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Am Fam Physician. 1998;58(2):575-583

Report on High School Students and Smoking

During the past six years, the overall prevalence of smoking among high school students has increased by nearly one third, according to results of a study released by the Centers for Disease Control and Prevention. The study, “Tobacco Use Among High School Students—United States, 1997,” reported data from the 1997 Youth Risk Behavior Survey, which measured cigarette, smokeless tobacco and cigar use among more than 16,000 students in grades nine to 12. The study found that nearly one half (48.2 percent) of male students and more than one third of female students reported using cigarettes, cigars or smokeless tobacco in the past month. The report also noted that a consistent decrease in smoking once seen in young blacks has now reversed. The number of black students who reported cigarette smoking in the past month increased by an estimated 80 percent between 1991 and 1997. The popularity of cigars is high among high school students, with 22 percent reporting that they had smoked a cigar in the past month.

To obtain a copy of the survey, contact the Office on Smoking and Health at 770-488-5705 (press 2 for publications), or write Office on Smoking and Health, CDC, Mailstop K-50, 4770 Buford Hwy., N.E., Atlanta, GA 30341. The study is also available on the CDC Web site (

Antibiotics and Gynecologic Infection

The American College of Obstericians and Gynecologists (ACOG) has published an educational bulletin on the use of antibiotics in gynecologic infections (Educational Bulletin No. 237). The purpose of the report is to help physicians use antibiotics appropriately in the prevention and treatment of gynecologic infections.

According to ACOG, gynecologic infections fall into two categories: those attributed to sexually transmissible organisms and those caused by endogenous vaginal flora. The report is divided into two main sections: prophylaxis and treatment of postoperative pelvic infections.

The section on prophylaxis discusses hysterectomy, elective abortion, insertion of an intrauterine device, other procedures, procedures in women at risk for bacterial endocarditis, and bowel preparation. The treatment section discusses pelvic inflammatory disease, bacterial vaginosis, lower urinary tract infection and upper urinary tract infection.

The information below has been excerpted from the discussion of lower urinary tract infections:

ACOG categorizes lower urinary tract infections into acute uncomplicated cystitis, acute complicated cystitis or recurrent cystitis. Uncomplicated cystitis can be treated with a three-day antibiotic regimen. Three-day regimens of antibiotics are more effective than single-dose therapy, according to ACOG. The following three-day regimens should be taken orally every 12 hours: 100 mg of trimethoprim (Proloprim), 160/800 mg of trimethoprim-sulfamethoxazole (Bactrim) or 100 mg of nitrofurantoin (Macrodantin). Quinolones should be used for treating resistant strains, for treatment failures, in recurrent infection or in patients with infection who cannot take other antibiotics. A three-day regimen of trimethoprim-sulfamethoxazole is effective because of its ability to eradicate Escherichia coli from the urethra.

Ten- to 14-day regimens with one of the quinolones may be most effective in patients with complicated cystitis. Complicated lower urinary tract infections are defined by ACOG as those typically caused by bacteria that are resistant to a variety of antibiotics or by bacteria found in patients with metabolic, anatomic or functional abnormalities.

The cause of recurrent cystitis should be documented by culture. Such patients may be candidates for continuous or postcoital prophylaxis with nitrofurantoin, trimethoprim, trimethoprim-sulfamethoxazole, or cephalexin. In young patients, the possibility of an anatomic anomaly should be explored.

More information on ACOG educational bulletins, committee opinions and criteria sets can be obtained from ACOG, 409 12th St., S.W., P.O. Box 96920, Washington, D.C. 10090-6920; telephone: 800-762-2264.

Hospitalization of the Abused Child

The American Academy of Pediatrics (AAP) recommends that, when special facilities or services are not available for children who are suspected of being abused and neglected, these children should be hospitalized and the hospitalizations should be covered by third-party payers. This recommendation is in an AAP policy statement published in the April 1998 issue of Pediatrics. The AAP believes that third-party payers should consider the evaluation and treatment of hospitalized abuse victims to be medically necessary.

Although special crisis intervention centers or emergency shelters may be more cost-effective and socially appropriate for children suspected of being abused or neglected, there may be instances in which the hospital is the only option, such as in smaller communities or on days when special services are not available. Emergency physicians may need to admit child abuse victims to the hospital to determine the extent of the injury and to provide a safe haven from a potentially life-threatening situation. The hospital may also be the ideal setting for medical, social services and behavioral sciences personnel to observe parents and children interacting with each other.

