Meningococcal Vaccine Not Routine 2-10yrs Child

MMWR Morbid Mortal Wkly Rep. 2008;57(17):462-465.

Clinical Context

The MCV4 (Menactra; Sanofi-Pasteur) was approved by the US Food and Drug Administration on October 17, 2007, for use in children aged 2 to 10 years, adding to the existing approval for use in persons aged 11 to 55 years. MCV4 licensure was based on clinical trials in which the safety and immunogenicity of MCV4 was compared with the MPSV4 and was found to be safe and noninferior to the MPSV4 for all serogroups.

From June 2007 to February 2008, the ACIP Meningococcal Vaccine Workgroup considered use of MCV4 in children aged 2 to 10 years. They reviewed data on MCV4 immunogenicity and safety in this age group, the epidemiology and burden of meningococcal disease, the cost-effectiveness of different vaccination strategies, and the programmatic implications. Based on this review, the expert opinion of workgroup members, and feedback from partner organizations, the ACIP decided at its February 2008 meeting not to routinely vaccinate children aged 2 to 10 years.

Study Highlights

• ACIP evaluated data and concluded that evidence was insufficient to determine that 1 dose of MCV4 administered at age 2 years would protect against meningococcal disease through late adolescence and college entry.
• Serum bactericidal activity among children aged 2 to 3 years who received MCV4 was lower vs children aged 4 to 10 years.
• ACIP also reviewed the burden of meningococcal disease among children aged 2 to 10 years.
• Between 1998 and 2007 in the United States, overall rates of meningococcal disease were lower in children aged 2 to 10 years vs infants younger than 2 years and adolescents aged 11 to 19 years.
• Of cases in children aged 2 to 10 years, 41% occurred among children aged 2 to 3 years.
• Among cases that occurred in children 2 to 10 years old, 59% were caused by serogroups contained in MCV4 (A, C, Y, and W-135) vs 77% of cases among those 11 to 19 years old.
• A cost-effectiveness analysis determined that vaccinating children aged 2 years was less cost effective than vaccinating children aged 11 years.
• As of February 2008, the ACIP does not recommend routine vaccination of children aged 2 to 10 years against meningococcal disease unless the child is at increased risk.
• ACIP continues to recommend vaccination for children aged 2 to 10 years who are at increased risk for meningococcal disease.
• Risk factors for meningococcal disease include travel to or residence in countries where meningococcal disease is hyperendemic or epidemic, terminal complement deficiencies, and anatomic or functional asplenia.
• Using clinical judgment on a case-by-case basis, clinicians may also decide to vaccinate children aged 2 to 10 years who are infected with HIV.
• MCV4 is preferred to MPSV4 for children aged 2 to 10 years at increased risk, for control of meningococcal disease outbreaks, and when clinicians or parents decide on meningococcal vaccination for other children aged 2 to 10 years.
• Children aged 2 to 10 years who have received MPSV4 and who are still at increased risk for meningococcal disease should be vaccinated with MCV4 3 years after receiving MPSV4.
• Children who last received MPSV4 less than 3 years before and who are still at increased risk for meningococcal disease should receive MCV4 vaccination as soon as possible.
• Recommendations for use of MCV4 in persons aged 11 to 55 years remain unchanged from earlier published guidelines.
• ACIP continues to recommend routine vaccination against meningococcal disease for all persons aged 11 to 18 years.
• ACIP recommends vaccination against meningococcal disease for persons aged 2 to 55 years who are at increased risk for meningococcal disease.
• Children at increased risk for meningococcal disease throughout their lifetime will most likely need subsequent doses of MCV4, with specific recommendations anticipated based on ongoing ACIP monitoring on duration of protection.
• A history of GBS is a precaution to MCV4 vaccination because these individuals might be at increased risk for GBS after MCV4 vaccination.

Pearls for Practice

• As of February 2008, the ACIP does not recommend routine vaccination of children aged 2 to 10 years against meningococcal disease unless the child is at increased risk because of travel to or residence in countries where meningococcal disease is hyperendemic or epidemic, terminal complement deficiencies, or anatomic or functional asplenia.
• Recommendations for use of MCV4 in persons aged 11 to 55 years remain unchanged from earlier published guidelines. ACIP continues to recommend routine vaccination against meningococcal disease for all persons aged 11 to 18 years. ACIP recommends vaccination against meningococcal disease for persons aged 2 to 55 years who are at increased risk for meningococcal disease.

