Clinical Briefs



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Am Fam Physician. 2004 Feb 1;69(3):745-749.

CDC Guidance Plan on SARS

The Centers for Disease Control and Prevention (CDC) has released a working draft version of its guidance plan for treating severe acute respiratory syndrome (SARS). “Public Health Guidance for Community-Level Pre-paredness and Response to Severe Acute Respiratory Syndrome”is available online at http://www.cdc.gov/ncidod/sars/sarsprepplan.htm.

The SARS plan is a working document that outlines the concepts and strategies that would guide the U.S. response in the event of a SARS outbreak. It also describes many of the activities needed at the federal, state, and local levels to prepare for and respond rapidly and decisively to a re-emergence of SARS. State and local health departments, hospitals, and public health professionals will have an opportunity to comment on the draft and provide input to an effective SARS preparedness plan for the United States.

The plan is designed to assist federal, state, and local public health partners in developing or coordinating their own SARS preparedness and response planning activities, while taking into account available health care and public health resources, and other factors that are unique at each level.

Updated information about SARS is available on the CDC's Web site at http://www.cdc.gov/ncidod/sars/. As of January 8, health authorities in China are treating one confirmed case and one suspected case of SARS infection in the southern province of Guangdong. At present, no epidemi-ologic evidence has linked the confirmed case with the suspected case. The possible source of exposure in both cases is under investigation.

ACEP Recommendations on Fever in Children

The Clinical Policies Committee and the Clinical Policies Subcommittee on Pediatric Fever of the American College of Emergency Physicians has published a statement on the diagnosis and treatment of fever in children younger than three years. “Clinical Policy for Children Younger Than Three Years Presenting to the Emergency Department With Fever” appears in the October 2003 issue of Annals of Emergency Medicine.

Fever is among the most common presenting complaints of children and infants presenting to the emergency department. In some cases, fever is a response to a serious or potentially life-threatening infection. The challenge for emergency physicians is differentiating the vast majority of children presenting with fever who will have an uneventful course from the indeterminate few who have serious infections with the risk of long-term morbidity and mortality.

The guidelines use a three-tier scale to indicate the strength of recommendations. Level A recommendations are those that are generally accepted for patient management, and that reflect a high degree of clinical certainty. Level B recommendations are those that may identify a particular strategy or range of management strategies that reflect moderate clinical certainty. Level C recommendations are based on preliminary, inconclusive, or conflicting evidence, or, in the absence of any published literature, based on panel consensus.

The following recommendations are given in the ACEP policy statement:

  • Infants between one and 28 days old with a fever should be presumed to have a serious bacterial infection. (Level A)

  • A response to antipyretic medication does not change the likelihood of a child having serious bacterial infection and should not be used for clinical decision-making. (Level A)

  • A chest radiograph should be obtained in febrile children younger than three months who have evidence of acute respiratory illness. (Level B)

  • A chest radiograph should be considered in children older than three months with a temperature higher than 39°C (102.2°F) and a white blood cell count (WBC) greater than 20,000 per mm3. A chest radiograph usually is not indicated in febrile children older than three months with a temperature lower than 39°C without clinical evidence of acute pulmonary disease. (Level C)

  • Children younger than one year with fever without a source should be considered at risk for a urinary tract infection (UTI). (Level A)

  • Females between one and two years of age presenting with fever without source should be considered at risk for having a UTI. (Level B).

  • Urethral catheterization and suprapubic aspiration are the best methods for diagnosing UTI. (Level B).

  • A urine culture should be obtained in conjunction with other urine studies when a UTI is suspected in a child younger than two years, because a negative urine dipstick or urinalysis result in a febrile child does not always exclude a UTI. (Level B).

  • Empiric antibiotic therapy should be considered for previously healthy, well-appearing children, three to 36 months of age, who have fever without a source (a temperature of 39°C or higher) when associated with a WBC of 15,000 per mm3 or greater, if obtained. (Level B).

  • When empiric antibiotics are not prescribed for children who have fever without a source, close follow-up must be ensured. (Level C)

Physical Activity Among Adults

The majority of U.S. adults were not physically active on a regular basis in 2000 or 2001, according to a report published by the Centers for Disease Control and Prevention (CDC). “Prevalence of Physical Activity, Including Lifestyle Activities Among Adults—United States, 2000-2001,” is available online at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5232a2.htm.

