Monday, July 27, 2009

H1N1 Flu Linked to Neurologic Complications in Children

From Medscape Medical News
by Allison Gandey

July 24, 2009 — Children with flulike symptoms and unexplained seizures or mental changes should be tested for H1N1 influenza, says a Centers for Disease Control and Prevention (CDC) report, published in the July 24 issue of the Morbidity and Mortality Weekly Report . It suggests that patients may benefit from prompt treatment with antivirals.

Concern was first sparked in May, when the Dallas County Department of Health and Human Services reported 4 children with neurologic complications associated with H1N1 flu.

Patients were aged 7 to 17 years and were admitted with flulike symptoms and seizures or altered mental status. In all 4 patients, clinicians detected H1N1 viral RNA in nasopharyngeal specimens, but not in cerebrospinal fluid. Three patients had abnormal electroencephalograms.

All patients received the antiviral oseltamivir and 3 received rimantadine. The patients fully recovered and had no neurologic sequelae at discharge.

Patients Fully Recovered

According to the CDC, just like with the seasonal flu, neurologic complications can occur after respiratory-tract infection with H1N1. Considering that clusters of influenza-associated encephalopathy in children have been reported during previous community outbreaks of seasonal flu and that children appear to be infected with H1N1 more frequently than adults, officials anticipate that additional neurologic complications are likely to be reported as the pandemic continues.

The CDC recommends that healthcare providers also consider a diagnosis of Reye's syndrome in patients with viral illness and altered mental status.

Clinicians should not administer salicylates or salicylate-containing products to children with influenza or other viral infections because this may also increase the risk for Reye's syndrome.

The CDC recommends that all children at least 6 months of age receive annual seasonal influenza vaccinations to prevent illness and complications from infection. No vaccination against H1N1 influenza is currently available.

MMWR Morb Mortal Wkly Rep. 2009;58;773-778.

Dilute Bleach Baths Plus Intranasal Mupirocin Eases Eczema Severity in Children

From Reuters Health Information

Apr 28 - In children with severe atopic dermatitis prone to infections, a regimen of dilute sodium hypochlorite baths and intermittent intranasal mupirocin reduces disease severity, according to physicians at the Feinberg School of Medicine in Chicago.

"We and others have found anecdotally the addition of dilute sodium hypochlorite baths to be helpful in decreasing infection rates and disease severity" in children with eczema, Dr. Amy S. Paller and associates note, but theirs is the first controlled trial of this strategy.

Their study in the May issue of Pediatrics included 22 patients ages 9 months to 17 years with moderate to severe atopic dermatitis and bacterial skin infections. On average, one third of body surface area was affected, and the mean Eczema Area and Severity Index (EASI) score was 19.7. Lesions in most patients were positive for Staphylococcus aureus.

All patients were initially treated for 2 weeks with oral cephalexin, and continued topical anti-inflammatory medication and emollient therapy throughout the 3-month trial.

Nine patients were assigned to the treatment arm, and they bathed in a dilute bleach solution for 5-10 minutes twice a week; the dilution was 0.5 cup of 6% bleach in 40 gallons water, with final concentration 0.005%. Additional plain-water baths were not restricted. In this group, mupirocin ointment was applied intranasally twice daily for 5 consecutive days per month.

Thirteen control patients bathed in plain water and used petrolatum instead of mupirocin.

Compared to the control group, the treatment group showed significantly greater improvement on the EASI scores: -10.4 vs -2.5 at 1 month (p = 0.017) and -15.3 vs -3.2 at 3 months (p = 0.004).

The percentage of body surface area affected also significantly declined in the treatment group, by 23.7% at 3 months, versus 3% in the placebo group (p = 0.004).

Tolerability to the dilute bleach baths was "excellent," the authors say, although early on, infected lesions were made more painful. One patient who complained of skin irritation stopped the baths. However, after he developed a methicillin-resistant S. aureus skin infection requiring hospitalization, he resumed treatment, with no reported adverse effects.

Active treatment did not eradicate S. aureus, however, leading Dr. Paller and her team to suggest that longer duration of this treatment strategy may be required.

Pediatrics 2009;123:e808-e814.

Monday, July 20, 2009

Vit D - how much do you need

American Academy of Dermatology Issues Updated Position Statement on Vitamin D
Laurie Barclay, MD From Medscape Medical News

July 16, 2009 — The American Academy of Dermatology (AAD) has issued an updated position statement on vitamin D after reviewing more recent evidence regarding the role of vitamin D in maintaining optimal health. The National Council on Skin Care Prevention also released its own position statement on July 14.

Individuals who regularly and properly practice sun protection may be at risk for vitamin D insufficiency and may require a higher dose of vitamin D, either from dietary sources or from supplements. Because of skin cancer risk from ultraviolet (UV) radiation, AAD does not recommend unprotected exposure to radiation from the sun or from indoor tanning devices.