Smoking Increase Death Risks

Vascular Benefits of Stopping Smoking Are Rapid

News Author: Lisa Nainggolan Medscape
CME Author: Charles Vega, MD

Smoking is clearly linked with an increased risk of mortality, and a previous report on the Nurses' Health Study by Kawachi and colleagues, published in the November 15, 1993, issue of Annals of Internal Medicine, described this risk in detail. Researchers demonstrated that the overall risk of mortality among smokers vs never smokers was 1.87, and the risk of former smokers vs never smokers was significantly elevated at 1.29. Participants who initiated smoking before the age of 15 years had the highest risks for total mortality and cardiovascular disease mortality, but these risks were attenuated to levels similar to never smokers after 10 to 14 years of abstinence from smoking.

The current report from the Nurses' Health Study provides greater detail with regard to cancer mortality risks associated with cigarette smoking in women.

Study Highlights

• The Nurses' Health Study began following 121,700 female nurses in the United States in 1976. Subjects have provided health information every 2 years since initiation of the study, including data regarding cigarette use. Women with a prior history of cancer were excluded from the current study.
• In the current study, researchers focused on reports of overall mortality as well as specific cancer, vascular, and respiratory causes of mortality from 1980 forward. Never smokers were used as the reference group, and the risk of study outcomes associated with smoking was adjusted for body mass index as well as disease and lifestyle factors.
• In 1980, 28% of the study cohort reported current smoking, and 26% were former smokers. The mean age at smoking initiation was 19 years.
• Current smokers had lower body mass index values and slightly less hypertension and also exercised less compared with never or former smokers.
• 12,483 deaths occurred in the study group, 28.9% and 35.2% of which occurred among current and former smokers, respectively. Only 8% of subjects alive in 2002 were current smokers.
• Current smokers experienced a HR of 2.81 for total mortality compared with never smokers, and they were also at higher risk for all major cause-specific mortality.
• Current smokers had a higher risk of death associated with all smoking-related cancers vs never smokers. These cancer sites included bladder, cervix, esophagus, lip and mouth, pharynx, pancreas, and stomach. Smokers were also at higher risk of mortality resulting from acute myeloid leukemia.
• Current smokers also had a significant increased risk of mortality resulting from colorectal cancer vs never smokers (HR = 1.63), but the effect of current smoking on the risk of ovarian cancer mortality was not significant. These same trends were evident among former smokers.
• Overall, 64% of deaths among current smokers were attributable to cigarette smoking.
• Earlier initiation of smoking was associated with a higher risk of death, particularly for death related to respiratory disease or cancer.
• The risk of death decreased by 13% within 5 years of quitting cigarettes, and this risk was further attenuated to levels comparable with never smokers at 20 years after quitting.
• The risk of death resulting from vascular disease declined more rapidly compared with other mortality risks following smoking cessation, with 61% of the full potential benefit for coronary heart disease mortality accrued in the first 5 years after quitting.
• Approximately 28% of deaths among former smokers were attributable to cigarette smoking.

Pearls for Practice

• A previous report from the Nurses' Health Study demonstrated that both current and former smokers had an increased risk of mortality compared with never smokers, but this risk was significantly attenuated after 10 to 14 years of abstinence from smoking. Women who began smoking prior to 15 years of age experienced the highest risk of mortality.
• In the current study, smoking increased the risk of death due to cancers of the cervix, colon and rectum, and stomach. However, the risk of ovarian cancer mortality was not significantly increased with smoking.

Guidelines on Strength Training for Children Revised

Pediatrics. 2008;121:835-840.

Clinical Context

Many young people become involved in strength training, also known as resistance training, in the context of sports and physical fitness programs. However, some adolescents use strength training to enhance muscle size and appearance. Free weights, weight machines, elastic tubing, or an athlete's own body weight may all provide resistance required for strength training. The type and amount of resistance used and the frequency of repetitions vary depending on specific program goals.

Because pediatricians are often asked to counsel young people on the safety and efficacy of strength-training programs, the AAP issued this revision of a previous policy statement. These revised guidelines define relevant terminology and provide updated evidence regarding the risks and benefits of strength training for children and adolescents.