Guidelines for physical activity to increase cardiorespiratory fitness in adults have been expanded to include health-related lifestyle activities, in addition to leisure-time physical activity (primarily vigorous-intensity exercise or sports-related activities).

According to the report, even with a more complete measure of physical activity than used previously, the majority of U.S. adults do not engage in physical activities consistent with the recommendation of a minimum of 30 minutes of moderate-intensity activity on most days of the week. In 2000, a total of 26.2 percent of adults engaged in activities consistent with the physical activity recommendations, compared with 45.4 percent in 2001. Physical inactivity was similar in 2000 (27.4 percent) and in 2001 (26 percent).

The CDC notes that, because of changes to the 2001 survey, the difference in the proportion of adults who engaged in activities consistent with physical activity recommendations in 2000 and 2001 might not reflect an actual increase in physical activity. The percentage of adults who obtained the recommended level of physical activity, as indicated by responses to the 2001 questions, increased for several reasons.

First, the new 2001 lifestyle activity questions covered more activity domains (e.g., household, transportation, and leisure-time); the 2000 questions covered only the leisure-time domain. Second, the 2001 lifestyle activity questions attempted to profile the activities in a usual week rather than reporting the top two activities during the preceding month; therefore, less frequent activities that might not have been mentioned in the 2000 question format could be included in the 2001 overall activity profile. Finally, in 2001, respondents were asked specifically to recall moderate- and vigorous-intensity activities separately, thereby increasing the potential to recall less intense lifestyle activities.

CDC Report on Rabies

The Centers for Disease Control and Prevention (CDC) has released a report on the first human death associated with raccoon rabies. The report is available online at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5245a4.htm.

In March 2003, a previously healthy 25-year-old man from northern Virginia died from a diagnosed illness of meningoencephalitis of unknown etiology after a three-week illness. Subsequent testing confirmed a diagnosis of rabies. Genetic sequencing identified a rabies virus variant associated with raccoons, but how the patient became infected is unknown.

The CDC report summarizes the investigation of the first documented case of human rabies associated with a raccoon rabies virus variant in the United States, and highlights the importance of continued education in the prevention and diagnosis of rabies. Guidelines for care are available on the CDC Web site at http://www.cdc.gov/ncidod/dvrd/rabies/.

Progesterone to Prevent Preterm Birth

The Committee on Obstetric Practice of the American College of Obstetricians and Gynecologists (ACOG) has released a committee opinion on the use of progesterone to help prevent preterm delivery. Committee Opinion No. 291, “Use of Progesterone to Reduce Preterm Birth,” appears in the November 2003 issue ofObstetrics and Gynecology and is available online at http://www.acog.org.

According to the committee, progesterone may be used as treatment to help prevent preterm birth but should be restricted to pregnant women with a documented history of preterm birth before 37 weeks of gestation.

The committee opinion is based on two recent randomized placebo-controlled trials. One large study compared birth outcomes of a select group of high-risk pregnant women who were given a weekly intramuscular progesterone (17α-hydroxypro-gesterone caproate) injection beginning at 16 to 20 weeks of gestation through 36 weeks or until delivery, or a weekly placebo injection. All of the women had a history of previous spontaneous preterm birth at less than 37 weeks of gestation.

The study was halted early because the results showed a significant protection against preterm birth. Pregnant women who received the progesterone injection had up to 42 percent fewer premature births than women who received the placebo. A smaller study showed that pregnant women with histories of preterm deliveries who received vaginal progesterone suppositories also had a significantly lower preterm birth rate (2.7 percent), compared with a placebo group (18.6 percent).

Despite the apparent benefit of this formulation of progesterone in a specific subset of high-risk women, the ideal progesterone formulation remains unknown until further research is done. According to ACOG, more research is needed to determine if women with other high-risk factors, including multiple gestations, short cervical length, and a positive fetal fibronectin test, can benefit from progesterone treatment. Because the optimal route of drug delivery and the long-term safety of the treatment remain unknown, it is important to restrict this treatment to women with a documented history of spontaneous preterm birth at less than 37 weeks of gestation.



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