Prevent Sudden Death in Athletes

AHA Guidelines for Screening Student Athletes

Physician's First Watch for November 19, 2007

The American Heart Association has updated its guidelines for screening student athletes, last issued in 1996. The AHA says its panel's recommendations remain "virtually unaltered."

The guidelines, issued earlier this year, include the following:

• Routine use of 12-lead ECG is not recommended for mass screening, despite use of ECG in Europe, because the idea "is probably impractical and would require considerable resources [to perform and interpret them] that do not currently exist."
• A complete and cardiovascular-targeted personal and family history and physical exam (including brachial artery blood pressure) should be performed.
• High school athletes should undergo exams every 2 years; college athletes should be examined at matriculation and then every year thereafter.

(Last autumn, we reported that sudden death had decreased by almost 90% in Italy since implementation of a national screening program that included the routine use of ECG.)

AHA guideline (Free PDF)

Cosmetic Eyelash-Lengthener & Eye damage

Cosmetic Eyelash-Lengthener Seized

The FDA says U.S. marshals have seized more than 12,000 applicator tubes of Age Interve ntion Eyelash, a cosmetic promoted to increase eyelash growth, because of concerns it may cause eye damage.

In a press release the agency said that the product is an "adulterated cosmetic" because it contains bimatoprost (Lumigan), used to treat elevated intraocular pressure. In patients taking the prescription drug, the agency said the extra dose of bimatoprost may decrease the treatment's effectiveness, leading to optic nerve damage. Other side effects could include macular edema and uveitis.

The cosmetic's maker, Jan Marini Skin Research, responded that no cases of eye damage have been reported. It said it reformulated the product last year to remove bimatoprost and that "several other companies have copied [Marini's] discontinued product and continue to market their competing products with 'drug' claims for eyelash growth."

FDA announcement (Free)

Jan Marini Skin Research statement (Free)

Breast Cancer Genetic Differences

Biologic Differences in Breast Cancer Across Diverse Populations: An Expert Interview With Dr. Olufunmilayo Olopade

Olufunmilayo I. Olopade, MDMedscape Hematology-Oncology. 2007; ©2007 Medscape

Posted 10/30/2007

Editor's Note:

In the United States, breast cancer tumor characteristics -- including hormone receptor status and histology -- differ by race/ethnicity, and both biological and lifestyle factors are thought to contribute to these differences.^[1] Although genetic testing has enabled the identification of women at risk for the development of breast cancer, and it is now possible to identify different forms of breast cancer for which therapy can be individualized, differential access to and utilization of genetic counseling and cancer care exists among racial and ethnic minorities and remains to be addressed.^[2]

Following the 2007 Breast Cancer Symposium, held in San Francisco, California, in September, Medscape's Jill Chamberlain, Editorial Director, Hematology-Oncology, spoke about these issues with Olufunmilayo I. Olopade, MD, Professor of Hematology/Oncology, Department of Medicine, Pritzker School of Medicine; Walter L. Palmer Distinguished Service Professor, Department of Medicine and Human Genetics; and Director, Center for Clinical Cancer Genetics, University of Chicago Medical Center, Chicago, Illinois. Dr. Olopade's research has focused on biological differences in breast cancer across diverse populations within and outside of the United States.

Medscape: How has the genomic revolution impacted the diagnosis and treatment of breast cancer?

Dr. Olopade: It wasn't until the genomic revolution occurred that it was realized that physicians have treated breast cancer as a single disease when, in fact, from 5 to 7 categories of breast cancer exist. Today, because of the genomic revolution, our focus is on individualizing breast cancer treatment and learning more about individuals and their specific cancers using genomic analyses. An important goal is to identify breast cancer while it is local and curable, thus decreasing morbidity and costs.

Medscape: During your presentation at the 2007 Breast Cancer Symposium, you pointed out that race and area of origin are different factors that influence breast cancer. Would you explain that premise?

Dr. Olopade: As scientists, when we consider race, we should be thinking not only about color, but also about ancestry. For example, a patient may be African American, but her genetic material may be more European than African. Thus, we need to turn to a patient's ancestry, not race, to provide reliable information about genetic material and breast cancer risk.

