Clinical Briefs

Am Fam Physician. 2003 May 15;67(10):2227-2228.

EPA Report on Children's Health

The U.S. Environmental Protection Agency (EPA) has released its second report on trends in protecting children's health. “America's Children and the Environment: Measures of Contaminants, Body Burdens, and Illnesses” is available online at www.epa.gov.

Drawing on information from various sources, the report shows trends in environmental contaminant levels in air, water, food, and soil; concentrations of contaminants measured in the bodies of children and women; and childhood illnesses that may be influenced by exposure to environmental contaminants.

The report shows improvements in health statistics in areas where the federal government has taken steps to reduce environmental contamination and poisoning, such as reductions in levels of children's blood lead poisoning, exposure to environmental tobacco smoke, and exposures to excessive levels of air pollution and contaminants in drinking water.

The incidence of asthma in children has, however, doubled from 3.6 percent in 1980 to 7.5 percent in 1995. The percentage dropped in 1996 to about 6 percent but reached 8.7 percent by 2001. Approximately 6.3 million children in the United States have asthma. According to the report, the EPA is researching precisely why childhood asthma is increasing.

The EPA is concerned about children potentially being exposed to mercury in the womb. About 8 percent of women of childbearing age in the United States have concentrations of mercury in their body at levels of potential concern. Children born to women with blood concentrations of mercury above 5.8 parts per billion are at some risk of adverse health effects, including reduced developmental IQ and problems with motor skills, such as eye-to-hand coordination.

The EPA's report provides groundwork for the agency to develop policies and regulations to protect the environment.

FDA Approvals

  • Eplerenone. The U.S. Food and Drug Administration (FDA) has approved eplerenone (Inspra) for the treatment of high blood pressure.

Eplerenone works by selectively blocking aldosterone receptors. Clinical studies suggest that aldosterone contributes to the development and progression of hypertension. Eplerenone can be administered separately or in combination with other antihypertensive therapies.

Side effects include dizziness, fatigue, influenza-like symptoms, diarrhea, and cough. Eplerenone is contraindicated in persons with significant elevations of potassium, renal insufficiency, or diabetes associated with microalbuminuria, or who are taking potassium supplements or certain diuretics.

  • Adefovir dipivoxil. The FDA has approved adefovir dipivoxil (Hepsera) for the treatment of chronic hepatitis B in adults with evidence of active viral replication and evidence of persistent elevations in serum aminotransferases (ALT or AST) levels or histologically active disease.

Adefovir is a nucleotide analog agent that blocks the replication of the hepatitis B virus in the body.

Common side effects include asthenia (weakness), headache, abdominal pain, nausea, flatulence, diarrhea, and dyspepsia.

As with other antiviral therapies for chronic hepatitis B, physicians need to monitor liver function for exacerbation of hepatitis following discontinuation of therapy.

ACCP Guidelines on Lung Cancer Treatment

The American College of Chest Physicians (ACCP) has released new guidelines on lung cancer treatment, calling for a coordinated team approach to the continuum of care for patients with lung cancer. “Diagnosis and Management of Lung Cancer: ACCP Evidence-Based Guidelines” appears in the January 2003 edition of Chest and is available online at www.chestjournal.org.

Lung cancer is currently the leading cause of cancer deaths in men and women in the United States. Despite the less than optimal survival rate of patients with lung cancer, there are many treatment options that can extend and increase the quality of a patient's life, such as using a balanced approach to patient care that provides multidisciplinary expertise and treatment appropriate for the individual patient. The multidisciplinary team approach reflects a growing trend in the medical field, according to the ACCP.

Among the ACCP guidelines are the following recommendations:

  • All cancer units, treatment facilities, and centers should have a multidisciplinary lung cancer conference that meets on a regular basis.

  • All patients with known or suspected lung cancer should be referred to a multidisciplinary team of physicians or a physician with experience in the management of lung cancer.

  • For patients in whom tissue diagnosis or staging remains incomplete, referral should be made to a subspecialist with expertise in these areas. When completed, the choice of referral may vary with the interventions(s) proposed.

  • A multidisciplinary group is particularly valuable for management of patients who may be offered multimodality therapy.

  • Management decisions emanating from the multidisciplinary conference should be guided by locally agreed-on adaptations of clinical practice guidelines or other evidence.

  • All patients should be evaluated as potential candidates for clinical trials, and enrollment should be encouraged.

  • A specific coordinator of care should be identified to the patient and caregivers.

  • For patients with suspected lung cancer, evaluation, diagnosis, and treatment planning should be expedited.

  • Patients with lung cancer should receive clear, understandable information about their diagnosis, treatment, and possible outcomes. Patients and their families should be offered clear, full, prompt, and culturally appropriate information, preferably in both verbal and written form.

  • All health care professionals involved in the care of the patient should be aware of the management plan. This communication should include the clinical staging, what the patient has been told, and the proposed treatment plan.

  • For all patients with lung cancer, explicit guidelines for follow-up and surveillance after the initial treatment should be developed. It should be clear to the patients who will be supervising their ongoing care and surveillance. Patients should know how to access assistance for urgent problems.

  • For patients with lung cancer in whom death or a significant change in clinical status occurs, the primary care physician and all management team members should be advised. Likewise, the primary care physician should notify the management team and all interested parties if a change in clinical status of the patient should occur at home.

ACOG/AAP Report on Infant Brain Damage

The American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) have issued a report examining the possible causes of infant brain damage. “Neonatal Encephalopathy and Cerebral Palsy: Defining the Pathogenesis and Pathophysiology” is available online at www.acog.org or by calling ACOG at 800-762-2264, ext. 277 (ask for item AA432).

According to the report, the majority of newborn brain injury cases do not occur during labor and delivery. Rather, most instances of neonatal encephalopathy and cerebral palsy are attributable to events occurring before labor begins.

Neonatal encephalopathy is characterized by abnormal consciousness, poor muscle tone and reflexes, difficulty initiating or maintaining breathing, or seizures, and may or may not result in permanent neurologic impairment. In contrast, cerebral palsy is a chronic developmental disability of the central nervous system recognized by uncontrollable movement and posture.

The vast majority of neonatal encephalopathy and cerebral palsy cases originate from developmental or metabolic abnormalities, autoimmune and coagulation defects, infection, trauma, or combinations of these factors.

Newborn encephalopathy and cerebral palsy are associated with significant mortality rates and long-term morbidity and have been central in the assignment of blame in obstetric litigation. However, the report confirms that hypoxia during labor or delivery is not a significant cause in most of the cases of neonatal encephalopathy or cerebral palsy, with less than one fourth of infants with neonatal encephalopathy having any evidence of hypoxia during labor.

The report also concluded that an underlying event before labor was the primary factor for the adverse outcome in 70 percent of neonatal encephalopathy cases and was contributory in another 25 percent.


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