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Am Fam Physician. 2000;61(5):1555-1562

Unintentional Injury in Native American Children

The Committee on Native American Children and the Committee on Injury and Poison Prevention of the American Academy of Pediatrics (AAP) completed a subject review of the prevention of unintentional injury among American Indian and Alaska Native children. The report appears in the December 1999 issue of Pediatrics.

According to the AAP, the high rate of mortality and morbidity from injury among American Indian and Alaska Native children must be addressed. More than 700,000 American Indian and Alaska Native children 19 years of age or younger live in the United States. Injury mortality rates for these children have decreased during the past 25 years but are still nearly double the injury rate for all children in the United States. Some of the risk factors for unintentional injury mortality among these children include poverty, alcohol abuse, substandard housing, limited access to emergency medical services, rural residences and low rates of seatbelt use.

The AAP urges physicians to do the following:

  • Form coalitions linking the Indian Health Service, the federal agency responsible for the health care of American Indian and Alaska Native persons, and tribal injury control specialists to determine the best way to introduce injury prevention strategies.

  • Respect tribal sovereignty and community-specific cultural factors when considering regulatory or legal approaches to injury prevention.

  • Assist in advocacy for tribal adoption of state motor vehicle safety laws for children and promote educational and media campaigns.

  • Support other child safety efforts, such as promoting bicycle helmet use, fire safety, firearm safety and the prevention of drowning and falls.

The AAP also suggests that physicians support federal funding efforts for monitoring epidemiology, research and injury control initiatives.

Report on Hormone Replacement Therapy

The American College of Preventive Medicine (ACPM) has issued a practice policy statement on perimenopausal and postmenopausal hormone replacement therapy, based on a review of current literature and recommendations. The statement appears in the October 1999 issue of the American Journal of Preventive Medicine.

According to the statement, menopause affects women in the United States at a median of 51 years of age. The estrogen loss at menopause is related to significant increases in the incidence of cardiovascular disease and osteoporotic fractures. Long-term estrogen replacement can reduce the risk of these pathologies. However, the ACPM reports that only 18 to 20 percent of postmenopausal women in the United States use hormone replacement therapy; of those, less than 30 percent are compliant. This noncompliance may be related to fear of side effects and associated risks, inconvenience and complications, such as venous thrombosis and uterine bleeding.

The ACPM concludes that the evidence is insufficient to make a generalized recommendation for or against the use of hormone replacement therapy by all menopausal women. They recommend that physicians always discuss the possible risks and benefits with all perimenopausal patients, and decide on a course of action based on the patient's risk-factor profile and preferences. For patients who have had breast cancer or thromboembolic disease, physicians should find alternative ways to reduce the risk of osteoporosis and cardiovascular disease. Newer synthetic estrogens have not been adequately studied, but preliminary evidence is positive. These agents may be appropriate in women with risk factors for cardiac disease or osteoporosis who are unwilling to accept the risk of breast cancer associated with conventional hormone replacement therapy.

Current evidence favors indefinite use of hormone replacement therapy once it has begun, but the risks of treatment over several decades are unknown. Physicians and patients should revisit the decision to use hormone replacement therapy at regular intervals, considering new data from randomized trials and the patient's response to treatment.

Report of the Drug Abuse Warning Network

The Substance Abuse and Mental Health Services Administration (SAMHSA) recently issued a report titled, “Year-End 1998 Emergency Department Data from the Drug Abuse Warning Network.” The report provides estimates of the number of drug-related emergency department visits or episodes in the United States and in 21 metropolitan areas. The report compares data from 1998 with the previous two years, and cites trends in substances that were most often mentioned during drug-related emergency department episodes from 1991 to 1998.

The report reveals that in 1998, an estimated 542,544 drug-related emergency department episodes occurred in the United States. There were 982,856 drug mentions in these episodes. Rates of drug-related emergency department visits were stable across gender, race/ethnicity and most age subgroups. Visits were down among 12 to 17 year olds, and up among persons 35 years of age and older. Frequently mentioned drugs included cocaine, heroine/morphine and marijuana/hashish. In 1998, suicide and dependence were the most frequently cited motives for taking substances, and overdose was the most frequently cited reason for visiting the emergency department. Of the 21 metropolitan areas covered in the report, only Dallas had a significant increase in overall drug-related emergency department episodes. The rest were unchanged.