I often use the example of Ashkenazi Jewish women, an ethnic population that is white but of eastern European descent. The prevalence of BRCA1 germline mutations is greater in the Ashkenazi Jewish population than in the general North American population.^[3] BRCA1 tumors have a distinct phenotype and are associated with a significantly lower level of HER-2/neu amplification. Thus, it is possible that BRCA1-associated and HER-2/neu highly amplified tumors progress through distinct molecular pathways. We are now using tumor phenotype and ancestry to identify individuals likely to benefit from BRCA1 testing.^[4]

Medscape: What is known about breast cancer in women of African descent?

Dr. Olopade: Women of African ancestry are more likely to be diagnosed with estrogen receptor-negative breast cancer than women of European ancestry. In a recent collaborative study in which gene expression was determined in breast cancer tissue from 378 women in Nigeria and Senegal and compared with a database of breast cancer tissue from more than 900 Canadian women, we found that breast cancers in African women were more likely to be estrogen receptor-negative.

Whereas in the United States, breast cancer typically occurs after menopause and usually affects women in their late 50s or early 60s, in Africa, breast cancer most commonly occurs in women in their late 40s. The rate and genetic profiles of breast cancers in African American women are likely to fall somewhere in between, with a slightly lower lifetime incidence of breast cancer than white women, but earlier onset and worse prognosis. African American women under the age of 35 have a 50% greater risk of developing breast cancer than white women of the same age group. This risk plateaus around the age of 50, and African American women over the age of 50 have less risk of developing breast cancer than white women.

Medscape: It is well known that triple-negative breast cancer has aggressive features and that patients with this form of the disease have a worse outcome than those with other breast cancer types. What are the population differences in triple-negative breast cancer?

Dr. Olopade: A number of studies have shown that triple-negative breast cancer is overrepresented in young African American women. In the Carolina Breast Cancer Study,^[5] a population-based, case-control study that oversampled premenopausal and African American women, triple-negative breast cancer was more prevalent among premenopausal African American women (39%) compared with postmenopausal African American women (14%) and non-African American women (15%) of any age (P < .001). In a study^[6] in which racial/ethnic differences in breast cancer incidence and outcome were examined in a large cohort of postmenopausal women who participated in the Women's Health Initiative, about 32% of African American women had triple-negative and poorly differentiated disease compared with rates of 10% to 17% in other ethnic groups.

Medscape: What are the clinical implications of these findings?

Dr. Olopade: Since most of the breast cancer screening guidelines used in the United States are based on studies that primarily included white women, we need to individualize breast cancer screening recommendations, inasmuch as current guidelines may not be optimal for African American women in whom breast cancer is less common but may develop earlier and progress rapidly. The practice of an annual mammogram beginning at age 50 may need to be adjusted based on individual risk assessment for women in all racial/ethnic groups.

In addition, since we know that all breast cancer is not the same, it is more critical for patients likely to develop aggressive types of breast cancer to have access to care than it is for those with more indolent forms of the disease. The practicing oncologist or radiologist -- or anyone else who cares for women with breast cancer -- should begin to focus on whether the individual patient has been diagnosed with a rapidly growing type of breast cancer, and treatment should not be unnecessarily delayed. A better understanding of breast cancer biology is crucial to developing and delivering tailored therapy to all patients. There's an intersection between biology and ensuring that oncologists aggressively treat certain forms of breast cancer rather than viewing the disease as a garden-variety cancer that can wait for treatment.

Medscape: How has the development of multigene assays facilitated the individualization of breast cancer treatment?

Dr. Olopade: The ability to examine thousands of genes using multigene assays has allowed us to learn that breast cancer is not one disease but rather multiple diseases. We are now using multigene assays for decision making in patients with breast cancer. We also know from genomic analysis that a certain proportion of outcome in a patient with breast cancer is contributed by that patient's genetic material as well as the genetic material from the tumor. Thus, it is important to know how the tumor develops within the patient.

Whenever a new genetic test is introduced, it is very important to determine how it performs in different populations. These newer multigene assays increasingly will be utilized and in the future will impact how oncologists practice. That is why it is important to educate both clinicians and patients about these tools and also to conduct more studies in diverse populations.

Medscape: As genomic research continues, what is likely to be the next advance?

Dr. Olopade: Right now, investigators are focusing on different treatments based on the results of genomic analysis. For example, we now know that women with HER2-positive breast cancer should receive trastuzumab because it is effective for that subgroup. However, there remain many different types of breast cancer for which we do not have specific drugs. In the near future, I believe that clinicians will have access to many new drugs targeted to different types of breast cancer. When that occurs, we will need to rely on genomic analysis to define which drug(s) should be given to the individual patient based on the breast cancer type and the toxicities they are expected to have.

