Clinical Briefs



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Am Fam Physician. 2001 Apr 1;63(7):1433-1439.

Safe Transportation of Children in Pickup Trucks

The Committee on Injury and Prevention of the American Academy of Pediatrics (AAP) has issued a position statement on children who ride in pickup trucks. The statement appears in the November 2000 issue of Pediatrics.

According to the AAP committee, in crashes involving fatalities, passengers in the cargo area of the truck were three times more likely to die than were occupants in the cab of the truck. When the occupants in the cab were restrained, the risk of death for those in the cargo area was eight times higher. The committee states that the most effective preventive strategies are the legislative prohibition of travel in the cargo area and requirements for age-appropriate restraint use and seat selection.

Parents should be counseled about the following considerations for selecting and using vehicles to safely transport their families:

  • No passengers should be transported in the cargo area of a pickup truck or a non passenger section of any vehicle.

  • Trips should be planned in advance so that an appropriate seat position and restraint device are used for each passenger.

  • Compatibility should be checked between the vehicle seat (front and back seats) and the car safety seat before a vehicle or car safety seat is purchased.

  • Infants in rear-facing car safety seats should not be placed in front passenger seats when an airbag is present and activated. If an appropriate rear seating position is not available, the infant may be placed in the front passenger seat if an airbag on/off switch is installed and turned off.

  • Car safety seats should fit completely on the rear seat of the pickup truck and can be properly secured facing the rear for infants younger than one year and weighing less than20 lb, and facing forward for older children. The addition of a tether may improve the security of a car safety seat.

  • All forward-facing car safety seats should be installed using a top tether in addition to the vehicle belt.

  • Teenagers should agree that they will not ride or transport others in the cargo area of a pickup truck.

  • The AAP statement also stresses that physicians have an important role in counseling families and advocating public policy measures to reduce the number of deaths and injuries to occupants of pickup trucks.

FDA Approves Tacrolimus for the Treatment of Eczema

The U.S. Food and Drug Administration (FDA) has approved a new treatment for eczema. Tacrolimus (Protopic) is available in 0.1 and 0.03 percent ointment for adults and 0.03 percent ointment for children two years and older.

Tacrolimus ointment is intended for patients with moderate to severe eczema, for whom standard treatments are inadvisable because of potential risks, or who are not adequately treated by or are intolerant of standard eczema therapies. In clinical trials, 28 to 37 percent of patients using tacrolimus had at least 90 percent improvement of their skin condition as measured by physicians. The trials also found that tacrolimus is safe for intermittent long-term use.

Side effects commonly associated with tacrolimus include temporary stinging or burning sensations where the ointment is applied, although this may lessen if the diseased skin heals. The adverse effects of ultraviolet light on the skin may be intensified. Therefore, patients should avoid exposure to sunlight and sunlamps, tanning beds and treatment with UVA or UVB light. Patients treated with tacrolimus ointment who need to be outdoors should wear loose fitting clothing to shield treated skin from the sun.

Patients who are allergic to tacrolimus or its inactive ingredients should not use this drug. Tacrolimus should not be used in breast-feeding women, and women who are planning to become pregnant should discuss use of this drug with their physician.

For more information ontacrolimus ointment, contact the FDA at 888-INFO-FDA (888-463-6332).

FDA Approval of Visicol for Colonoscopy

The U.S. Food and Drug Administration has approved Visicol sodium phosphate tablets for cleansing of the bowel in preparation for colonoscopy. The tablets were created in response to patients who sought a purgative preparation that would be better tolerated. The manufacturer hopes that Visicol will increase the number of patients who will undergo colonoscopy to prevent colon cancer. According to the manufacturer, colon cancer is the second leading cause of death from cancer in the United States.

AAP Statement on the Hazards of Snowmobiles

The Committee on Injury and Poison Prevention of the American Academy of Pediatrics (AAP) has developed a position statement on the hazards of snowmobile use. This statement, which has been updated from a previous AAP statement, appears in the November 2000 issue of Pediatrics.

The AAP committee makes the following recommendations for children younger than 16 years:

  • Children younger than 16 years should not operate snowmobiles. Furthermore, children younger than six years do not have the strength or stamina to be transported safely as passengers on snowmobiles.

  • Advertisements that promote snowmobiling should not be directed toward young adolescents.