National Cancer Institute Monograph on the Trends and Health Effects of Cigar Smoking

The National Cancer Institute (NCI) is offering a new monograph titled “Cigars: Health Effects and Trends.” According to the NCI, daily cigar smoking causes cancers of the lip, tongue, mouth, throat, larynx, esophagus and lung, as well as chronic obstructive pulmonary disease and coronary heart disease. The health effects of cigar smoking are the focus of one of the eight chapters. Additional topics include past and recent trends in cigar smoking, the toxic and carcinogenic compounds found in cigar smoke, the addictive potential of cigar smoking, marketing and advertising of cigars, and the policies regulating taxation, labeling and sale of cigars. The greatest increase in adult cigar smoking is in young and middle-aged white males (ages 18 to 44 years) with higher than average incomes and education.

The monograph points out that the risk of cancer in cigar smokers increases with the number of cigars smoked per day. Smoking three to four cigars per day increases the risk of oral cancers to 8.5 times the risk for nonsmokers; the risk for esophageal cancer is nearly four times that of nonsmokers.

A copy of the monograph is available by calling 800-4-CANCER. The report is also on the NCI Web site:; click on “public,” then on “prevention.”

IOM Report on Dietary Reference Intakes

All adults need 400 μg of folic acid daily in their diet, a level that many persons in the United States do not reach, according to the most recent report on Dietary Reference Intakes from the Institute of Medicine (IOM). The report, the second in a new series, provides Recommended Dietary Allowances (RDAs) and other dietary reference values for B vitamins, of which folate is one, and choline. The report emphasizes that it is especially important for women of childbearing age to include 400 μg per day of folic acid in their diet to reduce the risk of having a child with neural tube defects. These women should eat more foods fortified with folic acid or take vitamin supplements. The report also recommends that people older than 50 should get most of their recommended intake of vitamin B12 with synthetic B12 from fortified foods or vitamin supplements. Up to 30 percent of older adults lose their ability to adequately absorb the naturally occurring form of B12. The recommended intake of vitamin B12 for those older than 50 is 2.4 μg per day.

In addition to folate, the report recommends individual intakes for thiamin, riboflavin, niacin, vitamins B6 and B12, pantothenic acid, biotin and choline. The RDA levels of these vitamins are the same as those published in 1990.

The IOM established the tolerable upper intake level for vitamin B6 as 100 mg per day for adults, and for folic acid as 1,000 μg (1 mg) per day. For niacin, no more than 35 mg per day should be taken, and the upper level for choline is 3.5 g per day for adults. The IOM did not set upper limits for thiamin, riboflavin, vitamin B12, pantothenic acid and biotin. Extra caution is urged by the IOM with regard to excessive consumption of these vitamins.

Information on the report is available on the Internet at The report can also be ordered from the National Academy Press at 800-624-6242 or 202-334-3313. The cost is $40 plus shipping charges.

Ophthalmic Solution for Treatment of Glaucoma

The U.S. Food and Drug Administration has approved dorzolamide hydrochloridetimolol maleate ophthalmic solution (Cosopt) for the treatment of elevated intraocular pressure in patients with open-angle glaucoma or ocular hypertension who do not respond adequately to treatment with beta blockers alone. It is the first eye drop that combines a topical carbonic anhydrase inhibitor (Trusopt) and a topical beta-blocking agent (Timoptic). Each of the two components decreases elevated intraocular pressure in patients with open-angle glaucoma by reducing the secretion of fluids inside the eye.

In clinical studies, the combination ophthalmic solution administered twice daily reduced intraocular pressure more than that achieved when either component was used as the only therapy. The reduction was slightly less than that seen when both components were used individually in a concomitant daily treatment regimen of dorzolamide three times daily and timolol twice daily.

The combination therapy offers the convenience of two daily doses with just one drug regimen. It is contraindicated in patients with bronchial asthma and in those with a history of bronchial asthma, as well as in those with severe chronic obstructive pulmonary disease, certain heart conditions or hypersensitivity to any component of the product. The most common side effects were burning or stinging of the eyes, and changes in taste in up to 30 percent of patients. Only 5 percent of patients discontinued drug therapy as a result of side effects.

