Clinical Briefs

Am Fam Physician. 2004 Jun 15;69(12):2933-2934.

Cases of Measles in Adopted Children from China

The Centers for Disease Control and Prevention (CDC) has released a report on recent cases of measles among adopted children from China. “Multistate Investigation of Measles Among Adoptees from China—April 2004” appears in the April 9, 2004, issue of Morbidity and Mortality Weekly Report and is available online at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm53d409a1.htm.

The Public Health Department of Seattle and King County, Washington, reported in early April a laboratory-confirmed case of measles in a recently adopted child from China. Public health authorities in Washington state notified the CDC, which collaborated with health officials in other states to locate other recently adopted children from China and contact their adoptive families.

A multistate investigation is ongoing and so far has identified six confirmed and three suspected cases of measles among adoptees from China, underscoring the need for physicians to remain vigilant for measles and other vaccine-preventable communicable diseases in children adopted from international regions.

The investigation determined that a group of 11 families traveled to China in March to adopt children. The group and their 12 adopted children remained together for approximately 10 days during the adoption process before departing for the United States on March 26. The 12 children were adopted from two orphanages in the Hunan Province. They traveled to five U.S. states. Eight traveled to Washington, and one each traveled to Alaska, Florida, Maryland, and New York.

Vaccination status or history of measles illness is not known for any of the 12 children. State and local health departments are continuing to investigate, seeking potential cases, identifying and evaluating potential contacts, and providing prophylaxis when indicated, as recommended by the Advisory Committee on Immunization Practices.

Although measles is no longer endemic in the United States, it continues to be imported. Maintaining high levels of vaccination coverage and strong surveillance in the United States is critical. During 2001, an outbreak among children adopted internationally resulted in 14 U.S. measles cases, 10 among adopted children and four among caregivers and siblings aged 28 months through 47 years.

Physicians should have a high index of suspicion for measles in persons with febrile rash illness from families who recently adopted children from abroad and among persons who have had close contact with children who recently were adopted from abroad. Suspected cases should be reported to the local health department.

Report on Causes of Death in the United States

The Centers for Disease Control and Prevention (CDC) has released a fact sheet on the actual causes of death in the United States for the year 2000, which ranks obesity as the number two cause of death after tobacco use. The fact sheet is available online at http://www.cdc.gov/nccdphp/factsheets/death_causes2000.htm.

The most common actual causes of death in the United States in 2000 were tobacco (435,000), poor diet and physical inactivity (400,000), alcohol consumption (85,000), microbial agents such as influenza and pneumonia (75,000), toxic agents such as pollutants and asbestos (55,000), motor vehicle accidents (43,000), firearms (29,000), sexual behavior (20,000), and illicit drug use (17,000).

The CDC has initiated numerous activities and programs aimed at addressing the behavior and lifestyle factors that contribute to deaths from leading causes, including heart disease, cancer, and stroke. These factors, such as smoking, poor nutrition, and physical inactivity, are called “actual causes of death.” Information about the CDC initiatives is available online at http://www.cdc.gov.

AUA Practice Guideline on Premature Ejaculation

The Practice Guidelines Committee of the American Urological Association (AUA) has released a new guideline on the treatment of premature ejaculation. “Premature Ejaculation: Guideline on the Pharmacologic Management of Premature Ejaculation” is available online at http://www.auanet.org/timssnet/products/guidelines/pme.cfm.

The guideline does not explicitly rate the strength of evidence for recommendations, but it is based on consensus opinion.

While survey findings vary considerably, most epidemiologic studies suggest that premature ejaculation may be the most common male sexual disorder, occurring in 21 percent of men ages 18 to 59 in the United States. There are two forms of premature ejaculation: a primary (lifelong) form that begins when a male first becomes sexually active, and a secondary (acquired) form.

Premature ejaculation is a self-reported diagnosis. A sexual history in which the patient uses language that explicitly communicates the circumstances of the condition is the fundamental basis of assessment, with time to ejaculation as the most important feature. The opinion of a partner can provide a significant contribution to diagnosis. A complete description is essential in distinguishing premature ejaculation from erectile dysfunction because these conditions frequently coexist. Moreover, some men are unaware that loss of erection after ejaculation is normal; thus, they may erroneously complain of erectile dysfunction when the actual problem is premature ejaculation. In patients with concomitant premature ejaculation and erectile dysfunction, the erectile dysfunction should be treated first.

Premature ejaculation can be treated with psychotherapy and behavioral therapy. This guideline is the first to address pharmacologic treatment. Although not approved by the U.S. Food and Drug Administration (FDA) for this indication, oral anti-depressants and topical anesthetic agents have been shown to delay ejaculation in men with premature ejaculation and have minimal side effects when used for this purpose (see accompanying table). Dosages and dosing regimens for premature ejaculation frequently deviate from those used for FDA-approved indications, and this difference should be considered in the risk-versus-benefit assessment of pharmacologic therapy. Treatment with specific oral antidepressants known to cause anorgasmia and delayed ejaculation should be started at the lowest possible dosage that is compatible with a reasonable chance of success.

Therapy Options for the Treatment of Premature Ejaculation

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Topical anesthetic agents may be applied to the penis before intercourse to delay ejaculation. After topical application, these agents have been used with and without a condom. Prolonged application of topical anesthetic (30 to 45 minutes) has been reported in a significant percentage of men to result in loss of erection because of numbness of the penis. Diffusion of residual topical anesthetic on the penis into the vaginal wall also may result in numbness in the partner.

The choice of additional therapy is based on the patient and partner reports of efficacy, side effects, and acceptance of the therapy as well as on a regular review of alternative approaches. Support and education of the patient and, when possible, the partner are an integral part of therapy for premature ejaculation.


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