The AAP committee makes the following recommendations for the protection of snowmobilers 16 years and older:

  • Graduated licensing for snowmobile operators is recommended, consistent with the AAP policy on graduated licensing for motor vehicle drivers.

  • Newly licensed operators should be restricted to snowmobiling during daylight hours on groomed trails only and should have a learner's permit.

  • Snowmobilers should travel at safe speeds, especially on unfamiliar or rugged terrain where hazards, such as difficult-to-see barbed wire, may be found. A speed-limiting governor, to limit the maximal speed, may be used. Snowmobilers should avoid using alcohol or other drugs before or during the operation of a snowmobile.

  • Snowmobilers should wear wellinsulated protective clothing, including goggles, waterproof snowmobile suits, gloves and rubber-soled boots. All drivers and passengers should wear helmets that meet current standards for use while operating motorized vehicles.

  • Operators should carry a first-aid kit, a survival kit that includes flares and, if practical, a cellular phone. Snowmobilers should travel in groups of two or more and only on designated, marked trails away from roads, waterways, railroads and pedestrian traffic. The weather forecast should be checked before snowmobiling. Operators should know the signs of hypothermia and regularly check for frostbite.

  • Snowmobilers should avoid driving on ice if they are uncertain about its thickness or condition.

  • Snowmobilers should not carry more than one passenger. Headlights and taillights should be on at all times to improve visibility of the snowmobile to other vehicle operators.

  • Use of a saucer, tube, tire, sled orskis to pull someone behind a snowmobile is not recommended.

ACS Booklet on U.S. Cancer Facts and Figures

The American Cancer Society (ACS) has published a booklet of the society's annual estimates of expected numbers of new cancer cases and deaths. “Cancer Facts & Figures 2001” includes basic cancer facts, such as estimates of cancer death rates by gender, site and state; information on selected cancers; cancer in minorities; tobacco use; nutrition and diet; and environmental cancer risks.

Some of the highlights of the booklet include the following:

  • In 2001, an estimated 1,268,000 new cases of cancer and 553,400cancer deaths are expected in the United States.

  • The five-year relative survival rate for all cancers combined is 60 percent, an increase of 1 percent from the report in the year 2000.

  • The National Institutes of Health estimate for overall cost of cancer in the year 2000 is at an all-time high of $180.2 billion.

  • Lung cancer is still the number one cause of cancer deaths in the United States, with an estimated 157,400 deaths expected in 2001.

The booklet also has a special section on obesity, including evidence suggesting that obesity increases the risk for cancers of the breast, endometrium, cervix, ovary, gallbladder, colon and prostate. This section also discusses the obesity epidemic in the United States, the trends in obesity since 1971, obesity trends by state, obesity prevalence by gender, demographic and behavioral characteristics, factors influencing obesity, and suggested public health and public policy approaches to reduce the prevalence of obesity.

For more information on “Cancer Facts &Figures 2001,” contact the ACS, 1599 Clifton Rd. NE, Atlanta, GA 30329-4251; call 800-ACS-2345 (800-227-2345); or visit the ACS Web site at http://www.cancer.org.

FDA Approval of Ramipril for Cardiovascular Disease

The U.S. Food and Drug Administration (FDA) has approved an expanded indication for ramipril (Altace) to reduce the risk of stroke, myocardial infarction and death from cardiovascular causes in patients 55 years and older with a history of coronary artery disease, stroke or peripheral vascular disease, or with diabetes and one other cardiovascular risk factor (e.g., elevated cholesterol levels, cigarette smoking).

The new indication is based on the results of the HOPE (Heart Outcomes Prevention Evaluation) study, which included 9,297 patients in 267 centers in 19 different countries. Participants were randomized to receive 10 mg of ramipril or placebo once daily for four years. Rates of reduction of cardiovascular events included 32 percent for stroke, 20 percent for myocardial infarction, 26 percent for cardiovascular death and 22 percent for all three endpoints combined. In the HOPE trial, a 10-mg dosage of ramipril decreased the incidence of death from any cause by 16 percent. The HOPE study also evaluated 3,577 patients with diabetes and found that cardiovascular events were reduced by 25 percent.

