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.
Friday, May 22, 2009
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.
SOURCES:
Daniel Jernigan, MD, PhD, deputy director, influenza division, CDC, Atlanta.
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.
SOURCES:
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 - http://cme.medscape.com/viewarticle/702399?src=cmenews
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 - http://cme.medscape.com/viewarticle/702399?src=cmenews
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.
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 http://www.cdc.gov/swineflu/index.htm)
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 http://www.cdc.gov/h1n1flu/guidelines_infection_control.htm
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 http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm) 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 http://www.cdc.gov/h1n1flu/recommendations.htm
Where Can I Find the Latest Information?
The CDC Website offers additional guidance recommendations, case definitions, and more on screening at http://www.cdc.gov/h1n1flu/screening.htm
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 http://www.who.int/csr/disease/swineflu/en/index.html
Information is updated throughout the day at http://www.medscape.com/sites/swine-flu
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 http://www.cdc.gov/swineflu/index.htm)
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 http://www.cdc.gov/h1n1flu/guidelines_infection_control.htm
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 http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm) 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 http://www.cdc.gov/h1n1flu/recommendations.htm
Where Can I Find the Latest Information?
The CDC Website offers additional guidance recommendations, case definitions, and more on screening at http://www.cdc.gov/h1n1flu/screening.htm
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 http://www.who.int/csr/disease/swineflu/en/index.html
Information is updated throughout the day at http://www.medscape.com/sites/swine-flu
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: http://cme.medscape.com/viewarticle/702018
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: http://cme.medscape.com/viewarticle/702018
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.
http://www.medscape.com/viewarticle/702083?sssdmh=dm1.465854&src=nldne
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.
http://www.medscape.com/viewarticle/702083?sssdmh=dm1.465854&src=nldne
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