Clinical Briefs

Am Fam Physician. 2000 Jan 15;61(2):568-571.

Use of Surfactant Replacement Therapy

The Committee on Fetus and Newborn of the American Academy of Pediatrics (AAP) has made recommendations on the use of surfactant replacement therapy for respiratory distress syndrome in low-birth-weight infants. The statement appears in the March 1999 issue of Pediatrics.

Respiratory failure secondary to surfactant deficiency is a major cause of morbidity and mortality in low-birth-weight, premature infants. According to the AAP committee, the use of surfactant replacement therapy can substantially reduce mortality and respiratory morbidity in such infants.

The AAP committee makes the following recommendations:

  • Surfactant replacement therapy should be directed by physicians who are trained in its use and administration and who have experience in managing the respiratory care of low-birth-weight infants, especially those on mechanical ventilation.

  • Nursing and respiratory therapy personnel who have experience in managing low-birth-weight infants should be present when surfactant therapy is administered.

  • Equipment needed for managing and monitoring the condition of low-birth-weight infants, including that needed for mechanical ventilation, should be available on-site when surfactant therapy is administered. Radiology and laboratory support should also be available.

  • Surfactant therapy should only be used in institutions in which facilities and personnel are available for the management of multisystem disorders and low-birth-weight infants.

  • An institutionally approved protocol for surfactant therapy should exist.

  • In institutions that are unable to meet the above recommendations, and when timely transfer to an appropriate institution is not possible, surfactant therapy may be given, but only by a physician skilled in endotracheal intubation. In such circumstances, the physician should consult with a subspecialty center. If appropriate and when feasible, infants should be transferred from such institutions to a center equipped to care for multisystem morbidity in low-birth-weight infants.

National Plan for the Elimination of Syphilis

The Centers for Disease Control and Prevention (CDC) reported record lows in 1998 in the number and rates of cases of primary and secondary syphilis in the United States. In collaboration with Health Resources and Services Administration, Substance Abuse and Mental Health Services Administration, the National Institutes of Health, the National Institute of Justice and other partners, the CDC has developed a National Plan for Elimination of Syphilis. The report is published in the October 8, 1999 issue of Morbidity and Mortality Weekly Report.

Rates of syphilis have been declining in the United States since the last national epidemic in 1990. In 1998, the national rate of 2.6 cases per 100,000 population was the lowest level ever recorded. Syphilis is becoming more concentrated geographically; in 1998, one half of the cases occurred in less than 1 percent of U.S. counties, mainly in the South and selected urban areas. According to researchers, the lower infection rates and geographic concentration are signs of progress toward the elimination of syphilis.

Elimination of syphilis is defined as the absence of sustained transmission. The CDC hopes to reduce the number of syphilis cases to less than 1,000 and to increase the number of syphilis-free counties to 90 percent by 2005. To begin, the CDC has targeted 33 states and cities that have a high rate of syphilis or a high potential for re-emergence of the disease. The elimination plan includes five key strategies: enhanced community involvement and partnerships at local, state and national levels; intensified surveillance; rapid outbreak response; expanded access to health care for persons infected with or exposed to syphilis; and improved health promotion.

“At the close of this century, we have a brief window of opportunity to eliminate one of the public health threats we've been battling the longest,” said Jeffrey Koplan, M.D., M.P.H., director of the CDC. “But if we don't take the opportunity now, we will lose our chance. Another peak in syphilis cases is inevitable unless elimination becomes a reality.”

Oral Aspects of Child Abuse and Neglect

The Committee on Child Abuse and Neglect of the American Academy of Pediatrics (AAP) and the Ad Hoc Work Group on Child Abuse and Neglect of the American Academy of Pediatric Dentistry (AAPD) have published a joint statement on the oral and dental aspects of child abuse and neglect. The statement reviews the oral and dental aspects of physical and sexual child abuse and dental neglect and the role of physicians and dentists in evaluating such conditions. The statement also dicusses the oral manifestations of sexually transmitted diseases and bite marks, and addresses the collection of evidence and laboratory documentation of these injuries. The statement appears in the August 1999 issue of Pediatrics.

The AAP and AAPD committees recommend that physicians and dentists collaborate to increase the prevention, detection and treatment of these conditions. Physicians receive minimal training in oral health and dental injury and disease, and may not detect dental aspects of child abuse or neglect as readily as they notice abuse and neglect involving other areas of the body. Advanced dental education programs include a mandated child abuse curriculum; therefore, pediatric dentists and oral and maxillofacial surgeons should be able to give physicians valuable information and assistance.

In addition, physicians with experience and expertise in child abuse and neglect should make themselves available to dentists and dental organizations as consultants. Such efforts, according to the report, will strengthen the ability of health care professionals to prevent and detect child abuse and neglect, and to care for and protect children.

Incidence of Rh D Alloimmunization

The Committee on Practice Bulletins of the American College of Obstetricians and Gynecologists (ACOG) has published an educational bulletin on the incidence and prevention of Rh D alloimmunization (ACOG Practice Bulletin No. 4). The bulletin provides direction for the appropriate management of patients at risk to further decrease the frequency of Rh D alloimmunization. The paper appears in the May 1999 issue of Obstetrics and Gynecology.