Adverse effects commonly associated with ramipril include headache, dizziness, fatigue and dry cough. Rare cases of angioedema have also been reported. Patients who are hypersensitive to ramipril or who have a history of angioedema related to previous treatment with an angiotensin-converting enzyme (ACE) inhibitor should not use ramipril. Pregnant women should avoid use of all ACE inhibitors, including ramipril, because they may cause injury or death to the developing fetus.

Physicians' Role in Care of Foster Children

The Committee on Early Childhood, Adoption and Dependent Care of the American Academy of Pediatrics (AAP) has issued a statement on developmental issues for young children living in foster care. The AAP statement appears in the November 2000 issue of Pediatrics.

According to the AAP committee, all placement, custody and long-term planning decisions should be individualized for the child's best interest. These decisions should be based on a comprehensive assessment and periodic reassessment of the child and family by professionals who are experts in child development and pediatrics. Physicians should actively participate in prevention services for at-risk families and placement, custody and long-term planning decisions for children for whom they provide care.

The AAP committee stresses the following concepts to guide physicians as they advocate for the child:

  • Biologic parenthood does not necessarily confer the desire or ability to care for a child adequately. Supportive nurturing by primary caregivers is crucial to early brain growth and to the physical, emotional and developmental needs of children.

  • Children need continuity, consistency and predictability from their caregiver. Multiple placements are injurious to the child.

  • Attachment, sense of time and developmental level of the child are key factors in their adjustment to environmental and internal stresses.

  • Physicians can play a constructive role in the referral, assessment and treatment of children who are at risk for being abused, neglected or abandoned, or who are involved in the protective services system.

  • Physicians should encourage caregivers to do the following: give the child plenty of love and attention; be consistent with love, stimulation and discipline; stimulate the child through exposure to developmentally appropriate holding, conversation, reading, music and toys; expose the child to opportunities to improve language via direct voice and face-to-face contact; and match the environment to the child's disposition.

  • Parents should be given reasonable assistance and opportunity to maintain their family, while the present and future best interests of the child should determine what is appropriate.

  • A child's attachment history and sense of time should guide the pace of decision-making.

  • Foster care placements should always maximize the healing aspects of foster care and be based on the needs of the child.

  • Foster care placement with relatives should be based on careful assessment of the needs of the child and of the ability of the kinship care to meet those needs. As with all foster care placements, kinship care must be supported and supervised adequately.

Treatment of Decreased Libido

The Committee on Gynecologic Practices of the American College of Obstetricians and Gynecologists (ACOG) has issued a committee opinion on androgen treatment of decreased libido. ACOG Committee Opinion No. 244 appears in the November 2000 issue of Obstetrics and Gynecology.

Decreased libido is a manifestation of sexual dysfunction, which affects approximately 43 percent of women, according to a recent survey. Androgen replacement has been proposed as a treatment for certain types of sexual dysfunction. According to the ACOG committee, androgens consistently increase libido at superphysiologic levels, but physiologic androgen replacement therapy has not been shown to consistently affect libido.

Available oral testosterone preparations include methyltestosterone with or without esterified estrogens, fluoxymesterone and testosterone undecanoate. Testosterone can be given intramuscularly or topically with transdermal patches or gel. Side effects include hoarseness, acne, increased facial hair, clitoromegaly, hepatotoxicity, alopecia or undesirable lipoprotein alterations.

Another option for androgen replacement therapy is dehydroepiandrosterone (DHEA). DHEA can increase bone mineral density, provides estrogenic stimulation of vaginal cytology and enhances the immune system. However, results of a randomized, controlled trial indicated that libido, mood, dysphoria, cognition and well-being did not improve. At higher doses, DHEA can have adverse effects on lipoprotein levels, cortisol, glucose tolerance and central obesity. According to the ACOG committee, some DHEA products may have virilizing effects and may be hepatotoxic.

Decreased libido has also been treated with sildenafil citrate. While anecdotal experiences have been described, there have been no reported controlled trials or other studies to document the efficacy of sildenafil.

The ACOG committee concludes that while androgen therapy has been prescribed for sexual dysfunction for many years, data on the safety and efficacy are incomplete and this therapy has not been shown to consistently affect the libido. Patients most likely to benefit from androgen therapy are young women who have undergone oophorectomy. In general, lower doses of oral preparations are preferred, and appropriate monitoring for side effects, including lipoprotein alteration, should be done.


Copyright © 2001 by the American Academy of Family Physicians.
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