Study Highlights

• Muscle strains account for 40% to 70% of all strength-training injuries and usually involve the hand, low back, and upper trunk.
• Appropriate strength-training programs do not appear to adversely affect growth or cardiovascular health.
• Strength-training programs for young people should follow proper resistance techniques and safety precautions.
• Preadolescents and adolescents should avoid power lifting, body building, and maximal lifts until they reach physical and skeletal maturity.
• Athletes should not use performance-enhancing substances or anabolic steroids, and young people involved in strength training should be educated about the risks of using these substances.
• A pediatrician or family clinician should perform a medical evaluation before the young person begins formal strength training.
• Youth with uncontrolled hypertension, seizure disorders, or a history of childhood cancer and chemotherapy should not participate in strength training until they undergo additional treatment or evaluation.
• In some cases, referral to a pediatric or family clinician sports medicine specialist familiar with various strength-training methods as well as risks and benefits may be indicated.
• Before beginning a strength-training program, children with complex congenital cardiac disease (cardiomyopathy, pulmonary artery hypertension, or Marfan's syndrome) should be evaluated by a pediatric cardiologist.
• Aerobic conditioning should be coupled with resistance training to optimize general health.
• Strength-training programs should include 10 to 15 minutes of warm-up and cool-down.
• Adequate fluid intake and proper nutrition are needed to maintain muscle energy stores and improve recovery and performance.
• To master the proper technique, specific strength-training exercises should first be learned with no load (no resistance), with incremental loads and then added with either body weight or other forms of resistance.
• Strength training should include 2 to 3 sets of 8 to 15 repetitions 2 to 3 times weekly and should continue for 8 weeks or longer.
• A general strengthening program should target the core and all major muscle groups, with exercise through the complete range of motion. More sports-specific areas may be addressed subsequently.
• Illness or injury from strength training should be fully evaluated before resumption of the exercise program.
• Instructors or personal trainers for young people should be certified and specifically qualified in pediatric strength training.
• To ensure safety, any strength-training program for young people must include proper technique and strict supervision by a qualified instructor.

Pearls for Practice

• To ensure safety and efficacy, strength-training programs for young people should follow proper resistance techniques and safety precautions. Preadolescents and adolescents should avoid power lifting, body building, and maximal lifts until they reach physical and skeletal maturity.
• A pediatrician or family clinician should perform a medical evaluation before the young person begins formal strength training to identify risk factors for injury and to discuss previous injuries and other possible medical conditions that may prevent a young person from participating in strength-training programs.

Acne Treatment

Active ingredients in acne products

source: http://www.mayoclinic.com/health/acne-products/SN00039 (for full article)

Acne products work in different ways, depending on their active ingredient. Here are common active ingredients found in acne products and how they work to treat acne.

• Benzoyl peroxide. Probably the most effective active ingredient in acne products, benzoyl peroxide kills P. acnes, helps remove excess oils from the skin and removes dead skin cells that clog pores. Available in strengths from 2.5 percent to 10 percent, benzoyl peroxide can cause excessive dryness, scaling, redness and minor swelling. It can also make your skin more sensitive to ultraviolet (UV) exposure.
• Salicylic acid. This ingredient slows shedding of cells inside the hair follicles, which prevents the pores from clogging. It may also break down whiteheads (clogged pores that have no opening) and blackheads (pores that are open and have a dark surface). Salicylic acid can cause mild stinging and skin irritation. OTC acne products are available with 0.5 percent to 2 percent salicylic acid.
• Sulfur and resorcinol. Rarely used alone, sulfur and resorcinol are often found together in acne products. These ingredients remove dead skin cells that clog pores and help remove excess oil. They may also break down whiteheads and blackheads. Sulfur and resorcinol can cause redness and peeling, which may occur several days after using the product.
• Alcohol and acetone. Often available in astringents and other cleansing washes, alcohol and acetone remove dirt and oils from the skin. Acne products that contain these ingredients can cause a mild burning or stinging sensation.

Using acne products for best results

To minimize redness, excessive dryness and other skin problems, start out with lower strength acne products. If needed, gradually increase the strength and frequency of your applications so that your skin can adjust to the treatments.

Acne products are just one step in your skin care regimen. For best control of acne:

• Avoid oily cosmetics, sunscreens and hair products. Instead use products labeled "oil-free" or "noncomedogenic," which means they won't clog pores.
• Wash problem areas twice daily with a nonmedicated soap or mild cleanser. But don't overdo it. Excessive washing and scrubbing can worsen acne.
• Apply just enough acne product to cover the problem areas.
• Use an oil-free, water-based moisturizer to help alleviate dry, peeling skin.
• Don't pick or squeeze blemishes. Infection or scarring may result.

Treating acne with acne products takes time and patience. It may take four to six weeks of daily use of acne products to see results, and acne may look worse before it gets better. If your acne doesn't improve after two months of treatment, you may want to see your doctor or dermatologist for a prescription lotion or medication.

Burns - What U can do

MAJOR RECOMMENDATIONS For Burns Management

source: http://www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=11509

Definitions for grades of recommendation (A-C and good practice points [GPP]) are provided at the end of the "Major Recommendations" field.

Prevention

Opportunities for Prevention

A - Primary care providers should provide advice on smoke alarms.