Alzheimer's Disease Genetic Fact Sheet

The Alzheimer's Disease Education and Referral (ADEAR) Center of the National Institute of Aging is offering a fact sheet that summarizes new knowledge about the genetics of Alzheimer's disease. Topics discussed in the fact sheet include genes, chromosomes, familial and sporadic Alzheimer's disease, apolipoprotein E (apoE) testing, confidentiality of genetic test results, public policy regarding apoE testing and current questions for researchers to explore. For a free copy of “Alzheimer's Disease Genetics Fact Sheet” (publication number Z129), call the ADEAR Center at 800-438-4380. The fact sheet is also available through the Center's Web site at

In-Line Skating Injuries

A policy statement from the American Academy of Pediatrics (AAP), published in the April 1998 issue of Pediatrics, addresses in-line skating and the increasing number of injuries and deaths occurring among young persons who participate in this sport. In 1996, an estimated 76,000 children and adolescents were injured while in-line skating and required treatment in the emergency department. According to the AAP, the most common reasons cited for injuries during in-line skating were losing one's balance because of a road defect or debris, being unable to stop, speeding out-of-control or doing a trick. The wrist is the most common site of injury, and most wrist injuries are fractures. Of the 36 children who have died since 1992 of injuries incurred while in-line skating, 31 had collided with a motor vehicle.

The AAP recommends that physicians give the following advice to patients and their families concerned with in-line skating:

  • Children and their parents should know that injuries are particularly common in novice skaters, roller hockey players and in those performing tricks.

  • Full protective gear needs to be worn at all times, including a helmet, wrist guards, knee pads and elbow pads. The helmet should be certified by the American National Standards Institute, the American Society for Testing and Materials, the Snell Memorial Foundation or the Consumer Product Safety Commission. Skaters performing tricks need special heavy-duty protection.

  • Outside skating should only take place on streets that are blocked off or closed to through traffic or on bike paths, sidewalks or specifically designated skating areas.

  • Children with large muscle motor skill or balance problems and those with any uncorrected hearing or vision problems should skate only in a protected environment.

  • Physicians should encourage state legislation requiring helmet use.

The AAP emphasizes that parents need to know both the benefits and the risks involved with in-line skating. Although the AAP believes that most children aged seven to eight years should have the necessary skills for in-line skating, parents and physicians need to consider each child's individual physical and behavioral development when determining if the child is ready.

Approval of Drug for Paget's Disease

Risedronate sodium tablets (Actonel) have received approval from the U.S. Food and Drug Administration for the treatment of Paget's disease of the bone. It is indicated to induce remission in patients with Paget's disease of the bone who have a level of serum alkaline phosphatase at least two times the upper limit of normal, are symptomatic or are at risk for future complications from the disease.

Risedronate works by preventing the abnormal breakdown of bone that occurs in patients with Paget's disease. In an 18-month clinical study of 123 patients with moderate to severe Paget's disease, risedronate therapy for two months induced disease remission in most of the patients. The drug was generally well tolerated. Reported side effects have usually been mild or moderate and generally have not required discontinuation of treatment. The most common adverse reactions observed in studies were arthralgia, diarrhea and headache. The occurrence of adverse effects was not associated with age, sex or race.

Risedronate should not be used in patients with hypocalcemia and in those with a known hypersensitivity to bisphosphonate therapy. Recommended dosage is 30 mg daily for two months.

Prevention Advice for International Travelers

Immunizations and prevention of diarrhea and malaria in persons traveling outside the United States are the focus of the April 24, 1998, issue of The Medical Letter. According to the report, the most common cause of traveler's diarrhea is infection with enterotoxigenic Escherichia coli. Travelers to areas where hygiene is poor should be told to avoid raw vegetables, fruit that they have not peeled themselves, foods that are not steaming hot, and tap water, including ice. Prophylaxis is generally not used, but physicians should tell patients to start treatment promptly when they first notice symptoms. The report suggests that if prophylaxis is recommended, treatment may include 500 mg once daily of ciprofloxacin (Cipro), 500 mg once daily of levofloxacin (Levaquin), 300 mg once daily of ofloxacin (Floxin) or 400 mg once daily of norfloxacin (Noroxin) for a maximum of three weeks. Bismuth subsalicylate (two tablets four times daily) can also be used, but it is not as effective, according to the report.