According to Barry R. McCaffrey, director of the White House Office of National Drug Control Policy, “The overall finding that the number of drug-related hospital emergency department visits remains stable is encouraging. The decline in the number of young people entering hospitals with drug-related emergencies is an indicator that the country's team effort and National Drug Control Strategy are working. However, we must not let down our guard.”

McCaffrey continued, “This major sign of success has occurred because parents, teachers, coaches, ministers and community coalitions are all working together in a comprehensive national and local effort. The future should show additional improvements. The fact that the numbers are the best for the youngest (12 to 17 years) group in this and other recent surveys is a harbinger that use and the costly consequences will continue to fall as this group grows older.”

More information on this report is available on the SAMHSA Web site (

NCI Atlas of Cancer Mortality in America

The National Cancer Institute (NCI) has published a new atlas, the “Atlas of Cancer Mortality in the United States, 1950–94,” that shows the geographic patterns of cancer death rates in more than 3,000 counties in the United States over a period of 44 years. The atlas includes 254 color-coded maps to make identification of areas with high and low cancer rates easier. The maps also show patterns of cancer that might escape notice if larger areas were mapped. The NCI hopes that the atlas will provide important clues for more in-depth studies of the causes and management of cancer.

Previous atlases helped researchers to focus further studies in high-risk areas of the United States. Results of these studies are included in the new atlas. These findings include the following:

  • High rates of lung cancer among men in southern coastal areas were related to asbestos exposure from work in shipyards.

  • High mortality rates for oral and throat cancers among women living in the rural South were linked with the use of smokeless tobacco.

  • High mortality rates of esophageal cancer in Washington, D.C., and coastal areas of South Carolina were associated with alcohol consumption and tobacco use, along with deficiencies in fruit and vegetable consumption.

  • High mortality rates of lung cancer were seen among smelter workers and among persons who live close to arsenic-emitting smelters.

  • High mortality rates of colon cancer in eastern Nebraska occurred mainly among persons of Czechoslovakian heritage, in whom dietary factors appeared to contribute to the risk.

For the first time, sufficient data allow maps of white and black populations and the patterns for cancers of the liver and biliary tract to be shown.

To order a single copy of the atlas, contact the NCI Cancer Information Service at 800-4-CANCER (800-422-6237). A copy may also be ordered on the NCI Publications Locator Service Web site (

Prevention of Needlestick Injuries

The National Institute for Occupational Safety and Health (NIOSH) of the Centers for Disease Control and Prevention recently issued a new bulletin titled, “NIOSH Alert: Preventing Needlestick Injuries in Health Care Settings.” The bulletin is the first document from a federal agency to provide broad guidance and assistance to employers, workers and others in reducing needlestick injuries. The bulletin [DHHS (NIOSH) Publication No. 2000-108] was published in November 1999.

According to NIOSH, an estimated 600,000 to 800,000 occupational needlestick injuries happen each year. They can cause serious or potentially fatal infections with blood-borne pathogens such as hepatitis B virus, hepatitis C virus and human immunodeficiency virus.

The NIOSH bulletin includes an overview of needlestick injuries, background information, a discussion of the risk of infection and how needle-stick injuries occur, information on federal and state regulations, case reports, suggestions for prevention strategies, and safety recommendations for employers and employees.

The bulletin suggests eliminating the use of needles altogether where safe and effective alternatives are available. When these alternatives are not available, devices with safety features should be used. NIOSH gives examples of devices that may reduce the risk of needlesticks, but advises that no one device will be appropriate or effective for every workplace. Examples include needleless devices, such as connectors for intravenous delivery systems; devices in which safety features are part of the design; devices that operate passively without requiring user activation; devices in which the safety feature cannot be deactivated; and devices that perform reliably and are easy to use, practical, safe and effective.

