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Am Fam Physician. 1999;60(3):1023-1029

HIV Screening

The American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) have issued a joint statement in support of a recommendation from the Institute of Medicine for universal testing for human immunodeficiency virus (HIV) infection with patient notification as a routine component of prenatal care. While recognizing that some states may have laws that prevent physicians from following the recommendation at this time, AAP and ACOG encourage physicians “to include counseling as a routine part of care, but not as a prerequisite for and barrier to prenatal HIV testing.” The statement appears in the July 1999 issue of Pediatrics.

Pioglitazone for Type 2 Diabetes

The U.S. Food and Drug Administration (FDA) has approved pioglitazone (Actos) as monotherapy for patients with type 2 diabetes mellitus (formerly known as non–insulin-dependent diabetes). Pioglitazone is a new drug in the class of thiazolidinediones. It is also labeled for use in combination with sulfonylureas, metformin or insulin in patients who do not achieve adequate diabetes control using these agents alone.

In clinical trials of more than 2,300 patients, pioglitazone was shown to improve the ability of the patients to use insulin. Pioglitazone was well tolerated. Side effects included headache, upper respiratory tract infections and muscle pain.

The FDA recommends checking liver enzymes at the start of therapy and every two months during the first year. After the first year, testing should continue periodically. Symptoms suggesting liver problems may include unexplained nausea, vomiting, abdominal pain, fatigue, anorexia, dark urine and jaundice.

Thimerosal in Vaccines: A Joint Statement

Because of the potential that some children could be exposed to a cumulative level of mercury from the administration of vaccines during the first six months of life that exceeds federal guidelines, the American Academy of Pediatrics (AAP) and the Public Health Services (PHS) are recommending actions to ensure that thimerosal be removed from vaccines as soon as possible while maintaining the current high vaccination coverage levels throughout the entire childhood population. Some of the vaccines routinely recommended for children contain thimerosal.

The statement appears in the July 9, 1999, issue of Morbidity and Mortality Weekly Report. The AAP and the PHS are taking the following six actions:

  • A formal request to manufacturers for a clear commitment and a plan to eliminate or reduce as expeditiously as possible the mercury content of their vaccines.

  • A review of pertinent data in a public workshop.

  • Expedited review by the U.S. Food and Drug Administration of manufacturers' supplements to their product license applications to eliminate or reduce the mercury content of a vaccine.

  • Provide information to clinicians and public health professionals to enable them to communicate effectively with parents and consumer groups about thimerosal in vaccines.

  • Monitoring immunization practice, future immunization coverage, and vaccine-preventable disease levels.

  • Studies to better understand the risks and benefits of this safety assessment.

The PHS and AAP continue to recommend that all children receive the immunizations indicated in the recommended immunization schedule, given that the risks of not vaccinating children outweigh the unknown and much smaller risk of exposure to mercury.

The American Academy of Family Physicians has issued a statement supporting the actions of the AAP and the PHS in regard to thimerosal in vaccines.

Dehydration and Aging

Older persons and their families need to know about the age-related changes in hydrational needs to prevent disturbances in fluid balance, according to a statement from the American College of Sports Medicine (ACSM). As a person ages, the body's mechanisms that regulate water content become compromised. The ability to respond to dehydration and thirst sensations is also reduced with aging. Other factors, such as hormonal changes that occur during menopause, can exacerbate the problem.

According to the ACSM, the decreased ability to regulate fluid balance in older persons can lead to increased risk of dysfunction, morbidity or mortality. Many people of all ages do not drink enough water to replace their original fluid deficit. In older persons, thirst cannot be used as a reliable indicator of fluid requirements.

The mailing address for the ACSM is P.O. Box 1440, Indianapolis, IN 46206-1440; telephone: 317-637-9200; fax: 317-634-7817.

Postponement of Rotavirus Vaccine Use

In a report published in the July 16, 1999, issue of Morbidity and Mortality Weekly Report, the Centers for Disease Control and Prevention (CDC) recommends postponing administration of the rotavirus vaccine (Rotashield) to children scheduled to receive the vaccine before November 1999, including those who already have begun the rotavirus vaccine series. The recommendation was made after 15 cases of intussusception in infants who had received rotavirus vaccine were reported to the Vaccine Adverse Event Reporting System (VAERS). The report summarizes the clinical and epidemiologic features of these cases and preliminary data from ongoing studies of intussusception and rotavirus vaccine.

Of the 15 infants with intussusception reported to VAERS, 13 had intussusception following the first dose of the three-dose rotavirus series, and 12 had symptoms within one week of receiving a dose of rotavirus. The median age of the infants was three months; all recovered.