Updated Adult Immunisation Schedule 2008 USA

Ann Intern Med. Published online October 18, 2007.

Varicella and zoster vaccines:

• • Varicella vaccine is now extended through all age groups on the age-based schedule.
  • Varicella vaccine is extended to include HIV-infected persons with CD4⁺ T lymphocyte counts of 200 cells/µL or greater.
  • The varicella footnote has been revised to clarify that birth before 1980 in immunocompromised persons is not considered evidence of immunity.
  • Laboratory-confirmed diagnosis is required as evidence of varicella immunity in a healthcare provider diagnosis of a mild or atypical case.
  • Zoster vaccine has been added to the age-based schedule indicating that the vaccine is indicated for those aged 60 years and older.
  • Zoster vaccine is indicated for all conditions except pregnancy, immunocompromising conditions, and HIV.
• Influenza vaccine:
  • Healthcare workers can receive either TIV or LAIV.
  • The indication for influenza vaccine has been extended to include asplenia in the medical and other indications schedule.
• HPV vaccine:
  • The HPV footnote has been revised to clarify evidence of previous infection.
  • The HPV vaccine is not specifically indicated based on medical conditions.
  • Efficacy and immunogenicity of the HPV vaccine may be lower in immunocompromised persons or in those with certain medical conditions.
• Meningococcal vaccine:
  • Persons remaining at increased risk for meningococcal infection may be indicated for revaccination.
  • 1 or more doses of meningococcal vaccine may be indicated.
• Other changes:
  • HIV is considered an immunocompromising condition and the medical indication column has now been split into those with CD4⁺ T lymphocyte counts of less than 200 cells/µL and 200 cells/µL or greater.
  • The indication of "CSF leaks" has been moved from the immunocompromising condition column heading to the footnote text.
  • The hepatitis A vaccine is indicted for recipients of clotting factor concentrate.
  • Hepatitis B vaccine footnote has been revised to delete persons who receive clotting factor concentrates as a risk group and to clarify the dose schedule for special formulation indications.
  • The indication "recipients of clotting factor concentrates" has been removed from the chronic liver disease column.
  • Chronic alcoholism has been added to medical and other indications for the pneumococcal vaccine.

Changes in the 2007-2008 schedule from the previous one are as follows:

• Varicella vaccine is recommended for all adults without evidence of immunity to varicella.
  
  
• Zoster vaccine has been added to the age-based schedule and is recommended for persons 60 years of age or older.
  
  
• Because not all of the vaccines are recommended based on medical indications, the title of the medical and other indications schedule has been changed to "Vaccines That May Be Indicated for Adults Based on Medical and Other Indications."
  
  
• In the medical and other indications schedule, the immunocompromising conditions column heading has been shortened by removing the list of specific immunocompromising conditions.
  
  
• In the medical and other indications schedule, the HIV infection column has been moved next to the immunocompromising conditions column. To draw attention to vaccine indications based on CD4⁺ T lymphocyte counts, the HIV column in the medical and other indications schedule has been split into CD4⁺ T lymphocyte count less than 200 cells/µL and 200 cells/µL or greater.
  
  
• The indication "recipients of clotting factor concentrates" has been removed from the heading for the chronic liver disease column, because only 1 vaccine, the hepatitis A vaccine, has this recommendation. The indication for the hepatitis A vaccine indication remains in the footnote.
  
  
• In the medical and other indications schedule, indications for varicella vaccine have been extended to include HIV-infected persons with CD4⁺ T lymphocyte counts of 200 cells/µL or greater.
  
  
• In the medical and other indications schedule, indications for influenza vaccination of healthcare personnel now note that healthcare workers can receive either trivalent inactivated influenza vaccine (TIV) or live, attenuated influenza vaccine (LAIV).
  
  
• In the medical and other indications schedule, indications for influenza vaccine have been extended to include the asplenia risk group.
  
  
• In the medical and other indications schedule, indications for meningococcal vaccine have been revised to note that 1 or more doses of vaccine may be needed.
  
  
• Zoster vaccine has been added to the medical and other indications schedule, and it is now recommended for all indications except pregnancy, immunocompromising conditions, and HIV. Zoster vaccine is specifically contraindicated for pregnancy, immunocompromising conditions, and HIV infection with CD4⁺ T lymphocyte count less than 200 cells/µL.
  
