Am Fam Physician. 1999;60(6):1851-1857
Sterilization of Minors with Development Disabilities
The American Academy of Pediatrics (AAP) has updated a policy statement on the sterilization of minors with developmental disabilities to include males and females. The policy appears in the August 1999 issue of Pediatrics.
A decision to pursue sterilization of someone with developmental disabilities requires a careful assessment of the individual's capacity to make decisions, the consequences of reproduction for the persons and any child that might be born, the alternative means available to address the consequences of sexual maturation, and the applicable local, state and federal laws, according to the AAP statement. The following recommendations have been excerpted from the policy statement:
The AAP encourages physicians to explore the patient's and caregiver's understanding of the facts and implications of sexual maturation in persons with developmental disabilities as soon as the secondary sexual characteristics of puberty develop.
The AAP suggests that the focus should be on less radical options than sterilization whenever possible. The AAP encourages physicians to familiarize themselves with the resources in their community to which they might refer families for further information or for specialized education and counseling on such matters as appropriate expression of affection and sexual drives, effective menstrual hygiene, sexual abuse avoidance training and contraception.
Physicians should involve the minor with developmental disabilities in any reproductive decisions, and advocate for safe, alternative methods of contraception.
The minor with developmental disabilities should be included in all decision-making about reproduction issues, and their views respected insofar as they are capable of such participation.
Community-Acquired Drug-Resistant Disease
During the past two years, the Centers for Disease Control and Prevention (CDC) has received reports of more than 200 cases of community-acquired methicillin-resistant Staphylococcus aureus in persons in Minnesota and North Dakota without established risk factors. Four children who acquired methicillin-resistant S. aureus died (two of the children were from Minnesota and two from North Dakota). A report in the August 20, 1999 issue of Morbidity and Mortality Weekly Report describes the illnesses of the four children.
These fatalities caused by methicillin-resistant S. aureus are the first to be reported outside hospitals in the United States. None of the children had had any contact with anyone in a hospital or in a long-term care center. The children ranged in age from one to 13 years and had a variety of symptoms, including extremely high fever, rash, very low blood pressure and difficulty breathing. One child was black, one was American Indian, and two were Caucasian. Three were from rural areas, and one was from an urban area. All of the patients in this report were initially treated with a cephalosporin antibiotic.
According to the CDC, these four cases demonstrate the potential severity of community-acquired methicillin-resistant S. aureus infections. Betalactam antibiotics usually used in the treatment of various adult and pediatric infections are uniformly ineffective in treating methicillin-resistant S. aureus infections. The CDC recommends that physicians consider methicillin-resistant S. aureus infections in severe pediatric pneumonia or sepsis syndromes in areas where community-acquired methicillin-resistant S. aureus infections have been reported. The fact that these cases were from urban and rural areas and the racial diversity among these children suggest that methicillin-resistant S. aureus may be widespread, especially in this region of the country. The extent of this infection in other communities is not known. In critically ill patients with invasive infections, the CDC states that empiric treatment with vancomycin (in addition to a third-generation cephalosporin) pending culture results may be necessary in the treatment of cephalosporin-resistant Streptococcus pneumoniae or methicillin-resistant S. aureus.
Glucose Monitoring System for Persons with Diabetes
The U.S. Food and Drug Administration (FDA) has approved a new medical device that provides continuous measures of tissue glucose levels in adults with diabetes mellitus. The Continuous Glucose Monitoring System records tissue glucose levels at five-minute intervals for up to three days. The results can then be downloaded on a computer for review by a physician.
The monitoring system is intended for one-time or occasional testing. The information should supplement that obtained by standard fingerstick testing.
The FDA based its approval of the monitoring system on results of a multicenter study of more than 7,000 glucose readings in 62 adult patients with diabetes. Results showed that the system could help identify glucose trends and supplement standard readings.
The system was only approved for use in persons with type 1 diabetes mellitus (formerly known as insulin-dependent diabetes mellitus). Post-marketing studies will test the safety and effectiveness of the system in persons with other types of diabetes.
