Clinical Briefs



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Am Fam Physician. 2004 Feb 15;69(4):997-1004.

Strategies to Prevent Juvenile Violence

The Task Force on Community Preventive Services of the Centers for Disease Control and Prevention has issued a report evaluating the effectiveness of early childhood home visitations on violence prevention. The report is available online at http://ww.cdc.gov/mmwr.

Juvenile violence is a substantial problem in the United States. In the past 25 years, juveniles have been involved in at least 25 percent of serious violent crimes. In 1999, suicide was the sixth leading cause of death in children five to 14 years of age and the third leading cause in persons aged 15 to 24 years. Early childhood home visitation has been used for a wide range of public health goals, including violence prevention and other health outcomes, as well as educational achievement, problem-solving skills, and greater access to social services and other resources.

The task force found that home visitations by trained personnel play an effective role in the reduction of child maltreatment, including abuse and neglect. The task force recommends that home visits be considered for families at risk for maltreatment of children. Studies reviewed by the group suggest that approximately 40 percent of episodes of child maltreatment may be prevented through early childhood home visits. Families considered at high risk of child maltreatment include those with low birth weight infants, or those with single, young, or low-income mothers.

Home visitation programs include training parents about prenatal and infant care, parenting, child abuse and neglect prevention, family planning assistance, and problem-solving and life skills for parents.

Scientific Exhibit Deadline for AAFP Assembly

A call for scientific exhibits has been issued by the American Academy of Family Physicians (AAFP) for presentation at the 2004 Scientific Assembly occurring October 14–16 in Orlando, Fla. Applications must be submitted by April 2. Scientific exhibits provide a forum for the presentation of research that is of interest and educational value to family physicians. Membership in the AAFP is not a prerequisite for submission. The exhibits include those presented by residents and medical students.

Travel grants of $1,000 may be awarded to a maximum of 15 resident/student scientific exhibitors whose applications are accepted for presentation at the Assembly. In addition, cash prizes and ribbons for first and second place and ribbons for third place will be awarded to the senior exhibitor of the family medicine resident and medical student poster presentations. Application forms may be obtained from Jeana Higginbottom, Scientific Program Department, AAFP, 11400 Tomahawk Creek Pkwy., Leawood, KS 66211; telephone: 800–274–2237, ext. 6564; or by visiting the AAFP Web site at http://www.aafp.org/x20696.xml.

Immunotherapy in Patients with Guillain-Barré Syndrome

The Quality Standards Subcommittee of the American Academy of Neurology (AAN) has issued a practice guideline on the use of immunotherapy in patients with Guillain-Barré syndrome. The recommendations are available in the September 2, 2003, issue of Neurology.

Guillain-Barré syndrome affects up to four per 100,000 persons annually, causing respiratory failure in approximately 25 percent, death in 4 to 15 percent, persistent disability in 20 percent, and persistent fatigue in 67 percent. The disease is estimated to cost $110,000 per patient for direct health care and $360,000 per patient in lost productivity.

The subcommittee performed a systematic review regarding the use of immunotherapy in patients with Guillain-Barré syndrome. It found that treatment with plasma exchange or intravenous immunoglobulin (IVIg) hastens recovery, but that combining these treatments is not beneficial.

The subcommittee recommends that nonambulatory adult patients who seek treatment within four weeks of the onset of neuropathic symptoms be treated with plasma exchange. Ambulatory patients examined within two weeks of the onset of symptoms also should be considered for plasma exchange. IVIg therapy is recommended for nonambulatory adult patients within two to four weeks of the onset of neuropathic symptoms. The effects of plasma exchange and IVIg therapy are equivalent. Corticosteroids and sequential treatment with plasma exchange followed by IVIg therapy is not recommended. Plasma exchange and IVIg therapy can be considered for children with severe Guillain-Barré syndrome.

AAP Policy on Soft Drinks in Schools

The Committee on School Health of the American Academy of Pediatrics (AAP) has issued a policy statement on soft drinks. “Soft Drinks in Schools” appears in the January 2004 issue ofPediatrics and is available online at http://pediatrics.aappublications.org/content/113/1/152.full.

The AAP recommends that school districts consider restricting the sale of soft drinks to safeguard against health problems that result from overconsumption.

According to the policy, sweetened drinks constitute the primary source of added sugar in the daily diet of children, and that each 12-oz serving of a carbonated, sweetened soft drink contains the equivalent of 10 teaspoons of sugar. Sugared soft drink consumption has been associated with increased risk of overweight and obesity, currently the most common medical condition of childhood, and dental cavities and potential enamel erosion.