The ACOG bulletin discusses the causes of Rh D alloimmunization, the role of anti-D immune globulin in the prevention of alloimmunization, potential shortage of anti-D immune globulin and the cost-effectiveness of Rh D prophylaxis programs. It also features a section on clinical considerations and recommendations, which includes answers to the following questions: Should anti-D immune globulin ever be withheld from a woman undergoing sterilization? How much anti-D immune globulin should be given for first trimester events and procedures? Should anti-D immune globulin be given in cases of intrauterine fetal death occurring in the second or third trimester? Should all Rh D-negative women be screened for excessive fetomaternal hemorrhage after delivery of an Rh D-positive infant?

In summary, the ACOG committee feels that reducing the incidence of Rh D alloimmunization is a prototype for the effectiveness of preventive medicine. However, the use of anti-D immune globulin is controversial in patients with threatened abortion or antenatal hemorrhage.

Based on consistent scientific evidence, the ACOG committee recommends that the Rh D-negative woman who is not Rh D-alloimmunized should receive anti-D immune globulin at the following times:

  • Approximately 28 weeks of gestation, unless the father of the infant is also known to be Rh D negative

  • Within 72 hours after delivery of an infant who is Rh D positive

  • After the loss of a first trimester pregnancy

  • After invasive procedures, such as chorionic villus sampling, amniocentesis or fetal blood sampling

Based primarily on consensus and expert opinion, the ACOG committee recommends that anti-D immune globulin prophylaxis should be considered if the patient has experienced threatened abortion, antenatal bleeding during the second or third trimester, external cephalic version or abdominal trauma.

NRHA Agenda on Rural Minority Health

The National Rural Health Association (NRHA), in partnership with President Clinton's Initiative on Race, which has made a commitment to eliminate racial and ethnic disparities in six areas of health status by the year 2010, has issued the first in a series of issue papers that define an agenda for rural minority health. According to the issue paper, “this agenda is intended to serve as a document that can be used in a prescriptive manner by states and local health and health-related agencies for setting priorities and community funding for major rural minority health issues.”

The first issue paper titled “A National Agenda for Rural Minority Health” covers the value of a national agenda for rural minority health, discussing the overarching values of a health care delivery system on which the agenda is based. According to these values, the agenda should be community based, culturally and linguistically competent, comprehensive, creative, community involved and cost effective. The paper also details the four priority areas of the agenda: information and data, health policy and practices, health delivery systems and health professionals. A series of four issue papers that focus on each of the priority areas of the agenda will be written in the future.

Full text of the issue paper is available in the Advocacy section of the NRHA Web site (http://www.NRHArural.org). Free copies of the paper may also be obtained by contacting the NRHA Communications Department at the following telephone number: 816-756-3140.

Use of Mammograms and Papanicolaou Tests

In 1999, an estimated 175,000 women will be diagnosed with breast cancer; 43,300 will die of the disease. In the same year, an estimated 12,800 women will be diagnosed with invasive cervical cancer; 4,800 will die of the disease. These statistics underscore the need for early detection and timely treatment of breast and cervical cancers. A new report from the U.S. Department of Health and Human Services cites trends in the self-reported use of mammograms and papanicolaou tests to find the prevalence of regular screening for breast and cervical cancers. The complete report, “Trends in Self-Reported Use of Mammograms (1989–1997) and Papanicolaou Tests (1991–1997)—Behavioral Risk Factor Surveillance System,” appears in the October 8, 1999 issue of the CDC Surveillance Summaries series of Morbidity and Mortality Weekly Report (No. SS-6).

The report used the Behavioral Risk Factor Surveillance System (BRFSS), a state-based telephone survey, to gather information from women 40 years of age or older for measures of breast cancer screening (from 1989 through 1997) and from women 18 years of age or older for measures of cervical cancer screening (from 1991 through 1997). The survey found that for both types of screening, the proportion of women who were ever screened and the proportion who were screened within the previous two years differed substantially, indicating that some women who participated in the initial screening did not continue to be screened regularly.

The report concludes that national goals should be made to emphasize maintenance of screening levels among subgroups of women who are most likely to participate in screening, as well as increasing screening levels among subgroups of women who are less likely to participate.

Role of Raloxifene in Osteoporosis

Raloxifene hydrochloride (Evista) was recently approved by the U.S. Food and Drug Administration (FDA) for use in the treatment of postmenopausal osteoporosis. Raloxifene was first approved two years ago for use in the prevention of osteoporosis in postmenopausal women, making it the only selective estrogen receptor modulator approved for the prevention and treatment of postmenopausal osteoporosis.

Findings from an ongoing multi-center study involving 7,705 women with osteoporosis led to the FDA approval of the new indication. Taken once per day, raloxifene decreased the incidence of spinal fracture by about one half. It also significantly increased the bone mineral density of the spine and hip when compared with placebo.

Raloxifene is contraindicated in women who are or can become pregnant, are breast-feeding, have severe liver problems or have blood clots that require medical treatment. The most common adverse effects associated with use of raloxifene include hot flushes and leg cramps, but most women do not experience these symptoms. Blood clots in the veins are a serious, but infrequent side effect of treatment with raloxifene. Prescribing information is available via fax by calling the following number: 800-753-0352, ext. 708.


Copyright © 2000 by the American Academy of Family Physicians.
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