Monograph on Educational Strategies for Patients at High Risk for Acute Myocardial Infarction

A working group report of the National Heart Attack Alert Program of the National Heart, Lung, and Blood Institute (NHLBI) highlights the educational strategies necessary to keep patients who are at greater risk for an acute myocardial infarction from delaying seeking medical help for the signs and symptoms of a heart attack. “Educational Strategies to Prevent Prehospital Delay in Patients at High Risk for Acute Myocardial Infarction” identifies predictors of patient delay, emphasizes essential points to be covered with high-risk patients and discusses counseling opportunities in the clinical setting. It includes tools to be used by clinicians—including a reproducible patient advisory form, a telephone triage algorithm for medical office settings or clinics to use and a high-risk patient action plan.

The NHAAP is an education program of the NHLBI aimed to reduce death and disability from acute cardiac ischemia through faster identification and treatment of afflicted individuals. The program includes 41 major health organizations and federal agencies. Roger B. Rodrigue, M.D., represented the American Academy of Family Physicians and participated in the review and approval of the report.

A single copy of the full working group report (NIH Publication No. 97-3787F) can be ordered from the NHLBI Information Center, P.O. Box 30105, Bethesda, MD 20824-0105; telephone: 301-251-1222; fax: 301-251-1223. The full report is on the NHLBI Web site at

The immunizations covered in the report include cholera, hepatitis A, hepatitis B, Japanese encephalitis, measles, meningococcal disease, polio, rabies, tetanus and diphtheria, typhoid fever and yellow fever. A discussion of the prevention of malaria is also included in the report, accompanied by a table listing countries where there is a risk of malaria.

Automated information is available from the Centers for Disease Control and Prevention at 888-232-3228 or on the Internet at

Hypersensitivity Reactions to Chlorhexidine

The U.S. Food and Drug Administration has issued a warning about the potential for serious hypersensitivity reactions to chlorhexidine-impregnated medical devices. Anaphylactoid and other types of reactions have been reported with chlorhexidine used topically, intra-urethrally (as a lubricant on urinary catheters) and with chlorhexidine-impregnated catheters. In one study, six of 10 neonates weighing less than 1,000 g (2 lb, 3 oz) showed local hypersensitivity reactions to chlorhexidine gluconate-impregnated patches used to secure their central venous catheters.

The FDA recommends that patients who have a hypersensitivity reaction to a drug or medical device that contains a chlorhexidine compound be monitored carefully and given immediate respiratory and cardiovascular support as needed. Use of the drug or device should be discontinued immediately.

Physicians are asked to report any chlorhexidine hypersensitivity reactions in patients to the FDA by telephone at 800-FDA-1088, by fax at 800-FDA-0178 or by mail to Med Watch, FDA, HFA-2, 5600 Fishers Lane, Rockville, MD 20857-9787.

Report on Radon, Smoking and Lung Cancer

Smokers who are exposed to radon appear to be at an even greater risk for lung cancer, because the effects of smoking and of radon are stronger when the two factors are combined, according to a report by a committee of the National Research Council (NRC). The report, “Health Effects of Exposure to Radon,” examined data from 11 major studies of underground miners exposed to radon, and new epidemiologic data on lung cancer in the general population. The NRC estimates that exposure to indoor radon accounts for 15,400 to 21,800 of the estimated 157,400 lung cancer deaths each year in the United States. The majority of radon-related deaths occur among smokers.

The committee found that for both smokers and nonsmokers, the risk of developing lung cancer from radon is proportionate to the amount of exposure to radon. No evidence exists that shows a threshold of exposure below which levels are harmless. The committee concluded that the incidence of lung cancer in the general population, including that in smokers, can be reduced by limiting exposure to radon.

Copies of the report may be obtained from the National Academy Press ($75 plus shipping) by calling 202-334-3313 or 800-624-6242. A summary is also available on the Internet at

Hydroxyurea for Sickle Cell Anemia

Hydroxyurea (Droxia) has been approved by the U.S. Food and Drug Administration for the treatment of patients with sickle cell anemia. It is indicated for reducing “the frequency of painful crises and to reduce the need for transfusions in adult patients with sickle cell anemia with recurrent moderate to severe painful crises (generally at least three during the preceding 12 months).” It is the first drug approved for sickle cell anemia.