  
• Because the footnotes now primarily summarize the indications for vaccine use, language on vaccine contraindications in pregnancy has been removed from the footnotes of human papillomavirus (HPV); measles, mumps, rubella (MMR) vaccine; and varicella vaccine. Pregnancy contraindications appear in the body of the medical and other indications schedule.
  
  
• The footnote for HPV has been revised to clarify evidence of a previous infection, to note that the HPV vaccine is not specifically indicated based on medical conditions, and to point out that the efficacy and immunogenicity may be lower in immunocompromised persons or in persons with certain medical conditions.
  
  
• The footnote for varicella has been revised to indicate that birth before 1980 in immunocompromised persons is not considered evidence of immunity and to note that an epidemiologic link to a laboratory-confirmed case is required for evidence of immunity in a healthcare provider diagnosis of a mild or atypical case.
  
  
• In the footnote for pneumococcal (polysaccharide) vaccine, chronic alcoholism has been added to make it consistent with the column heading in the medical and other indications schedule, and the list of specific immunocompromising conditions has been deleted. The "CSF [cerebrospinal fluid] leaks" indication now appears in the footnote text instead of in the immunocompromising condition column.
  
  
• The footnote for hepatitis A vaccine has been revised to clarify the dose schedule.
  
  
• The footnote for hepatitis B vaccine has been revised to clarify the dose for special formulation indications and to no longer designate as risk group persons who receive clotting factor concentrates.
  
  
• The footnote for meningococcal vaccine has been revised to clarify that persons who remain at increased risk for infection may need to be revaccinated.
  
  
• Two additional footnotes have been added: one to reflect ACIP recommendations for herpes zoster vaccination for persons age 60 years or older, and one to cite a reference for the use of vaccines in persons with immunocompromising conditions.

"General information about adult vaccinations, including recommendations on vaccination of persons with HIV and other immunosuppressive conditions is available from state and local health departments and at www.cdc.gov/vaccines/default.htm," the study authors conclude. "Vaccine information statements are available at www.cdc.gov/vaccines/pubs/vis/default.htm. Persons can view, download, and print ACIP statements for each recommended vaccine and provisional vaccine recommendations at www.cdc.gov/vaccines/pubs/acip-list.htm."

Obesity increase Cancer risks

Medscape Medical news 2007 Oct 31 by Roxanne Nelson

There is convincing evidence that excess weight and obesity can increase the risk for 6 different cancers, colon, kidney, adenocarcinoma of esophagus and endometrium, postmenopausal breast cancer and pancreas according to report by American Institute for Cancer Research and the World Cancer Research fund

There is convincing evidence that the consumption of alcohol, red meat, and processed meat elevates cancer risk.

Alcohol is linked to the cancers of colon, breast, esophagus, mouth, larynx and pharynx.

Consumption of red meat (beef, pork, lamb) is linked to colorectal cancer - panel recommends limit consumption of red meat to 18 oz per week because evidence shows that for every 1.7 oz of red meat consumed per day the risk for cancer increases by 15%

Recommendation for processed meat (bacon, ham, sausage, lunch meat) is more stringent - panel unable to find a level at which the consumption can reliably be considered safe. for every 1.7 oz of processed meat consumed per day, the risk for colorectal cancer increases by 21%

for full article-


Cancer Risk Increased by Excess Body Fat, Red and Processed Meats, and Alcohol

Roxanne Nelson

October 31, 2007 — There is convincing evidence that excess weight and obesity can increase the risk for 6 different cancers, including those of the colon, kidney, and pancreas, according to a report issued by the American Institute for Cancer Research (AICR) and the World Cancer Research Fund. The second expert report, Food, Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective, considered to be the most comprehensive scientific analysis of cancer prevention and causation ever undertaken, also reported that there is convincing evidence that the consumption of alcohol, red meat, and processed meat elevates cancer risk.

"The most striking finding in the report is that excess body fat increases risk for numerous cancers. That is why body weight is the focus of our first recommendation," expert panel member W. Phillip T. James, MD, DSc, from the International Obesity Task Force, in London, United Kingdom, told journalists.

The document, which was written by an international expert panel, reviewed 7000 research studies over a 5-year period and classified the accumulated evidence for specific diet-cancer links. It is the second one to be published in the past 10 years and provides the most inclusive evidence to date linking cancer risk to diet, physical activity, and weight.

