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Am Fam Physician. 1999 Apr 1;59(7):2021-2027.
Reported Increase in Sexual Risk Behaviors
Data from San Francisco's annual behavioral survey among men who have sex with men and disease reports from sexually transmitted disease clinics in San Francisco from 1994 to 1997 document significant increases in self-reporting of unprotected anal intercourse and in rates of rectal gonorrhea. The report, published in the January 29, 1999, issue of Morbidity and Mortality Weekly Report, states that the proportion of men who have sex with men reporting unprotected anal intercourse increased significantly (from 30.4 percent to 39.2 percent) during this period, with the most dramatic increases among men 26 to 29 years of age. The proportion of men who have sex with men reporting unprotected anal intercourse with multiple sex partners increased from 23.6 percent to 33.3 percent, with the youngest respondents (those under age 25 years) reporting the largest increases (from 22.0 percent to 32.1 percent). During the same period, rates of male rectal gonorrhea in San Francisco's sexually transmitted disease clinics almost doubled (from 21 to 38 cases per 100,000 adult men), reversing a three-year decline. The data presented in this report suggest that the substantial reduction in sexual risk behaviors among men who have sex with men and the decreases in rectal gonorrhea during the 1980s and early 1990s cannot be assumed to be maintained indefinitely. Researchers believe that advances in therapy for human immunodeficiency virus (HIV) infection may have led some men who have sex with men to perceive HIV to be a less serious disease and to relax safe sex practices.
Rehabilitation for Traumatic Brain Injury
More research is needed on the effectiveness of rehabilitation for traumatic brain injury, according to a study sponsored by the Agency for Health Care Policy and Research (AHCPR) under its evidence-based practice program. The document “Rehabilitation for Traumatic Brain Injury” is the second in a series of evidence reports and technology assessments sponsored by the AHCPR to provide comprehensive, science-based information on common, costly conditions and health care technologies. The study's conclusions are based on a systematic review of the best available evidence from published research. The year-long study, conducted at Oregon Health Sciences University, found no strong evidence supporting one rehabilitation strategy over another.
The following are the main findings of the study:
Although the evidence is weak, some patients with severe traumatic brain injury may benefit from early initiation of coordinated, multidisciplinary rehabilitation as soon as possible after their admission to the trauma center. There is no evidence for or against early rehabilitation in patients with mild to moderate injury.
When measured as the hours of application of individual or grouped therapies, there is no indication that the intensity of acute, inpatient rehabilitation for patients with traumatic brain injury is related to outcome. A better measure of intensity must be developed and new studies conducted to address this issue.
Some existing evidence shows that a personally adapted electronic device, a notebook and an alarm wristwatch help reduce everyday memory failures for persons with traumatic brain injury. There is evidence from one study that compensatory cognitive rehabilitation reduces anxiety and improves self concept and relationships for persons with traumatic brain injury.
Supported employment appears to be a promising way to increase the success of survivors of traumatic brain injury in the workplace, but the studies do not give definitive proof of its effectiveness and do not provide enough clarity on why it works or its best application and use.
No clear research evidence for or against the effectiveness of case management for persons with traumatic brain injury and their families is available at this time.
A summary of the report is available on the AHCPR Web site at http://www.ahcpr.gov. The full report may be obtained free from the AHCPR Publications Clearinghouse by calling 800-358-9295 or by writing to the Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907.
Tuberculosis Guidelines to Protect Health Care Workers
The American College of Occupational and Environmental Medicine (ACOEM) has released guidelines for protecting health care workers from acquiring active pulmonary tuberculosis. The ACOEM guidelines were based on those from the Centers for Disease Control and Prevention, the National Institute of Occupational Safety and Health and the Occupational Safety and Health Administration. ACOEM recommends the use of multiple steps to reduce the risk, including updated training of health care workers; optimal design, ventilation and patient flow in clinical spaces; periodic testing of health care workers; effective respiratory protection; active infection control procedures; and periodic updating of written tuberculosis control plans. Dr. Lawrence Raymond, lead author and a member of the ACOEM Lung Disorders Committee, which developed the guidelines, reports, “Employers are asked to perform two-step tuberculosis testing of all newly hired health care workers who have not had a tuberculosis test within the previous 12 months. Health care workers who could potentially care for or have airborne exposure from patients with active tuberculosis should have tuberculin testing every three to 12 months.”
The guidelines are available by contacting ACOEM, 55 W. Seegers Rd., Arlington Heights, IL 60005; by visiting the ACOEM Web site (http://www.acoem.org); or from the ACOEM fax-on-demand service at 800-226-3626.
NCI Statement on Cervical Cancer Treatment
The National Cancer Institute (NCI) issued a clinical announcement stating that strong consideration should be given to adding chemotherapy to radiation therapy in the treatment of invasive cervical cancer. Previously, surgery or radiation therapy alone has been considered the standard treatment for cervical cancer that has spread locally or regionally.