Copies of the bulletin may be obtained at no charge by calling 800-35-NIOSH (800-356-4674). The document is also available on the NIOSH Web site (

AAP Report on Thimerosal in Childhood Vaccines

The Committee on Infectious Diseases and the Committee on Environmental Health of the American Academy of Pediatrics (AAP), in collaboration with the U.S. Public Health Service have issued a joint statement on the risks of thimerosal, a mercury-containing preservative used in some vaccines. The statement appears in the September 1999 issue of Pediatrics.

According to the AAP, thimerosal has been used in vaccines since the 1930s because of its effectiveness in killing bacteria and preventing bacterial contamination, especially in opened multidose containers. Some of the vaccines recommended for childhood immunization in the United States contain thimerosal. When normal doses of vaccines containing thimerosal have been given, hypersensitivity has been noted, but no other harmful effects have been reported. However, massive overdoses from inappropriate use of thimerosal-containing products have resulted in toxicity. The U.S. Food and Drug Administration (FDA) has determined that infants who receive thimerosal-containing vaccines at several visits may be exposed to more mercury than recommended by federal guidelines for total mercury exposure.

In response to the concern over mercury toxicity in children, the AAP committees made the following recommendations:

  • All children should be immunized against the diseases listed in the Recommended Childhood Immunization Schedule of the AAP, the American Academy of Family Physicians and the Advisory Committee on Immunization Practices.

  • The use of vaccines containing thimerosal should be reduced or eliminated. Benefits and risks of such vaccines should be discussed with parents. However, the use of vaccines containing thimerosal is preferable to withholding vaccination.

  • When available, Comvax, the only thimerosal-free hepatitis B vaccine, should be given to infants born to women who test negative for hepatitis B surface antigen, beginning at the two-month visit. If Comvax is not available, hepatitis B vaccination should begin at six months of age.

  • The FDA and vaccine manufacturers are asked to reduce or eliminate mercury-containing preservatives in vaccines.

  • Infants and children who have received thimerosal-containing vaccines do not require testing for mercury because the concentrations would be low and would not require treatment.

  • Physicians should counsel parents about reducing exposures to other sources of mercury.

Risk of HIV Infection in the Athletic Setting

The Committee on Sports Medicine and Fitness of the American Academy of Pediatrics (AAP) recently released a statement on the risk of infection with human immunodeficiency virus and other blood-borne viral pathogens in the athletic setting. The report appears in the December 1999 issue of Pediatrics.

Because athletes and athletic program staff members can be exposed to blood during athletic activity, they have a small risk of infection from human immunodeficiency virus, hepatitis B virus or hepatitis C virus. This update of a previous AAP position statement discusses sports participation for athletes infected with these pathogens and precautions that should be taken to lower the risk of infection to other persons in the athletic setting.

The following is a summary of the AAP committee recommendations:

  • Athletes with human immunodeficiency virus, hepatitis B virus or hepatitis C virus infection should be allowed to participate in all competitive sports.

  • The infection status of patients should be kept confidential. Confidentiality about an athlete's infection with a blood-borne pathogen is necessary to prevent exclusion of the athlete from sports because of inappropriate fear among others in the program.

  • Athletes should not be tested for blood-borne pathogens because they are sports participants.

  • Physicians should counsel athletes who are infected with human immunodeficiency virus, hepatitis B virus and hepatitis C virus that they have a very small risk of infecting other athletes. These athletes can then consider choosing a sport with a low risk of virus transmission. This will not only protect other participants from infection but also will protect the infected athletes themselves by reducing their possible exposure to blood-borne pathogens other than the one(s) with which they are infected. Wrestling and boxing, a sport opposed by the AAP, probably have the greatest potential for contamination of injured skin by blood.

  • Athletic programs should inform athletes and their families that they have a very small risk of infection, but that the infection status of other players will remain confidential.

  • Physicians and athletic program staff should aggressively promote hepatitis B virus immunization of all persons who may be exposed to athletes' blood. If possible, all athletes should receive hepatitis B virus immunization; more than 95 percent of persons who receive this immunization will be protected against infection.