Although cancer is considered to be a disease of genes that are vulnerable to mutation, evidence indicates that only a small number of cancers are inherited, write the experts. Instead, it appears that environmental factors are the most important, and these can often be modified with a resultant reduction in risk. These factors include tobacco use, infectious agents, radiation, industrial chemicals, pollution, medications, nutrition, physical activity, and body composition.

One of the strongest findings in the report was that excess body fat is associated with an increased cancer risk and can increase the risk for 6 different types of the disease: colon, kidney, pancreas, adenocarcinoma of the esophagus and endometrium, and postmenopausal breast cancer. They also reported that alcohol is convincingly linked to a number of cancers, including those of the colon, breast, esophagus, and mouth, larynx and pharynx.

To combat excess weight and maintain a healthy body-mass index, the experts recommend limiting the intake of energy-dense foods, particularly those that are highly processed. These products tend to be high in sugar and fat and low in fiber. They also advise increasing physical activity and getting some exercise for at least 30 minutes a day. Physical activity not only helps individuals keep excess weight off, but it helps reduce the risk for cancer in its own right.

Evidence has also increased since the first report, issued in 1997, which links the consumption of red meat (beef, pork, and lamb) to colorectal cancer. The panel's recommendation is to limit the consumption of red meat to 18 ounces per week because, beyond this amount, evidence shows that for every additional 1.7 ounces of red meat consumed per day, the risk for cancer rises by 15%.

Their recommendation concerning the consumption of processed meats is even more stringent. Processed meats, such as bacon, ham, sausage, and lunch meat, should be avoided entirely; the panel was unable to find a level at which the consumption of these products can be reliably considered completely safe. For every 1.7 ounces of processed meat consumed per day, the risk for colorectal cancer rises by 21%.

Evidence also indicates that the majority of diets that are protective against cancer are made up primarily of foods of plant origin. Higher consumption of several plant foods might offer protection against cancers of various sites.

"We are recommending 5 servings or more of vegetables and fruit daily because, like physical activity, they pack a double whammy against cancer. Probable evidence indicates that they help reduce cancer risk on their own and, as low energy-dense foods, they help maintain a healthy weight, which the evidence shows has a big influence on cancer risk," Dr. James said during a press conference.

The panel also looked at factors that included birth weight, childbearing, breast-feeding, and adult height and found that they all can influence the risk for cancer. High birth weight is associated with an increased risk for premenopausal breast cancer, which is likely linked to excess body fat and the resultant hormonal changes.

Exclusive breast-feeding appears to offer protection for both mother and child. It can help lower the risk for breast cancer in women and also lower the risk of becoming overweight and obese in children.

"The evidence is uniformly strong on breast-feeding, and the fact that it offers cancer protection to both mothers and their children is why we made breast-feeding 1 of our 10 recommendations to prevent cancer," said expert panel member Walter J. Willett, MD, PhD, from the Harvard School of Public Health, in Boston, Massachusetts, at a press conference.

The panel also found an association between adult height and cancer risk. Tall adults appear to have a higher risk of colorectal and postmenopausal breast cancer, and there is some evidence linking tallness to an increased risk for ovarian, pancreatic, and premenopausal cancer.

The recommendations made in this report are applicable to cancer survivors when appropriate and unless otherwise advised by their healthcare practitioner. Because increasing numbers of cancer patients survive their disease and live long enough to develop new primary cancers or other chronic diseases, the expert panel believes that these recommendations can help reduce the risk.

Recommendations for Cancer Prevention

1. Be as lean as possible within the normal range of body weight.
2. Be physically active as part of everyday life.
3. Limit consumption of energy-dense foods; avoid sugary drinks.
4. Eat mostly foods of plant origin.
5. Limit intake of red meat; avoid processed meat.
6. Limit alcoholic drinks.
7. Limit consumption of salt; avoid moldy cereals (grains) or pulses (legumes).
8. Aim to meet nutritional needs through diet alone.

Special Population Recommendations

9. Mothers should breast-feed; children should be breast-fed.
10. Cancer survivors should follow the recommendations for cancer prevention.

World Cancer Research Fund/American Institute for Cancer Research. Food, Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective. Washington, DC: AICR; 2007.