The policy recommends that physicians work to eliminate sweetened soft drinks in schools. This entails educating school authorities, patients, and parents about the health ramifications of soft drink consumption.

The statement also recommends that physicians advocate for the creation of a school nutrition advisory council as one means of ensuring that the health and nutritional interests of students form the foundation of nutritional policies in schools.

As part of the effort to reduce consumption of soft drinks in schools, the policy recommends that vending machines not be placed within the cafeteria space where lunch is sold, and that soft drinks not be sold as part of, or in competition with, the school lunch program.

Call for Papers of Family Medicine Research Presentations

A call for papers has been issued by the American Academy of Family Physicians (AAFP) for presentation at the 2004 Scientific Assembly occurring October 13–17 in Orlando, Fla. Applications must be submitted by April 2. Membership in the AAFP is not a prerequisite for submission.

Applications may be submitted in two different categories. Category I is for original research relevant to family medicine; Category II includes case studies and literature reviews. Each category has six author classifications: family physicians and fellows primarily in academic medicine, family physicians primarily in clinical practice, family medicine residents, medical students, international attendees, and others. The international attendee classification is open to anyone outside the United States who conducted clinical or educational research relevant to family medicine.

Up to six first place winners in Category I and one first place winner in Category II will each receive a cash award of $1,000. Up to six runners-up in Category I and one runner-up in Category II will receive $250 cash awards. All awards are given at the discretion of the Subcommittee on Family Medicine Research Presentations. Application forms may be obtained by visiting the AAFP Web site at http://www.aafp.org/x20696.xml or from Carrie Vickers, Scientific Program Department, AAFP, 11400 Tomahawk Creek Pkwy., Leawood, KS 66211; telephone: 800–274–2237, ext. 6568 or cvickers@aafp.org.

IOM Report on Cancer Prevention

The Institute of Medicine (IOM) of the National Cancer Policy Board (NCPB) has released a new report on cancer prevention. “Fulfilling the Potential of Cancer Prevention and Early Detection” is available online at http://www.nap.edu/books/0309082544/html.

According to the report, an estimated 100,000 new cases of cancer and 60,000 deaths could be prevented each year by 2015 if more Americans used the cancer prevention and early detection knowledge and recommendations currently available.

The report suggests that to save the most lives from cancer, physicians should concentrate their resources on helping people to stop smoking, maintain a healthy weight and diet, exercise regularly, and keep alcohol consumption at low to moderate levels. The IOM report also reviews the evidence supporting interventions for cancer prevention and early detection, and recommends that federal and state legislatures enact and provide funding for enforcement of laws to substantially reduce and ultimately eliminate the adverse public health consequences of tobacco use and exposure; develop a national strategy to address the epidemic of obesity, unhealthy diet, and physical inactivity; and increase funding for programs that provide primary care to uninsured and low-income people.

AHA/ADA Statement on Congestive Heart Failure

The American Heart Association and the American Diabetes Association have released a consensus statement on congestive heart failure. “Thiazolidinedione Use, Fluid Retention, and Congestive Heart Failure” appears in the December 9, 2003, issue ofCirculation and is available online at http://www.circulationaha.org.

Numerous drugs have been introduced for the treatment of type 2 diabetes that are effective in lowering blood glucose levels to achieve glycemic goals. Two such drugs, rosiglitazone and pioglitazone, belong to the class called thiazolidinediones (TZDs). Both agents are indicated either as monotherapy or in combination with a sulfonylurea, metformin, or insulin, when diet, exercise, and a single agent do not result in adequate glycemic control. Both agents may benefit cardiovascular parameters, such as lipid levels, blood pressure, inflammatory biomarkers, endothelial function, and fibrinolytic status. However, evidence is lacking regarding clinical outcomes such as vascular disease and mortality.

These potentially beneficial effects have made them a therapeutic option in patients with type 2 diabetes who are at high risk for cardiovascular disease. However, edema can occur in patients who take either drug. The edema that sometimes accompanies the use of a TZD can be cause for concern, because it may be a harbinger or sign of congestive heart failure (CHF). Physicians should be aware of the safety profile of TZDs in patients with and without underlying heart disease.

Before prescribing TZD treatment, the committee recommends that physicians:

  1. Ascertain whether the patient has underlying cardiac disease.

  2. Note whether the patient is taking any drugs associated with fluid retention or pedal edema.

  3. Evaluate the pathogenesis of edema that may be already present to be sure that CHF is not present at the time the TZD is prescribed. The presence of edema, when not caused by CHF, is not a contraindication for TZD use. However, if present, the degree of edema should be monitored carefully during TZD administration.