The manufacturer's label warns against the potential carcinogenicity of hydroxyurea. Side effects are hematologic, with neutropenia, and low reticulocyte and platelet recovery necessitating temporary cessation in almost all patients. Recovery usually occurs within two weeks. The label notes that blood counts must be tested every two weeks. The drug will be available in 200-mg, 300-mg and 400-mg capsules.

AHCPR Prevention Materials

Surgeon General David Satcher, M.D., Ph.D., has joined the Agency for Health Care Policy and Research (AHCPR) and the Office of Disease Prevention and Health Promotion in urging physicians, health care plans and consumers to work together to make prevention (screening, immunizations and counseling for health behavior change) a part of every health care visit.

Materials available from the Put Prevention Into Practice (PPIP) initiative were created to make it easier for clinicians and their office staff members to deliver recommended prevention services and to perform them properly. The “Clinician's Handbook of Preventive Services, 2nd Edition” includes summaries of recommendations for screening tests, immunizations and counseling for children and adolescents, and adults and older adults by major authorities, including the U.S. Preventive Services Task Force, federal health agencies, national professional organizations, national voluntary health organizations and the Canadian Task Force on the Periodic Health Examination. A pocket-size “Personal Health Guide” for adults and the “Child Health Guide” include record forms to prompt patients to receive and keep track of timely care.

The two health guides are available free (up to a combined order of 200) through the AHCPR Publications Clearinghouse by calling 800-358-9295 or writing the AHCPR Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907. The clinician's handbook can be ordered from the AHCPR Clearinghouse for $20. One copy each of the “Personal Health Guide” and the “Child Health Guide” are included with the handbook. These PPIP materials, as well as preventive care flow sheets and patient reminder postcards, will soon be available on AHCPR's Web site at

Treatment of Patients with Schizophrenia

Fewer than one half of persons undergoing treatment for schizophrenia are receiving appropriate doses of antipsychotic medications or appropriate psychosocial interventions, according to findings from a national study on schizophrenia funded by the Agency for Health Care Policy and Research (AHCPR) and the National Institute of Mental Health (NIMH). The study results and the “Schizophrenia Patient Outcomes Research Team (PORT) Treatment Recommendations” were published in the NIMH Schizophrenia Bulletin.

The evidence-based evaluation and recommendations are intended to educate health care professionals about more effective medical approaches to treat patients with schizophrenia. The study found that patient outcomes were better when a comprehensive and individualized strategy was adopted, combining proper dosages of appropriate medications, patient and family education and support, and, for high-risk patients, assertive community treatment.

Other findings include the following:

  • Minority patients were more likely to receive higher doses of antipsychotic medications and were less often prescribed an antidepressant when depressed.

  • Fewer than 10 percent of families of outpatients with schizophrenia receive education and support, even though most families are in regular contact with their relative who has schizophrenia.

  • Psychosocial treatments are often prescribed at the point of hospital discharge, but follow-up in the community is low.

The complete findings of the PORT study and recommendations are available from the NIMH at 301-443-4536. Reprints of the articles in the Schizophrenia Bulletin (AHCPR Publication 98-R036 and 98-R037) are also available from the AHCPR Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907; telephone: 800-358-9295. The reprints are on the Internet at

In response to these latest findings, the National Alliance for the Mentally Ill (NAMI) is offering the “Consumer and Family Guide to Schizophrenia Treatment.” The guide is designed to help consumers and their families become more skillful partners in treatment decisions. A copy may be ordered by calling the NAMI Helpline at 800-950-6264.

Capecitabine for Metastatic Breast Cancer

The U.S. Food and Drug Administration (FDA) has granted accelerated approval for capecitabine (Xeloda), the first approved oral anticancer drug for patients with metastatic breast cancer whose tumors are resistant to standard chemotherapy with paclitaxel and an anthracycline-containing regimen. As a condition of accelerated approval, ongoing studies are being performed to confirm clinical outcomes.

In a multicenter trial including 162 postmenopausal women with metastatic breast cancer, one out of four patients with difficult-to-treat tumors (a subset of 43 patients) had a reduction in tumor size of more than 50 percent. One patient had a complete remission. Median survival time in this group was more than one year.

The most frequently reported adverse effects were diarrhea, nausea, stomatitis, fatigue and hand-foot syndrome. Adjustment of the dosage alleviated these effects.

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