C - Primary care providers should support local initiatives in primary prevention, where possible.

GPP - Primary care providers should provide advice on the regulation of hot water temperature and appropriate first aid management.

First Aid

Stopping the Burning Process and Cooling

C - Ensure your own safety.

C - If on fire, 'stop, drop and roll', smother with blanket or douse with water.

C - For electrical burns, disconnect the person from the source of electricity.

C - Remove clothing and jewellery.

C - Cool burns or scalds by immediate immersion in running tap water (8 to 15 degrees C) for at least 20 minutes. Irrigation of chemical burns should continue for one hour.

C - Do not use ice for cooling.

C - Avoid hypothermia: keep the person with the burn as warm as possible, consider turning the temperature of the water up to 15 degrees C (tepid).

C - If there has been a delay in starting cooling, this should still be started up to three hours after injury.

C - Do not attempt to remove tar.

Gel Pads

C - Gel pads can be used as an alternative to running tap water where water is unavailable or not practical.

Initial Coverings

Polyvinyl Chloride Film (Cling Film)

C - Following cooling, polyvinyl chloride (PVC) film may be used as a temporary cover prior to hospital assessment. It should be applied by persons knowledgeable in its use.

C - PVC film should be layered onto the wound and not applied circumferentially around a limb.

C - Topical creams should not be applied as they may interfere with subsequent assessment.

GPP - PVC film should not be used as a substitute for a dressing product.

Burn Assessment

Emergency Management

C - For major burns perform an ABCDEF primary survey* and X-rays, as indicated.

C - Address analgesic requirements.

C - Establish and record the cause of the burn, the exact mechanism and timing of injury, other risk factors and what first aid has been given.

C - Assess burn size and depth.

C - Give tetanus prophylaxis if required.

C - Be alert to the possibility of non-accidental injury.

*ABCDEF primary survey:
Airway maintenance with cervical spine control
Breathing
Circulation with haemorrhage control
Disability: Neurological status
Exposure with environmental control
Fluid resuscitation

Burn Size

Assessment and Recording of Total Body Surface Area Burn (TBSA)

B - Where time allows, use the Lund and Browder chart as the standard assessment tool for estimating the TBSA of the burn.

Burn Depth

C - The depth of a burn injury should be reassessed two to three days after the initial assessment, preferably by the same clinician.

C - Testing for pinprick sensation by using a needle should be avoided.

GPP - The extent and speed of capillary refill can be used as a clinical method of assessing burn depth.

Non-Accidental Injury

C - If non-accidental injury is suspected, refer to a regional burns unit.

C - If non-accidental injury is suspected, examine for other signs of abuse and photograph injuries.

Classification of Burns

C - Avoid use of the terms first-degree/primary, second-degree/secondary and third-degree burns.

C - Distinguish between burns that will probably heal without skin grafting and those that will probably require grafting (deep dermal burns and full thickness burns).

C - Burns that are unlikely to heal within 21 days without grafting should be referred early to secondary care, ideally by day 10 to 14.

GPP - Use the Australian and New Zealand Burn Association (ANZBA) system of burn classification (see Table 3.3 of the original guideline document for the ANZBA classification of burns based on depth with photographs).

Referral

Emergency Referral

C - Health care practitioners should follow the ANZBA referral guidance when deciding the level of care that is appropriate for people with a new burn injury.

C - When seen in primary care, smaller burns that look like they will fail to heal by 14 days should be discussed with a secondary care service for consideration of an acute referral.

Referral Between Services

C - Transfer between services is facilitated by prompt assessment, recognised communication channels and locally developed protocols agreed between centres on whom to transfer and when to transfer.

C - Referrals to National Burn Centre level care should be via the regional burns units.

GPP - Primary care and accident services will generally develop their own systems for referral depending on the distances involved in travel to secondary services or regional burns units. In general, those people who have less severe injuries than in the ANZBA criteria, but who still require inpatient care, should be referred to local secondary services.

Management of Epidermal Burns or Scalds

Dressings and Creams

GPP - A protective dressing or cream product can be used for comfort in epidermal burns and scalds.

GPP - Review epidermal burns or scalds after 48 hours. If the skin is broken, change to a moist wound-healing product (or alternatively double-layer paraffin gauze).

Management of Superficial and Mid Dermal Burns or Scalds

Preventing Infection

GPP - Products with antimicrobial action (such as silver sulphadiazine cream) should be used on all burns for the first 72 hours (three days) after burn injury.

GPP - Burn wounds with signs of mild cellulitis can be treated with topical silver sulphadiazine and/or oral antibiotics.