  4. Determine whether the patient has any shortness of breath, particularly with exertion, that might be associated with cardiac or other causes so that an adequate assessment of baseline symptoms is established. Patients with these symptoms should be monitored carefully, particularly in the first three months of TZD treatment.

  5. Review most recent electrocardiogram (ECG) findings, if indicated. The ECG may show a clinically silent myocardial infarction or left ventricular hypertrophy.

  6. Instruct the patient before initiation of TZD to report any new sign or symptom during the course of treatment, such as weight gain, pedal edema, shortness of breath, or fatigue without other apparent cause.

Regarding use of TZD therapy in patients with diabetes and without symptomatic heart disease, the committee recommends the following:

  • Both pioglitazone and rosiglitazone should be prescribed according to the package insert guideline for each drug. It should be recognized that weight gain and/or edema will be encountered more often in patients receiving concomitant insulin treatment.

  • When a TZD is prescribed to patients who do not have established heart disease, but have one or more risk factors for CHF, the physician should consider starting with low doses and increasing the dosage gradually as required to optimize glycemic control, while observing for any signs of excessive weight gain, peripheral edema, or CHF.

  • In patients who do not have symptoms or signs of CHF but are known to have a depressed ejection fraction, TZDs may be used at the lower dosage range of each drug. Dosages can be adjusted gradually after several months of treatment to optimize glycemic control with careful observation for edema and symptoms and signs of CHF.

Regarding use of TZDs in patients with diabetes and symptomatic heart disease, the committee recommends the following:

  • In patients with class I or II New York Heart Association (NYHA) CHF categories, TZDs may be used cautiously, with initiation of treatment at the lower dosage of each drug. Observation with gradual dose escalation is warranted to identify weight gain, edema, or an exacerbation of CHF. The physician should allow more time than usual to achieve a target A1C in these patients.

  • In patients with symptoms and signs of NYHA class III or IV CHF, TZDs should not be used at this time.

Additional recommendations for monitoring patients who receive TZD therapy are given in the statement.

Role of Warfarin in Stroke Prevention

The American Heart Association, the American Stroke Association, and the Stroke Council have released an advisory statement on stoke prevention.“Role of Warfarin in Primary or Secondary Stroke Prevention” is available online at http://www.strokeassociation.org/presenter.jhtml?identifier=3007546.

Warfarin is not superior to aspirin for preventing a second stroke in patients with noncardioembolic stroke, as reported in the Warfarin-Aspirin Recurrent Stroke Study (WARSS). The primary end point of the WARSS trial was recurrent stroke or death from any cause within two years of blinded treatment with warfarin or aspirin. WARSS found no significant difference between the two treatment groups in recurrent ischemic stroke, death, or serious hemorrhage. Even in cases of so called “aspirin failure” (patients who had a stroke while taking aspirin before entering the study), warfarin was no better than aspirin in preventing recurrent stroke. For prevention of secondary stroke in patients with normal heart function and rhythm, warfarin given to achieve any International Normalized Ratio level is more costly and difficult to manage than aspirin.

Warfarin remains the treatment of choice for patients with nonvalvular atrial fibrillation (NVAF) with prior transient ischemic attack or stroke who can take it safely, and for selected NVAF high-risk patients for primary prevention, as well as patients with high risk of cerebral embolization associated with a cardiac valvular prosthesis constructed of synthetic materials. Patients with NVAF who take warfarin to achieve an INR range of 2.0 to 3.0 have stroke reduced by 65 percent compared with no antithrombotic therapy, and by 45 percent compared with aspirin treatment. Prospective trials comparing use of warfarin to aspirin in other disorders with increased stroke risk are ongoing. Until these studies are completed and published, the current data support aspirin and/or other antiplatelet agents, rather than warfarin, as treatments of choice for most patients to prevent recurrent noncardioembolic stroke.

AMA Guide on Obesity Management

The American Medical Association (AMA) has released a new guide to help physicians identify and treat obesity in their adult patients. “Assessment and Management of Adult Obesity: A Primer for Physicians” is available free of charge at http://www.ama-assn.org/ama/pub/category/10931.html.

The guide offers practical advice on evaluating patients for current and potential health risks related to weight, beginning with a body mass index measurement; recommendations for weight management through healthy eating and physical activity; information on surgical and pharmacotherapeutic options; suggestions for improving communication and counseling; and tips for making the office environment friendlier to overweight and obese patients. In addition, the guide provides tools to help physicians integrate obesity management into their everyday practice.


Copyright © 2004 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

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