Cervical Cancer Followup

Women still face cancer risk 25 years after treatment
(Risk of invasive cancer after treatment for cervical intraepithelial neoplasia grade 3: population based cohort study)
(Cervical intraepithelial neoplasia and higher long term risk of cancer)
http://www.bmj.com/onlinefirst_date.dtl


Cancer experts are now calling for cytological smears to be offered at regular intervals for at least 25 years after a woman has had severe dysplasia/CIS (carcinoma in situ).

CIS is not cancer but close to it as some cells look cancerous but are superficially in the mucosa (the soft skin-like layer that lines many body cavities such as the nasal and genital passages) and not in any tissue.

Researchers in Sweden studied data from the National Swedish Cancer Register, which included information recorded between 1958 and 2002 on 132,493 women who had a diagnosis of severe dysplasia/CIS.

They found that 881 women had developed cervical cancer and 111 women had vaginal cancer more than one year after the CIS diagnosis.

Women with such a diagnosis are more than twice as likely to develop cancer as the general female population.

They also found that there was an increasing risk of cervical cancer if the woman was older at the time of diagnosis, with a much higher risk for women aged over 50.

The risk also grew as the decades went by as the researchers found that women were twice as likely to develop invasive cervical cancer after diagnosis of CIS if that diagnosis was made in the period 1991-2000 as in the period 1958-1970. This could be due to changes in the forms of treatment in different decades.

The observed number of cases of women who developed vaginal cancer was almost seven times higher than expected

The authors say: "Although most women with high-grade dysplasia have been protected from invasive cancer it must be considered a failure of the medical service when women participate in screening, their pre-cancerous lesions are found and they subject themselves to treatment of those lesions, presumably participate in follow-up programmes and still develop invasive cancer."

They conclude that follow-up care has, so far, been insufficient and women should be offered cytological smears at regular intervals for at least 25 years after treatment. Long term follow up should not stop for women when they reach the age of 60 if they were older than 35-40 at the time of treatment for CIS.

This view is reiterated in accompanying BMJ editorial, which suggests that women treated for CIN3 should have long term screening, even if beyond the normal age limit of regular screening.

Contact:
Bjorn Strander, Senior Consultant, Department of Obstetrics and Gynecology, Sahlgren's Academy, University of Gothenburg, Sweden
Email: bjorn.strander@oc.gu.se

2 dose Measles Vaccine Protects up to 10yrs

Second Dose of Measles Vaccine in Childhood Protects for Up to 10 Years

News Author: Laurie Barclay, MD
CME Author: Penny Murata, MD


March 12, 2007 — Children in a rural area had low susceptibility rates to measles for as long as 10 years after a second dose of the measles vaccine, according to the results of a prospective study reported in the March issue of Archives of Pediatrics & Adolescent Medicine.

"Measles was declared eliminated from the United States in 2000, an achievement attributed to effective implementation of a routine 2-dose vaccination policy," write Charles W. LeBaron, MD, from the Centers for Disease Control and Prevention in Atlanta, Georgia, and colleagues

Stop Gaining Excess Weight - Simple Measures

Simple Measures Help Prevent Excess Weight Gain in Kids

Physician's First Watch for October 25, 2007

Small changes in activity and diet help overweight children limit their weight gain, a Pediatrics study reports.

Researchers randomized nearly 200 families with at least one child who was overweight (or at risk) either to a program that advocated taking an additional 2000 steps daily and reducing calories by 100 kcal or to a control group that simply self-monitored steps taken. (The study sponsor was the manufacturer of a noncaloric sweetener provided to the intervention group.)

After 6 months, both groups showed significant decreases in BMI for age, but the between-group differences were not significant. More children in the intervention group maintained or reduced their BMI for age; fewer in that group showed an increase.

The authors comment that the result still left most of the subjects in the overweight category, but, they say, "it is better than continuing to gain excessive weight."

Minor Stroke Treated Early Reduces Recurrence

Urgent Treatment of TIA or Minor Stroke Cuts Risk for Early Recurrence

Physician's First Watch for October 19, 2007

Urgent treatment after a TIA or minor stroke can reduce the 90-day risk for stroke by 80%, Lancet reports.

A study examining stroke outcomes was divided into two phases. In the first, 310 patients presenting to primary care with a TIA or minor stroke were referred to a neurovascular clinic, where patients were assessed and treatment recommendations were faxed to the primary care clinician. In phase 2, about 280 patients were sent directly to the neurovascular clinic, where they received appropriate treatment.