GPP - Acute referral to secondary care is required for people with burns with signs of serious or systemic infection.

Wound Healing

C - Use dressings that encourage re-epithelialisation by moist wound healing.

B - The prolonged use of silver sulphadiazine cream (more than seven days) should be avoided in non-infected burns.

GPP - Following initial silver sulphadiazine cream or antimicrobial dressing, a technique that promotes moist wound healing (such as a hydrocolloid dressing) is recommended.

GPP - The convenience of a reduced number of dressing changes with hydrocolloid products should be considered where this is important to the person.

GPP - Double-layer paraffin gauze can be used where hydrocolloids are unavailable.

GPP - Moisturisers and non-drying, non-perfumed soap should be used to protect the skin after burn injury and may also be helpful for pruritus.

GPP - Burn wounds require extra care when exposed to sun.

When to Review

GPP - Superficial and mid dermal burns should be reviewed daily for the first three days, then subsequently every three days.

Management of Blisters

GPP - Preferably leave small blisters intact unless likely to burst or interfere with joint movement.

GPP - If necessary, drain fluid by snipping a hole in the blister.

Scarring

C - Any burns that are unlikely to heal within 21 days without grafting should be referred to a burns unit for scar management by day 10 to 14.

GPP - A person presenting with scarring some months after a burn should still be referred for specialist opinion.

Management of Chemical Injury

General Treatment Advice

First Aid

C - Irrigation of chemical burns should continue for one hour.

C - All chemical burns should be referred to a burns unit.

GPP - Acid burns should not be neutralised with an alkali in primary care.

Eye Injury

C - All significant chemical injuries to the eye should be referred acutely to ophthalmology services.

C - Treat all chemical burns to the eye with copious irrigation of water.

Specific Substances

Hydrofluoric Acid

GPP - Anyone exposed to hydrofluoric acid should be promptly referred to a burns unit for definitive treatment after appropriate first aid.

Phosphorus

GPP - Anyone exposed to phosphorus should be promptly referred to a burns unit for definitive treatment after appropriate first aid.

Management of Electrical Injury

C - All electrical injuries should be referred to a burns unit.

Electrocardiogram (ECG) Monitoring

C - Following electrical injuries people should receive a resting 12-lead ECG.

B - If this initial ECG is normal in people with low-voltage injuries, there is no need for a repeat ECG or for continuous monitoring.

Pain Management

Burn Pain Management

C - Immediately after the injury, cooling and covering the burn may provide analgesia.

C - Paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) can be used to manage background pain.

C - Consider administering opioids for intermittent and procedural pain.

GPP - Refer to secondary care if failing to manage dressing-change pain.

GPP - Consider the use of non-pharmacological approaches as a supplement to pharmacological management of pain.

Plastics Exposure Harmful?

Widely Used Plastics Compound Raises Concerns

A chemical used in the production of polycarbonate plastics, bisphenol A (BPA), is raising concern over its effects in fetuses and children, according to a draft report from the NIH.

The report, from the National Toxicology Program, concludes that BPA presents "some concern" that exposure of fetuses and children "can cause changes in behavior and the brain, prostate gland, mammary gland, and the age at which females attain puberty." The report cites "negligible concern" that BPA exposure leads to birth defects.

Polycarbonate plastics are used in, among other things, bottles for water and infant formula or breast milk. The draft report says that infants and children have the highest intakes of BPA in the population.

The Canadian government may declare the compound toxic as early as this week, an anonymous source told the New York Times.

Physician's First Watch for April 16, 2008
David G. Fairchild, MD, MPH, Editor-in-Chief

National Toxicology Program report (Free PDF)

New York Times story (One-time registration required)

Food Additives cause Hyperactivity

EU Panel: 'Limited Evidence' Food Additives Cause Hyperactivity in Kids

Physician's First Watch for March 17, 2008

An analysis by the European Food Safety Authority downplays the significance of a Lancet study suggesting some synthetic food colors and sodium benzoate preservative cause hyperactivity in children.

The study, published in 2007, concluded that two mixtures of four synthetic colors and sodium benzoate increased hyperactivity in 3-year-olds and 8- to 9-year-olds. The agency said it used "a more justifiable and conventional statistical model" to analyze those results.

The new analysis showed a small and statistically significant effect of the additives on some children's attention and activity. However, the effects were not seen in all ages and were inconsistent for the two mixtures. The panel said there were not enough data on dose-response, nor was there a biologically plausible mechanism for additives to cause hyperactivity.

The agency said the clinical significance "remains unclear," and the findings cannot be used for changing acceptable daily intakes of the additives.

European Food Safety Authority summary (Free PDF)