Zaleplon for Insomnia
The U.S Food and Drug Administration has approved zaleplon (Sonata) for the short-term treatment of adults with insomnia. Zaleplon is a nonbenzodiazepine hypnotic, the first in a new class of drugs called pyrazolopyrimidine. It has a unique mechanism of action that allows for flexible administration.
In clinical trials involving more than 2,800 persons, including persons ranging in age from 65 to 85 years, zaleplon was shown to be effective in helping the subjects fall asleep within 30 minutes. The medication was not associated with memory loss, difficulty concentrating or lack of motor coordination four hours after dosing.
Zaleplon has a short half-life of approximately one hour. It can be administered as needed, such as immediately before going to bed or after a patient has gone to bed and has experienced difficulty falling asleep, provided the patient remains in bed for at least four hours before becoming active again. If patients take zaleplon while still active, they may experience short-term memory impairment, hallucinations, impaired coordination, dizziness and light-headedness.
The most common side effects in the clinical trials were headache, drowsiness and dizziness. None of these were significantly different from those in subjects receiving a placebo.
The recommended dose for most adults under 65 years of age is one 10-mg capsule; for elderly patients, the recommended dose is one 5-mg capsule.
Nonoccupational HIV Postexposure Prophylaxis Registry
The National Nonoccupational HIV Postexposure Prophylaxis (PEP) Registry has been established to monitor isolated episodes of potential exposure to human immunodeficiency virus (HIV) through sexual activity, injecting-drug use and other nonoccupational events. Information is collected about the type of exposure, the decision to use or not use PEP, drugs taken, risk-reduction referrals made and results of HIV-antibody tests. No names or other identifying information will be collected. More information about the registry is available by calling the toll-free number (877-448-1737). Information can also be found on the registry's Web site (http://www.HIVpepregistry.org).
Rabeprazole for Reflux Disease and Duodenal Ulcers
A new proton pump inhibitor, rabeprazole sodium (Aciphex), has been approved by the U.S. Food and Drug Administration for healing of erosive gastroesophageal reflux disease (GERD), maintenance of healed erosive GERD and healing of duodenal ulcers. It has also been approved for the treatment of pathologic hypersecretory conditions, including Zollinger-Ellison syndrome.
Like other proton pump inhibitors, rabeprazole inhibits the action of the proton acid pump in the acid-secreting cells of the stomach lining. It is available in 20-mg, enteric-coated tablets to be taken once daily for most indications.
In clinical trials, rabeprazole significantly decreased intragastric acidity for each of four meal-related intervals and the 24-hour time period overall. The antisecretory effect began within one hour after oral administration. Headache was the most common side effect. Rabeprazole is contraindicated in patients with known sensitivity to rabeprazole, substituted benzimidazoles or any component of the formulation.
Guidelines for the Diagnosis and Treatment of Rhinitis
The Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology has issued guidelines for the diagnosis and management of rhinitis. The guidelines were published in the November 1998 issue of the Annals of Allergy, Asthma and Immunology. The task force that developed the guidelines was a national panel of allergist-immunologists representing the American College of Allergy, Asthma and Immunology, the American Academy of Allergy, Asthma and Immunology and the Joint Council on Allergy, Asthma and Immunology.
The guidelines state, “Rhinitis is defined as inflammation of the membranes lining the nose, and is characterized by nasal congestion, rhinorrhea, sneezing, itching of the nose and/or postnasal drainage.” The document includes a treatment algorithm and discussions of the differential diagnosis, evaluation and management of rhinitis.
The guidelines point out that some studies have shown the use of some first-generation antihistamines can cause serious health risks, including delayed reactions, decreased work performance and productivity, and problems maintaining focus. Based on these findings, the guidelines recommend that second-generation antihistamines, associated with lower risk of side effects than first-generation antihistamines, should usually be the first-line therapy for treatment of allergic rhinitis. The guidelines also cite evidence that rhinitis treatment, including use of antihistamines, oral decongestants and some prescription and nonprescription nose sprays, can improve asthma that frequently coexists with rhinitis. The use of cortisone steroid injections for rhinitis is discouraged.
A discussion of special diagnostic and therapeutic considerations in selected patient subsets is included in the practice parameter. Special subsets of patients include children, elderly patients, pregnant patients and athletes.