More data on the association of the rotavirus vaccine with cases of intussusception are anticipated within several months. Health care professionals should consider the diagnosis of intussusception in infants who have recently received the rotavirus vaccine and who present with a consistent clinical syndrome. Early diagnosis may increase the chance of successful treatment without surgery. Intussusception and other adverse events following vaccination with Rotashield should be reported to VAERS. Case report forms can be requested 24 hours a day by telephone (800-822-7967). Forms are also available on the World Wide Web (

FDA Warning on HIV Tests Purchased on the Internet

The Federal Trade Commission (FTC) has issued a warning that the home kits for testing for human immunodeficiency virus (HIV) infection that can be purchased over the Internet might give false-negative results. The FTC issued the warning after officials purchased such kits and found that negative results were received using samples that the FTC knew were positive.

The FTC recommends that health care professionals advise their patients against relying on self-diagnosis of HIV status and, instead, have safe, reliable HIV tesing performed by a medical professional or by using the HIV home collection test system (Home Access Express HIV-1 Test System) that is approved by the U.S. Food and Drug Administration.

More information is available on the U.S. Consumer Gateway Web site (

NCI Monograph on Cancer Research in Native American Populations

The National Cancer Institute (NCI) has released a monograph that summarizes the NCI's nationwide effort to address cancer prevention and control needs of the Native American population.“Native Outreach: A Report to American Indian, Alaska Native and Native Hawaiian Communities” documents the findings from seven of eight studies that were funded by the NCI between 1989 and 1996. Cancer rates among Native Americans varied greatly between the smaller groups of Native Americans. The leading cause of cancer cases and deaths among American Indian, Alaska Native and Hawaiian women was breast cancer. The leading cause of cancer cases and deaths among Alaska Native and Hawaiian men was lung cancer, while the leading cause of cancer cases and deaths among American Indian men was prostate cancer.

The monograph is targeted to community leaders and health care professionals. Single copies of the report (National Institutes of Health [NIH] publication 98-4341) and an executive summary (NIH publication 99-4341S) are available from NCI's Cancer Information Service at 800-4-CANCER.

Epilepsy Foundation Brochure on Surgical Intervention for Intractable Seizures

The Epilepsy Foundation has written a brochure that discusses the types of surgical intervention available for patients with epilepsy. Cautioning that not all persons with epilepsy are good candidates for surgery for intractable seizures, the Epilepsy Foundation brochure discusses the three major types of surgery: lobectomies (the removal of all or part of the lobes on either side of the head), hemispherectomies (removal of all or almost all of one side of the brain) and corpus callosotomies (cutting the nerve fibers connecting one side of the brain to the other). The brochure also explains the various types of presurgical evaluation tests.

Single copies of the brochure are available free of charge by calling 800-332-1000. Additional copies can be purchased by calling 800-213-5821.

Maternal Mortality in Black and White Women

Although the nation's infant mortality rate has steadily declined over the past decade, the percentage of women who die of complications from childbirth has remained essentially unchanged (7.5 deaths per 100,000 live-born infants), and black women are four times more likely to die of complications from childbirth than white women, according to a report in the June 18, 1999, issue of Morbidity and Mortality Weekly Report. The report presents state-specific maternal mortality ratios from 1987 through 1996 and focuses on the disparities in maternal mortality between black and white women.

In the report, maternal deaths were defined as deaths that occurred during pregnancy or within 42 days after pregnancy termination from any cause related to or aggravated by the pregnancy. The three leading causes of pregnancy-related death, according to the report, were hemorrhage, pregnancy-induced hypertension and embolism. Black women are at greater risk than white women for dying from all pregnancy-related complications. The report notes that health care access and use do not fully explain this disproportionate risk.

The CDC recommends that all states establish maternal mortality review committees to help identify and investigate the factors that may contribute to maternal deaths; it is recommended that the committees share the findings of these investigations and provide recommendations for preventing future mortality.

The CDC also recommends public health surveillance and research to clarify the disparity in maternal mortality between black and white women and to guide appropriate interventions and improvements in maternal health care.

AAP Statement on Iron-Fortified Infant Formulas

Infants who are not breast-fed or who are partially breast-fed should receive an iron-fortified formula from the age of birth to 12 months, according to a new statement from the American Academy of Pediatrics (AAP). The formula should contain between 4.0 and 12.0 mg per L of iron, states the AAP. Published in the July 1999 issue of Pediatrics, the statement emphasizes that human milk is the preferred feeding for all infants, but the AAP recognizes that most infants in the United States are not breast-fed beyond three months of age.

The statement discusses iron requirements during the first year of life, the rationale for iron-fortified infant formulas, iron concentrations in low-iron versus iron-fortified cow's milk formulas, causes of resistance to the use of iron-fortified formulas, iron fortification and gastrointestinal distress, continued manufacture of low-iron formulas, iron content of human milk, labeling requirements and potential contraindications to iron-fortified formulas.

The AAP discourages the use of low-iron infant formulas and believes they should not be used to treat colic, constipation, cramps or gastroesophageal reflux. The AAP recommends that parents and health care clinicians be educated about the role of iron in infant growth and cognitive development.

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Copyright © 1999 by the American Academy of Family Physicians.

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