study examines this simple intervention prior to administration of routine vaccination at 2 and 4 months of age.
Participants received either a 24% disaccharide solution at a dose of 0.6 mL/kg, or matching placebo. Infants were not swaddled, cuddled, or restrained during vaccination or the ensuing data collection period.
Sucrose has previously been demonstrated to improve outcomes among neonates undergoing painful procedures. In an analysis of 21 randomized controlled trials involving 1616 infants, sucrose at a wide range of doses (0.012 mg to 0.12 mg) improved the rate of crying at 30 and 60 seconds after heel lance.[8] However, sucrose was not effective in reducing heart rate at 1 and 3 minutes after heel lance.
Some practices employ other analgesic measures to reduce the pain of pediatric vaccinations. The application of the lidocaine-prilocaine patch prior to the first measles-mumps-rubella vaccine among children at least 12 months of age resulted in a significant reduction in Behavior Pain Scale scores vs placebo treatment.[9] Moreover, rates of irritability after vaccination were 16% in the lidocaine-prilocaine group vs 31% in the placebo group, and the antibody responses in the 2 groups to the vaccine components were similar.
Parents may also pretreat their children with oral analgesic medications prior to appointments for vaccination, and a study of acetaminophen delivered prior to administration of the diphtheria-pertussis-tetanus toxoids-polio vaccine largely supports this practice.[10] Compared with placebo, acetaminophen reduced the risk for fever greater than 38 degrees Celsius from 44% to 27%. Rates of behavioral changes after vaccination were 0.9% among the acetaminophen group vs 13% with placebo. However, acetaminophen was superior to placebo for primary vaccinations at 2 to 6 months of age but not for booster vaccination at 18 months of age. At the 18-month vaccination, the overall rate of systemic and local reactions was higher in both the acetaminophen and placebo groups. Another study has demonstrated that neither acetaminophen nor ibuprofen was effective in reducing the risk for local reactions such as erythema and swelling following the fifth diphtheria-tetanus toxoids-acellular pertussis vaccination.
Two key questions remain regarding the implementation of sucrose for the prevention of pain in pediatric vaccinations. First, the weight-based dosing algorithm for sucrose in the current study certainly appeared effective, but the dosage range used in different studies has generally been quite wide. Further research should address the issue of the optimal dose of sucrose. In addition, it would be very easy to conceive that using other analgesics such as acetaminophen in addition to sucrose could be synergistic in improving pain and behavior after vaccination. Moreover, the use of antipyretic medications could also reduce the risk for postvaccination fever.
Regarding the practical utility of different methods of analgesia for routine infant vaccinations, lidocaine-prilocaine can be difficult to apply and maintain in place for the 30 minutes required for effective analgesia prior to procedures.
Oral analgesics must also be delivered well before the vaccine is administered to be effective, and they expose infants and children to the remote possibility of significant adverse events.
In contrast, sucrose appears to be a readily available and applicable means to reduce infants' pain with vaccination. It is inexpensive and safe. Sucrose can also help parents to feel actively involved in protecting their infant from pain, and this should help increase acceptance of routine vaccinations. And that outcome should taste just like sugar for clinicians.
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