Am Fam Physician. 2000 Nov 15;62(10):2364-2366.
Reducing Falls Among Older Women
Among persons 65 years and older, injuries related to falls are the main cause of injury deaths and disabilities. The most serious fall injury is hip fracture. In 1996, 340,000 hospitalizations for hip fracture occurred among persons 65 years and older, and 80 percent of these patients were women. About 50 percent of older adults hospitalized for hip fracture never regain their previous level of function. A report on the incidence and prevention of hip fracture resulting from falls appears in the March 31, 2000 issue of the reports and recommendations series of Morbidity and Mortality Weekly Report (MMWR).
About 95 percent of hip fractures are caused by falls. Risk factors for hip fracture resulting from falls among older women include increasing age, muscle weakness, functional limitations (e.g., difficulty with daily activities such as bathing or dressing), environmental hazards, cognitive impairment or dementia, use of psychoactive medications, a history of falls, lack of current or previous physical activity, osteoporosis, low body mass index and previous hip fracture.
The MMWR report stresses that minimizing risk of falls is the practical approach to reducing serious injury. Primary prevention of fall-related injuries involves reducing the occurrence of falls in persons living independently or in nursing homes. Effective intervention programs use a multifaceted approach involving behavioral and environmental elements, as follow: exercises to improve strength and balance, environmental modifications, education on fall prevention, review and assessment of medications to minimize side effects, and risk factor reduction.
Secondary prevention of fall-related injuries involves preventing injury when falls occur. Because most hip fractures happen when the person falls directly on the hip, use of a pad that shunts the energy away from the point of impact is highly effective in reducing the force of a fall. Researchers have developed an undergarment with energy-absorbing hip pads and are testing a safety floor with a firm walking surface that is made of energy-absorbing flooring material.
Physical Activity and Fitness in Schools
The Committee on Sports Medicine and Fitness and the Committee on School Health of the American Academy of Pediatrics (AAP) have issued a statement on physical fitness and activity in schools. The statement appears in the May 2000 issue of Pediatrics.
According to the committees, schools are in a unique position to increase physical activity and fitness among their students. The development of a physically active lifestyle should be a goal for all children. This policy statement reaffirms the support of the AAP for the efforts of schools to include increased physical activity in the curriculum and offers schools and physicians suggestions for ways in which to meet physical fitness goals for students.
The AAP committees have adapted the following recommendations for health care professionals from those published in 1997 by the Centers for Disease Control and Prevention and in 1998 by the Council for Physical Education for Children:
Help schools to adapt programs to meet the needs of children and adolescents who have activity limitations because of temporary or chronic illness, injury or developmental disability.
Provide schools and children with safe options for continuing with physical activity, even when students are affected by illness, injury or disability.
Identify and encourage the appropriate use of safety equipment for sports and physical activities in all settings.
Assess activity patterns as part of routine health maintenance and provide advice about ways of increasing physical activity levels.
Encourage physical activity at the family and community levels.
Help to identify and reduce barriers to regular physical activity, including doubts, fear of injury and the lure of more sedentary pursuits.
Work to ensure the availability of funding and personnel resources.
The statement also provides recommendations for use by school personnel.
Exercise in the Patient with Diabetes Mellitus
The American Diabetes Association (ADA) has issued a position statement to update current information on the role of exercise in patients with type 1 or type 2 diabetes mellitus (formerly known as insulin-dependent diabetes and non–insulin-dependent diabetes, respectively). The position statement appears in a supplement to the January 2000 issue of Diabetes Care.
According to the ADA position statement, exercise may be a therapeutic tool for a variety of patients who have or are at risk for diabetes, but as with any therapy, its effects must be understood. The diabetes health care team must understand how to analyze the risks and benefits of exercise in a given patient. Working with a professional who is trained in exercise physiology is recommended. The ADA also stresses that the diabetes health care team should educate primary care physicians and others involved in the care of a given patient.
Patients who have diabetes should undergo a detailed medical evaluation before beginning an exercise program. The examination should focus on the cardiovascular system, peripheral artery disease, retinopathy, nephropathy, and peripheral and autonomic neuropathy.
Physical activity plays a pivotal role in health promotion and disease prevention. The ADA reports that the worldwide epidemic of type 2 diabetes is associated with decreasing levels of activity and an increasing rate of obesity. Exercise provides the greatest benefits in improvement of the metabolic abnormalities of type 2 diabetes when it is used early in the progression from insulin resistance to impaired glucose tolerance to overt hyperglycemia requiring treatment with oral glucose-lowering agents and finally to insulin. The therapeutic regimen of patients with type 1 diabetes should be adjusted to allow safe participation in all forms of physical activity.
Blueprint for Development of Tuberculosis Vaccine
In response to the rapid spread of tuberculosis (TB) throughout the world, researchers have created a plan to set guidelines for the development of an effective TB vaccine. TB kills an estimated 1.5 to 3 million persons in the world each year. The only way to conquer the disease is through vaccination. The “Blueprint for TB Vaccine Development” was developed by the National Institute of Allergy and Infectious Diseases (NIAID) and the National Vaccine Program Office to encourage an international collaborative effort to develop a vaccine. The blueprint appears in a supplement to the Clinical Infectious Diseases (Clin Infect Dis 2000;30[suppl 3]:S233–42).
The blueprint describes three different vaccine concepts that are currently being developed: live, attenuated vaccines; subunit vaccines; and naked DNA vaccines. In the live, attenuated approach, researchers genetically modify the TB bacterium in the laboratory to reduce its ability to cause disease. When used in humans, the weakened bacteria should cause an immune response but not cause disease.
In the subunit vaccine approach, researchers dissect the TB bacterium and use only a fragment of it in the vaccine to produce an immune response.
The naked DNA vaccine is a relatively new strategy. In this approach, researchers take DNA from the TB bacterium and modify it so only a small piece of the original genetic material is left. When the modified, naked DNA is used in humans, it prompts the body's own cells to generate protective immune responses against TB.
When researchers have identified a promising vaccine candidate, its safety and effectiveness will be studied in human clinical trials. A task-force convened by the Department of Health and Human Services now oversees the implementation of the blueprint. The blueprint is available on the NIAID Web site at http://www.niaid.nih.gov/publications/blueprint. Information on TB and vaccine research may be obtained on the NIAID publications page at http://www.niaid.nih.gov/publications.
Copyright © 2000 by the American Academy of Family Physicians.
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