Clinical Briefs



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Am Fam Physician. 2002 Sep 15;66(6):1110-1113.

AHA Cardiovascular Disease Prevention Guidelines

The American Heart Association (AHA) has updated its recommendations for cardiovascular disease prevention. “AHA Guidelines for Primary Prevention of Cardiovascular Disease and Stroke: 2002 Update” appear in the July 15 issue of Circulation.

To avert a first heart attack or stroke, physicians should begin “risk factor screening” as early as age 20 to assess patients' general risk of developing cardiovascular disease or strokes. Risk factor screening includes measuring blood pressure, body mass index, waist circumference, and pulse at least every two years and ordering cholesterol profiles and glucose testing at least every five years, beginning at age 20.

The AHA also recommends that physicians estimate the “global risk” of developing cardiovascular disease in the next decade for people age 40 years and older, or for anyone who has two or more risk factors.

Global risk estimation combines information from all existing risk factors to determine a person's percentage of risk for developing cardiovascular disease over 10 years. Multiple areas of slight risk can be more important than one area of very high risk. This estimation is recommended every five years for people age 40 years or older or for anyone with two or more risk factors.

The updated guidelines incorporate new findings and expert opinions that have emerged since the AHA published the recommendations in 1997. The guidelines also reflect recent data on the degree of risk imposed by specific risk factors and new efforts to categorize people more specifically according to their number and types of risk factors.

The AHA update integrates recommendations from other guideline-issuing organizations, such as the U.S. Preventive Services Task Force.

Guidelines for Employees with HIV, AIDS

The American College of Occupational and Environmental Medicine (ACOEM) has issued guidelines for dealing with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) in the workplace. The recommendations appear in the June 2002 Journal of Occupational and Environmental Medicine.

The recommendations address the role that physicians have within the context of the Americans with Disabilities Act of 1990 (ADA) and the Family Medical Leave Act of 1993 (FMLA). They also address issues specific to the health care industry, such as infected health care workers, exposure prevention, handling sensitive medical information, and prophylactic therapy.

Among the guidelines is a recommendation that a physician who performs preplacement medical examinations should ask newly hired employees if they are able to perform the essential functions of the job and determine whether any accommodations are necessary. The physician should not ask about HIV status, and HIV serologic screening should not be undertaken.

If an employee reports that he or she has AIDS or HIV, “reasonable accommodations” required by the ADA might include modifying facilities, restructuring jobs, changing schedules, or transferring marginal functions to another employee. The physician should work with administrative personnel to make sure that the accommodations are appropriately implemented but should not reveal the employee's health condition.

Health care workers who are infected with HIV or AIDS always should practice standard precautions, and workers who perform invasive procedures should know their own HIV status. The ACOEM does not recommend notifying patients of a health care worker's HIV status unless the worker has exposed the patient to the virus.

Physicians in practice settings where employees have potential bloodborne exposure should promote workplace education efforts that address standard precautions, proper use of medical devices, and procedures for immediate exposure triage.

Health care workers exposed to HIV-positive patients should be given retroviral medications and monitored for specific side effects associated with the medications. Prophylaxis should be administered for four weeks. Serologic follow-up to determine whether HIV seroconversion has occurred should be performed at six weeks, three months, and six months following exposure.

Updated National Vaccine Supply Shortages

The August 12,2002 update from the U.S. Centers for Disease Control and Prevention: only those vaccines included on the recommended childhood immunization schedule are included in this update.
Vaccine Shortage Expected duration Temporary change from routine recommendation

Hepatitis B1

No

Diphtheria, Tetanus, and Pertussis (DTaP)

No2

Tetanus and Diphtheria Toxoids (Td)

No

Haemophilus influenzae type b (Hib)1

See note3

Inactivated Polio (IPV)

No

Measles, Mumps, and Rubella (MMR)

No2

Varicella

No

Pneumococcal (PCV)

Yes

Last quarter of 2002 or later

Yes (see www.cdc.gov/mmwr/preview/mmwrhtml/mm5050a4.htm)

Hepatitis A

No


1— Two to four weeks are required to fill Hepatitis B/Hib combination orders. Full availability should return by fall 2002.