  • Coaches and athletic trainers should receive training in first aid and emergency care, and in the prevention of transmission of pathogens in the athletic setting.

  • Coaches and health care team members should teach athletes about the precautions listed above and about high-risk activities that may cause transmission of blood-borne pathogens. Sexual activity and needle sharing during the use of illicit drugs, including anabolic steroids, carry a high risk of viral transmission. Athletes should be told not to share personal items, such as razors, toothbrushes and nail clippers, that might be contaminated with blood.

  • In some states, depending on state law, schools may be required to comply with the Occupational Safety and Health Administration (OSHA) regulations for the prevention of transmission of blood-borne pathogens. The rules that apply must be determined by each athletic program. Compliance with OSHA regulations is a reasonable and recommended precaution, even if it is not required by the state.

The AAP committee also recommends that the following precautions be taken in sports with direct body contact and sports in which an athlete's blood or other bodily fluids may contaminate the skin or mucous membranes of other participants or staff members of the athletic program:

  • Athletes should cover existing cuts, abrasions, wounds or other areas of broken skin with an occlusive dressing before and during participation. Caregivers must also cover their own damaged skin to prevent transmission of infection to or from an injured athlete.

  • Disposable, water-impervious vinyl or latex gloves should be worn to avoid contact with blood or other bodily fluids visibly tinged with blood and any object contaminated with these fluids. Hands should be cleaned with soap and water or an alcohol-based antiseptic handwash as soon as gloves are removed.

  • Athletes with active bleeding should be removed from competition immediately and bleeding should be stopped. Wounds should be cleaned with soap and water or skin antiseptics. Wounds should be covered with an occlusive dressing that remains intact during further play before athletes return to competition.

  • Athletes should be told to report injuries and wounds in a timely fashion before or during competition.

  • Minor cuts or abrasions that are not bleeding do not require interruption of play but can be cleaned and covered during scheduled breaks. During breaks, if an athlete's equipment or uniform is wet with blood, the equipment should be cleaned and disinfected and the uniform should be replaced.

  • Equipment and playing areas contaminated with blood should be cleaned and disinfected with an appropriate germicide. The decontaminated equipment or area should be in contact with the germicide for at least 30 seconds. The area may be wiped with a disposable cloth after the minimum contact time or be allowed to air dry.

  • Emergency care should not be delayed because gloves or other protective equipment is not available. If the caregiver does not have appropriate protective equipment, a towel may be used to cover the wound until a location off the playing field is reached and gloves can be obtained.

  • Breathing bags and oral airways should be available for giving resuscitation. Mouth to mouth resuscitation is recommended only if this equipment is not available.

  • Equipment handlers, laundry personnel and janitorial staff should be trained in the proper procedures for handling washable or disposable materials contaminated with blood.

Obstructive Sleep Apnea in Adults

The Health Technology Advisory Committee (HTAC) has published a report on the treatment of obstructive sleep apnea in adults. HTAC was established in 1992 by the Minnesota state legislature. It is an independent, nonpartisan advisory body that evaluates new and emerging health care technologies based on existing scientific research and technology assessments.

The report provides information on obstructive sleep apnea, evaluation of the evidence used to compile the report, diagnosis and monitoring of the disorder, treatment options and related costs and cost-effectiveness.

The HTAC committee offers the following recommendations:

  • The presence and extent of obstructive sleep apnea should be documented by established methods. Conditions that may exacerbate sleep apnea should be treated.

  • In cases that are uncomplicated and nonemergent, conservative treatment is suggested. This may include decreased use of alcohol or sedatives, sleeping in the lateral position and weight loss in overweight patients.

  • In clinically significant cases, nasal continuous positive airway pressure should be used before considering surgery.

  • Patients requiring surgery should be educated about the success rates, complications and late failure rates of each possible procedure.

  • Patients must consult with their physician to identify the sleep disorder facility appropriate for their needs.

This report and others published by HTAC may be obtained by calling 651-282-6374 or by sending an e-mail to There is no charge for the reports. All HTAC reports are also available through the World Wide Web (

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Copyright © 2000 by the American Academy of Family Physicians.

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