The median delay to clinic assessment dropped from 3 days in phase 1 to less than a day in phase 2. Likewise, the median delay to treatment fell from 20 days to 1 day. The incidence of stroke within 90 days also fell significantly — from 10% to 2%.

Editorialists conclude that patients with TIA or minor stroke "should receive the same urgent attention as is provided for those with acute coronary syndromes."

Hepatitis A Post Exposure Prophylaxis

Vaccine as Effective as Immune Globulin for Hepatitis A Postexposure Prophylaxis — ACIP Changes Guidance

For postexposure prophylaxis, hepatitis A vaccine is as effective as immune globulin in preventing transmission, according to reports in NEJM and MMWR.

Researchers randomized 1090 susceptible household or day-care contacts of patients in Kazakhstan to prophylaxis with either hepatitis A vaccine or immune globulin within 2 weeks of exposure. They hypothesized that the effect of the vaccine would be similar to immune globulin. That criterion was met — between 2 and 8 weeks after exposure, vaccine recipients showed a 1.35 relative risk for developing symptomatic infection as compared with those receiving immune globulin. (The confidence interval for the apparent increased risk ranged from 0.70 to 2.67, which an editorialist comments "could signal a true difference between the interventions.)

Consequently, the CDC's Advisory Committee on Immunization Practices has changed its guidelines for postexposure prophylaxis, recommending vaccine for healthy individuals between the ages of 1 and 40. All others should receive immune globulin, if possible.

Physician's First Watch for October 19, 2007

Updated Adult Immunisation Schedule 2008

ACIP Releases Adult Vaccine Schedule


The Advisory Committee on Immunization Practices (US) has approved an updated Adult Immunization Schedule for October 2007 to September 2008.

MMWR reports changes from the previous schedule, which include:

Varicella vaccine is recommended for all adults without evidence of immunity.
Zoster vaccine is advised for adults aged 60 or older.
Recommendations for HIV-infected individuals are organized according to CD4 cell count.

Healthcare workers have the option of either trivalent inactivated flu vaccine or live, attenuated vaccine.

Physician's First Watch for October 19, 2007
David G. Fairchild, MD, MPH, Editor-in-Chief

Infant Cough and Cold Medicines

Infant Cough and Cold Medicines Pulled From the Market

Given concerns that accidental misuse can lead to overdose, many manufacturers of over-the-counter infant cough and cold medicines are voluntarily pulling their products off the market, reports the New York Times.

The withdrawal comes 2 weeks after the industry’s trade group, the Consumer Healthcare Products Association, advised that the oral products not be used in children younger than 2 years. The group says that between 1969 and 2006, at least 45 children died after using decongestants, and 69 after antihistamines.

An FDA advisory panel will meet next week to discuss the medicines' safety.

Not only may the medications be unsafe, but there is scant evidence that they're effective in young children, according to the Times story.

Withdrawn medicines include Dimetapp Decongestant Infant Drops, Pediacare Infant Drops Decongestant, and Tylenol Concentrated Infant Drops Plus Cold and Cough.

New York Times story (Free)

Physician's First Watch coverage of hydrocodone in pediatric cough suppressants (Free)

pregnant women should eat more seafood

New Seafood Recommendations for Pregnant Women

Physician's First Watch for October 5, 2007 David G. Fairchild, MD, MPH, Editor-in-Chief

The National Healthy Mothers, Healthy Babies Coalition has recommended that pregnant, breast-feeding, and postpartum women consume at least 12 ounces of seafood weekly, especially oily ocean fish like salmon and sardines. Six of the twelve ounces may come from albacore tuna.
The coalition, which comprises groups such as the American Academy of Pediatrics and the CDC, says that "recent studies indicate the nutritional benefits of fish consumption during pregnancy greatly outweigh potential risks from trace methyl mercury consumption."

The recommendation contrasts with that previously issued by the FDA and the Environmental Protection Agency. In 2004, these groups advised that women who are pregnant, breast-feeding, or planning a pregnancy consume up to 12 ounces of lower-mercury seafood (e.g., shrimp, canned light tuna) weekly, with albacore limited to 6 ounces. They also recommend that such women avoid high-mercury fish (e.g., shark, swordfish).

The FDA plans to review this information but is not ready to change its current stance, reports the Washington Post.

National Healthy Mothers, Healthy Babies Coalition seafood recommendations (Free)
FDA and EPA 2004 seafood recommendations (Free)
Washington Post story (Free)