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Am Fam Physician. 2002;66(9):1781-1784

Updated Post-Event Smallpox Response Plan and Guidelines

The Centers for Disease Control and Prevention (CDC) has released an updated version of the post-event Smallpox Response Plan and Guidelines. The guidelines are available online at

Version 3 of the guidelines contains the “Smallpox Vaccination Clinic Guide.”This guide provides the operation and logistic considerations associated with implementing a large-scale, voluntary vaccination program as part of a multifaceted response to a confirmed smallpox outbreak. Following a confirmed smallpox outbreak within the United States, rapid, voluntary vaccination of a large segment of the population might be required to (1) supplement priority surveillance and containment control strategies in areas with smallpox cases, (2) reduce the at-risk population for additional intentional releases of smallpox virus if the probability of such occurrences is considered significant, and (3) address heightened public concerns about access to voluntary vaccination.

According to the guidelines, the most important component of smallpox containment is the rapid identification, isolation, and vaccination of close contacts of infected patients and contacts of their contacts (i.e., ring vaccination). This strategy involves identification of infected persons through intensive surveillance, isolation of infected persons, vaccination of household contacts and other close contacts of infected persons (i.e., primary contacts), and vaccination of household and other potential contacts of the primary contacts (i.e., secondary contacts).

The clinic guide can assist planning for larger-scale, post-event vaccination when exposure circumstances indicate the need to supplement the ring vaccination approach with broader protective measures. The clinic guide describes the activities and staffing needs associated with large-scale smallpox vaccination clinics, including suggested protocols for vaccine safety monitoring and treatment. The clinic guide provides an example of a model smallpox clinic and provides samples of pertinent clinic consent forms and patient information sheets that would be used.

Obstetric Management of Patients with Spinal Cord Injuries

The Committee on Obstetric Practice of the American College of Obstetricians and Gynecologists has issued an opinion paper on obstetric management of patients with spinal cord injuries. Committee Opinion no. 275 appears in the September 2002 issue of Obstetrics and Gynecology.

Effective rehabilitation and modern reproductive technology may increase the number of women considering pregnancy who have spinal cord injuries (SCIs). Women with SCIs who are considering pregnancy should have a preconception evaluation. Chronic medical conditions and the woman's adaption to her disability must be evaluated. Baseline pulmonary function and renal studies may be appropriate. Fertility in these patients usually is not affected, and family planning should be discussed.

Physicians caring for such patients should acquaint themselves with the problems related to SCIs that may occur throughout pregnancy. Common complications affecting women with SCIs include urinary tract infections, decubital ulcers, impaired pulmonary function, and autonomic dysreflexia. Additional potential complications include anemia, deep vein thrombosis, pulmonary emboli, and unattended delivery.

Autonomic dysreflexia is the most significant medical complication seen in women with SCIs, and precautions should be taken to avoid stimuli that can lead to this potentially fatal syndrome.

For all patients, elevation of the legs and range-of-motion exercises may be implemented as pregnancy advances.

Women with SCIs may give birth vaginally. Women with spinal cord transection above the T10 segment may have painless labor. In a patient with total transection at a lower thoracic level, labor pain may be so reduced that the patient is unaware of the uterine contractions, especially during sleep. However, symptoms under the control of the sympathetic nervous system (e.g., abdominal or leg spasms, shortness of breath, increased spasticity) concurrent with uterine contractions may make patients aware of labor. Patients should be instructed in uterine palpation techniques to detect contractions at home. When cesarean delivery is indicated, adequate anesthesia (spinal or epidural, if possible) is needed.

The possibility of an increased need for social support services should also be addressed.

AAP Report on Maltreatment of Children

The American Academy of Pediatrics (AAP) has issued a technical report that identifies parents' actions that may amount to psychologic maltreatment of children, as well as the consequences of such actions. “The Psychological Maltreatment of Children” is available online at

According to the report, psychologic maltreatment is a repeated pattern of damaging interactions between parent(s) and child that becomes typical of the relationship.

Psychologic maltreatment makes a child feel worthless, unloved, endangered, or as if his or her only value is in meeting someone else's needs. Some examples include belittling, degrading, or ridiculing a child; terrorizing a child by committing life-threatening acts or making him or her feel unsafe; exploiting or corrupting a child; failing to express affection, caring, and love; and neglecting mental health, medical, or educational needs. When such behaviors are severe and/or repetitious, children may experience problems that include the following: emotional troubles ranging from low self-esteem to suicidal thoughts; antisocial behaviors; low academic achievement; and impaired physical health.

Because negative effects on the child can be reduced with early recognition, reporting, and therapy, the AAP report says physicians should recognize psychologic maltreatment and the risk factors that predispose families to it.

NCI Call for Lung Cancer Study Participants

In September, the National Cancer Institute (NCI) launched a new study to determine if screening people with either spiral computed tomography (CT) or chest radiography before they have symptoms can reduce deaths from lung cancer. The National Lung Screening Trial (NLST) will enroll 50,000 current or former smokers and will take place at 30 sites throughout the United States.