The NCI reports that five large, randomized clinical trials have shown that women with invasive cervical cancer were found to benefit from the use of radiation therapy and chemotherapy in combination. Several hundred women were enrolled in each of the five trials, which were sponsored by the NCI's Clinical Trials Cooperative Groups in centers around the country. The NCI believes that these results will change the standard of care for invasive cervical cancer. Three of the studies will be published in the New England Journal of Medicine, and the remaining two will be published later this year.
The clinical announcement states that, although the best chemotherapy regimen for cervical cancer has not been determined, “significant results were seen using cisplatin alone or cisplatin in combination with 5-fluorouracil and other agents.”
The NCI's clinical announcement can be found on the NCI Internet site for clinical trials at http://cancertrials.nci.nih.gov . It can also be obtained from CancerFax by calling 301-402-5874 from a fax machine and using the code number 400262.
AAP Policy on Children with HIV-Infected Parents
A new policy statement from the American Academy of Pediatrics (AAP) calls for the development of plans to ensure the future care of the growing number of children and adolescents whose parents die of acquired immunodeficiency syndrome (AIDS). The AAP reports that as many as 80,000 children soon will be orphaned as a result of the human immunodeficiency virus (HIV)/AIDS epidemic. The policy statement, which is published in the February 1999 issue of Pediatrics, addresses the difficult issues parents face in the context of HIV infection. One such difficulty is that children orphaned by the HIV/AIDS epidemic often are from families who have experienced poverty, lack of access to services, discrimination and family disruption. The AAP calls on physicians to assist chronically ill and dying parents in planning for the future of their children.
The policy gives examples of existing state laws and regulations that help chronically ill parents plan for their children's future. The AAP also stresses the need for sensitive, long-term bereavement counseling services for children who have experienced the death or face the impending death of a parent. Plans need to be made to provide not only for a stable environment for these children but also for the medical and social interventions necessary to help children cope with their loss.
New Drug for Intermittent Claudication
Cilostazol (Pletal) has been approved by the U.S. Food and Drug Administration (FDA) for the reduction of symptoms in patients with intermittent claudication. Cilostazol is the first drug to be approved for intermittent claudication in 15 years. Intermittent claudication is caused by peripheral arterial disease. Symptoms include pain, aches, cramps or severe fatigue involving one or both legs when walking.
According to the manufacturer, cilostazol targets multiple processes related to peripheral circulation. It also may increase high-density lipoprotein cholesterol levels and lower triglyceride levels. The recommended dosage is 100 mg twice daily.
In clinical trials, patients who received cilostazol for 24 weeks had an increased walking distance of 345 ft, compared with patients who received placebo. The most common side effects were headache, diarrhea, abnormal stools, dizziness, palpitations and tachycardia. Most of the side effects were mild to moderate.
According to the FDA, cilostazol is pharmacologically related to a class of drugs called phosphodiestrase III inhibitors, several of which have caused increased death rates in patients with severe heart failure. Cilostazol is contraindicated in patients with congestive heart failure of any severity and in patients with known or suspected hypersensitivity to any of its components. Full prescribing information for cilostazol can be obtained on the Internet at http://www.otsuka.com.
CDC Report on Screening for Colorectal Cancer
A new report from the Centers for Disease Control and Prevention (CDC) indicates a relatively low use of sigmoidoscopy/proctoscopy and fecal occult blood testing in the detection of colorectal cancer in persons over 50 years of age. Data used in the report, published in the February 19, 1999, issue of Morbidity and Mortality Weekly Report, were from the 1997 Behavioral Risk Factor Surveillance System.
A total of 52,754 persons over age 50 were asked if they had ever had fecal occult blood testing with a home kit and whether they had ever undergone sigmoidoscopy or proctoscopy, and when the last test was performed. Overall, 39.7 percent of respondents reported ever having had fecal occult blood testing, and 41.7 percent reported ever having had a sigmoidoscopy or proctoscopy during the recommended interval of once every year for fecal occult blood testing and once every five years for sigmoidoscopy or proctoscopy. Men were more likely than women to report ever having undergone a sigmoidoscopy or proctoscopy (35.1 percent and 26.7 percent, respectively), and women were more likely than men to report having had fecal occult blood testing (20.9 percent and 18.3 percent, respectively). Hispanics were less likely than other groups to have had either test. Persons with health care coverage, high incomes and more education were more likely to have had these tests.
The CDC believes that the findings in this report emphasize the need to increase the use of screening for colorectal cancer. The CDC recommends that public health officials and health care professionals intensify efforts to increase awareness of the effectiveness of screening and to promote the use of colorectal cancer screening tests.
A fatal case of rabies in a 29-year-old man in Virginia in December 1998 emphasizes the need for medical personnel to consider rabies as a diagnosis in any person presenting with the acute onset and rapid progression of compatible neurologic signs, regardless of whether the patient reports a history of an animal bite or animal contact. The report in the February 12, 1999, issue of Morbidity and Mortality Weekly Report summarizes the investigations by the Virginia Department of Health and the Centers for Disease Control and Prevention (CDC).