2— Vaccine supplies are sufficient to return to the routine schedule as recommended by the Advisory Committee on Immunization Practices (ACIP). However, additional vaccine is not available for ambitious recall or special initiative programs at this time.

3— Hib vaccine is available from Aventis Pasteur. Hib vaccine orders from Wyeth require up to 60 days to fill, and their supply is not likely to improve in 2002. Orders from Merck are taking 6 to 8 weeks to fill, with little improvement expected before December 2002.

Updated National Vaccine Supply Shortages

View Table

Updated National Vaccine Supply Shortages

The August 12,2002 update from the U.S. Centers for Disease Control and Prevention: only those vaccines included on the recommended childhood immunization schedule are included in this update.
Vaccine Shortage Expected duration Temporary change from routine recommendation

Hepatitis B1

No

Diphtheria, Tetanus, and Pertussis (DTaP)

No2

Tetanus and Diphtheria Toxoids (Td)

No

Haemophilus influenzae type b (Hib)1

See note3

Inactivated Polio (IPV)

No

Measles, Mumps, and Rubella (MMR)

No2

Varicella

No

Pneumococcal (PCV)

Yes

Last quarter of 2002 or later

Yes (see www.cdc.gov/mmwr/preview/mmwrhtml/mm5050a4.htm)

Hepatitis A

No


1— Two to four weeks are required to fill Hepatitis B/Hib combination orders. Full availability should return by fall 2002.

2— Vaccine supplies are sufficient to return to the routine schedule as recommended by the Advisory Committee on Immunization Practices (ACIP). However, additional vaccine is not available for ambitious recall or special initiative programs at this time.

3— Hib vaccine is available from Aventis Pasteur. Hib vaccine orders from Wyeth require up to 60 days to fill, and their supply is not likely to improve in 2002. Orders from Merck are taking 6 to 8 weeks to fill, with little improvement expected before December 2002.

ACOG Opinion Paper on VBAC

The Committee on Obstetric Practice of the American College of Obstetricians and Gynecologists (ACOG) has issued an opinion paper on induction of labor for vaginal birth after cesarean (VBAC) delivery. ACOG Committee Opinion No. 271 appears in the April 2002 issue of Obstetrics and Gynecology.

In an attempt to lower cesarean delivery rates in the United States, attention has been focused on increasing the percentage of VBACs. However, reports have suggested a significant risk of uterine rupture with poor outcomes for both the mother and infant attendant to VBAC attempts.

Although it is clear that the bulk of maternal and perinatal morbidity and mortality are caused by unsuccessful VBAC attempts, there are no reliable ways to predict whether a trial of labor will be successful in an individual patient. For these reasons, the safety of VBAC has been the subject of intense scrutiny.

The committee reviewed recent evidence and concluded that the risk of uterine rupture during VBAC attempts is substantially increased with the use of various prostaglandin cervical-ripening agents for the induction of labor, and their use is discouraged during VBAC attempts.

RSV Hospitalization Rates

Respiratory syncytial virus (RSV) bronchiolitis is the leading cause of hospitalization for infants under the age of one year, according to the study “Respiratory Syncytial Viruscoded Pediatric Hospitalizations, 1997 to 1999.” The study appears in the July 2002 issue of the Pediatric Infectious Disease Journal.

The study is based on National Hospital Discharge Survey (NHDS) data from 1997 to 1999, from the National Center for Health Statistics, Centers for Disease Control and Prevention. However, the true number of hospitalizations cannot be ascertained from available databases.

The study is the first to conclude that RSV causes the most infant hospitalizations in the United States. A number of studies have already documented that RSV is the most common cause of lower respiratory-tract infections in infants, and that premature infants and children with chronic lung disease are known to face a higher risk of hospitalization with RSV.

An estimated 280,730 infants younger than 12 months were identified as having a primary or secondary diagnosis of RSV between 1997 and 1999. This equals an incidence rate of 23.7 per 1,000 U.S. infants. RSV was the primary diagnosis in almost 260,000 of these cases.

The average hospital stay is 6.4 days for infants with RSV pneumonia and 3.5 days for infants with RSV bronchiolitis.



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