To carry out the trial, the NCI is using two research networks: one network has been conducting the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial, and the other is the American College of Radiology Imaging Network (ACRIN), a network of researchers who conduct imaging studies.

Participants will be randomly assigned to receive either a chest radiograph or a spiral CT scan once a year for three years. Researchers will continue to contact participants annually to monitor their health until 2009. There is no cost to participate.

Men and women can participate if they meet the following requirements:

  • Are current or former smokers between the ages of 55 and 74 years.

  • Have never had lung cancer and have not had any cancer within the past five years (except skin cancer or in situ cancers).

  • Are not currently enrolled in any other cancer screening or cancer prevention trial.

  • Have not had a CT scan of the chest or lungs within the last 18 months.

Additional information about the NLST is available by calling the NCI's Cancer Information Service at 800-4-CANCER (800-422-6237), and online at

IOM Report on Diet and Chronic Disease Prevention

The National Academies' Institute of Medicine has issued a report on recommendations for healthy eating and exercise to reduce risk of chronic diseases. “Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids” is available free of charge online at Printed copies are available for purchase from the National Academies Press by calling 800-624-6242.

To meet the body's daily energy and nutritional needs while minimizing risk for chronic disease, adults should get 45 to 65 percent of their calories from carbohydrates, 20 to 35 percent from fat, and 10 to 35 percent from protein.

To maintain cardiovascular health at a maximal level, regardless of weight, adults and children also should spend a total of at least one hour each day in moderately intense physical activity, which is double the daily minimum goal set by the 1996 Surgeon General's report.

Because carbohydrates, fat, and protein all serve as energy sources and can substitute for one another to some extent to meet caloric needs, the recommended ranges for consuming these nutrients should be useful and flexible for dietary planning. Earlier guidelines called for diets with 50 percent or more of carbohydrates, and 30 percent or less of fat; protein intake recommendations are the same.

The new acceptable ranges for children are similar to those for adults, except that infants and younger children need a slightly higher proportion of fat—25 to 40 percent of their caloric intake.

The report stresses the importance of balancing diet with physical activity, recommending total calories to be consumed by individuals of given heights, weights, and genders for each of four different levels of physical activity.

The new one-hour-a-day–total activity goal stems from studies of how much energy is expended on average each day by individuals who maintain a healthy weight. Energy expenditure is cumulative, including both low-intensity activities of daily life, such as stair climbing and house cleaning, and more vigorous exercise such as swimming and cycling. Someone in a largely sedentary occupation can achieve the new exercise goal by engaging in a moderate-intensity activity, such as walking at four miles per hour, for a total of 60 minutes every day, or engaging in a high-intensity activity, such as jogging for 20 to 30 minutes four to seven days per week.

Since the publication of the Recommended Dietary Allowances (RDAs) in 1989 and the Canadian Recommended Nutrient Intakes in 1990, new information has emerged about nutrient requirements that warrants the development of updated guidelines. This report develops new guidelines for the United States and Canada for the consumption of energy, carbohydrates, fiber, fat, fatty acids, cholesterol, protein, and amino acids, collectively known as macronutrients.

RDAs have served as the benchmarks of nutritional adequacy in the United States. New Dietary Reference Intakes (DRIs) are established using an expanded concept that includes indicators of good health and the prevention of chronic disease, as well as possible adverse effects of overconsumption. The authors assessed thousands of scientific studies linking excessive or inadequate consumption of fats, carbohydrates, and protein with increased risk for dietary deficiency diseases, obesity, heart disease, diabetes, and other chronic illnesses. The DRIs include not only recommended intakes, intended to help individuals meet their daily nutritional requirements, but also tolerable upper intake levels (ULs) that help them avoid harm from consuming too much of a nutrient.

The DRIs are designed to meet the needs of individuals who are healthy and free of specific diseases or conditions that may alter their daily nutritional requirements. It is expected that people known to have specific conditions or chronic diseases will get nutritional advice from their physician that is tailored to their special needs.

NIDA Drug Abuse Education Materials

The National Institute on Drug Abuse (NIDA) has released a new elementary school curriculum entitled “Brain Power! The NIDA Junior Scientists Program,” which is available online at Limited hard copies are available free of charge for second- and third-grade teachers.

The program is designed for use in second- and third-grade classrooms and focuses on the biologic effects of drug abuse on the body and the brain.

According to the NIDA, research has shown that the highest-risk periods for children initiating drug use are as they move from one developmental stage to another, or when they experience important transitions in their lives. The first big transition for children is when they leave the security of their families and enter school.

“Brain Power!” lays the foundation for future learning and substance abuse prevention efforts by providing children with a basis of knowledge and critical thinking skills.

Additional information is available by calling the National Clearinghouse for Alcohol and Drug Information at 800-729-6686. Ask about publication no. BPPACK.

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