The patient, an inmate at a correctional center in Virginia, died of rabies encephalitis caused by a rabies virus variant associated with insectivorous bats. There was no reported contact or bite from an animal in recent months. The patient first complained of malaise and back pain while working on a roadside cleanup crew, and his condition worsened, with visual hallucinations, disorientation, hypersalivation, priapism, and wide fluctuations in body temperature and blood pressure. Toxicity studies were negative, and a computed tomography scan of the head did not reveal abnormal findings. The patient was intubated and heavily sedated. A diagnosis of rabies was first considered five days after the patient sought medical care.
The CDC notes that the use of sedatives may have masked the classic rabies sign of hydrophobia in this patient. Postexposure prophylaxis was administered to 48 persons who possibly had contact with the patient's saliva between the time that he first exhibited clinical signs of illness and the time of his death.
The CDC emphasizes that early diagnosis of rabies can help minimize the number of potential exposures and the need for postexposure prophylaxis. In the reported case, consideration of rabies earlier may have minimized the number of hospital staff who had to receive postexposure prophylaxis.
ACIP Recommends Hepatitis A Vaccination
The Advisory Committee on Immunization Practices (ACIP) has recommended that 11 states with a high incidence of hepatitis A consider routine vaccination of all children against hepatitis A. ACIP based its recommendation on a review of data from community-based hepatitis A vaccination programs.
“Vaccinating children against hepatitis A is one of the most effective—and cost-effective—strategies for building long-term immunity against hepatitis A and preventing further spread of the disease,” said Thelma King Thiel, chairman and CEO of Hepatitis Foundation International. “We applaud ACIP for taking action that will protect children and adults from this serious, yet preventable disease.”
ACIP urges that states require routine vaccination against hepatitis A if the incidence is over 20 cases per 100,000 persons (twice the national average for hepatitis A cases from 1987 to 1997). The 11 states that fall into this category are Arizona, Alaska, California, Idaho, Nevada, New Mexico, Oklahoma, Oregon, South Dakota, Utah and Washington. Together, these states have only 22 percent of the U.S. population but have accounted for 50 percent of reported hepatitis A cases from 1987 to 1997.
In addition, ACIP recommends that routine hepatitis A vaccination for children be considered in states where the average annual hepatitis A rate from 1987 to 1997 was at least 10 cases per 100,000 persons but less than 20 cases per 100,000 persons. These states include Missouri, Texas, Colorado, Arkansas, Montana and Wyoming.
CDC Report on Hispanics and Diabetes
According to new data released by the Centers for Disease Control and Prevention (CDC), 6 percent of Hispanic adults in the United States and Puerto Rico have been diagnosed with diabetes, which is twice the rate of diabetes in whites in the United States. These data were taken from the Behavioral Risk Factor Surveillance System, which includes data from 1994 to 1997, and analyzed for the report published in the January 15, 1999, issue of Morbidity and Mortality Weekly Report. The report did not distinguish between type 1 diabetes (formerly known as insulin-dependent diabetes mellitus) and type 2 diabetes (formerly known as non–insulin-dependent diabetes mellitus).
The study found that the prevalence of diabetes among Hispanic adults increases with age. Diabetes has been diagnosed in approximately 2.3 percent of Hispanics ages 18 to 44 years, 12 percent of those ages 45 to 64 years and 21.4 percent of those ages 65 and older. The prevalence varied according to geographic location. Hispanics in Puerto Rico and the West/Southwest were more likely to have diabetes than Hispanics living elsewhere in the country. Regardless of ethnicity, the prevalence of diabetes also varied by education. The prevalence was higher among persons without a high school education than among persons with at least a high school education (9.8 percent versus 6.5 percent among Hispanic adults and 5.9 percent versus 3.6 percent among non-Hispanic white adults).
The report notes that it is estimated that another 6 percent of Hispanic persons have diabetes but have not been diagnosed. The CDC calls for effective intervention strategies in this population to reduce the burden of diabetes and its complications. In persons with diabetes, secondary prevention measures such as improved glycemic and blood pressure control reduces the risk for developing diabetes-related complications. The CDC also recommends screening for diabetic eye disease and diabetic foot disease to reduce the incidence of blindness and amputation. A copy of the CDC patient-care guide, “Take Charge of Your Diabetes,” is available in Spanish and English by calling the toll-free number 877-232-3422.
Supplemental Test for Hepatitis C Virus
The U.S. Food and Drug Administration (FDA) has approved a more accurate test to confirm screening test results for hepatitis C virus (HCV). The blood test (RIBA HCV 3.0 Strip Immunoblot Assay [SIA]) is a supplemental test used to evaluate blood specimens that have already had positive test results for HCV. It is more sensitive than other supplemental tests, thus reducing the likelihood of false-positive results.
The new test is significant because the U.S. Department of Health and Human Services has recommended that blood banks and medical facilities notify patients who received blood from donors who subsequently were found to be infected with HCV. Use of RIBA HCV 3.0 SIA may prevent many notifications from being sent to blood recipients based on inconclusive HCV test results. In clinical trials, about 30 percent of repeatedly reactive test results were interpreted as indeterminate by a previous test, but only about 7 percent of these same results were interpreted as indeterminate by the RIBA HCV 3.0 SIA.
Copyright © 1999 by the American Academy of Family Physicians.
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