"The vitamin D position statement supports the Academy's long-held conviction on safe ways to get this important vitamin — through a healthy diet which incorporates foods naturally rich in vitamin D, vitamin D-fortified foods and beverages, and vitamin D supplements," dermatologist and AAD president David M. Pariser, MD, FAAD, said in a news release.

"The updated recommendation for individuals who practice daily sun protection acknowledges that while protecting the skin from the damaging rays of the sun is important, so is maintaining adequate vitamin D levels," Dr. Pariser said. "Concern about vitamin D should not lead people to forego sun protection, but rather prompt a conversation with their physician about how to ensure adequate and safe vitamin D intake while guarding against skin cancer."

In addition to individuals who protect themselves from sun or other UV exposure by daily use of sunscreen on exposed skin or by wearing sun-protective clothing, others at risk for vitamin D insufficiency include elderly individuals or those who have dark skin, photosensitivity, obesity, or fat malabsorption. These at-risk individuals should consult their physician regarding options for ensuring adequate vitamin D levels through dietary intake or supplement use, and physicians should be equipped to advise them properly.

Although serum vitamin D level (25-hydroxyvitamin D) can be easily measured and is a widely available blood test, further studies are required to identify appropriate serum concentrations of vitamin D needed for optimal health.

The standard reference now recommended by the AAD to advise patients regarding their needed minimum intake levels is the National Academy of Sciences Institute of Medicine guidelines for vitamin D. Because of new developments regarding knowledge of the clinical benefit of vitamin D, current recommendations for adequate vitamin D intake levels established by the Institute of Medicine may be increased in the near future.

The US Department of Agriculture Dietary Guidelines recommend that those at risk for vitamin D insufficiency receive supplementation with a total daily dose of 1000 IU vitamin D, according to the AAD statement.

The AAD recommends supplementation with 200 IU vitamin D from birth to age 50 years for those who are not at increased risk for vitamin D insufficiency. However, the American Academy of Pediatrics recommends supplementation with 400 IU vitamin D per day for children younger than 18 years of age, including infants.

Because vitamin D can be toxic in high doses, the US Food and Nutrition Board has set an upper limit for safety for vitamin D intake of 2000 IU per day for individuals older than 12 months of age and 1000 IU per day for infants.

For vitamin D supplementation, vitamin D3 (cholecalciferol), which is the form of vitamin D naturally produced in the skin, is preferred to vitamin D2 (ergocalciferol).

The updated AAD statement now emphasizes that there is no scientifically proven safe threshold for exposure to the sun or indoor tanning devices that optimizes vitamin D synthesis in the skin without increasing skin cancer risk. Laboratory research has shown that UV radiation from either the sun or tanning devices can cause oncogenic mutations in skin cells, and use of sunbeds has also been associated with increased risk for melanoma and squamous cell carcinoma. UV radiation exposure has also been linked to cataracts, premature aging, and immune suppression.

"It is well documented in the medical literature that unprotected exposure to UV radiation from natural sunlight or indoor tanning devices causes skin damage," Dr. Pariser said. "There is no current research available that provides a safe limit for sun exposure to maximize vitamin D production that does not put the individual's health at risk for developing skin cancer."

Low levels of vitamin D have been linked in numerous studies to greater risk for certain cancers and for some neurologic, autoimmune, and cardiovascular diseases, but clinical trials have not yet been performed to show a causal relationship of vitamin D to these diseases.

"Contrary to some reported information about vitamin D and the prevention of certain cancers and diseases — other than for bone health — we simply need more clinical data to determine what role, if any, vitamin D plays in these conditions," Dr. Pariser said.

The AAD still recommends avoiding use of tanning beds. The National Council on Skin Cancer Prevention recommends protection from UV exposure when outdoors by seeking the shade between 10 am and 4 pm whenever possible, generously applying sunscreen with a sun protection factor of at least 15, and wearing sun-protective clothing, including wide-brimmed hats, long sleeves, pants, and UV-protective sunglasses.

"For those who are concerned about vitamin D insufficiency, diet and vitamin D supplementation are the most appropriate methods to obtain adequate vitamin D — it is not appropriate to seek exposure to ultraviolet radiation," said National Council on Skin Cancer Prevention co-chair Henry Lim, MD, FAAD, chairman of dermatology at Henry Ford Hospital in Detroit, Michigan.

Thursday, July 16, 2009

Reduced Doses of PCV-7 May Reduce Nasopharyngeal Carriage of Pneumococcus in Infants

Laurie Barclay, MD

July 15, 2009 — Infants who receive 2 or 3 primary doses of 7-valent pneumococcal conjugate vaccine (PCV-7) have a decreased rate of nasopharyngeal carriage of pneumococcus vs infants who are not vaccinated, according to the results of a randomized controlled trial reported in the July 8 issue of the Journal of the American Medical Association.

"The effects of reduced-dose schedules of...PCV-7 on pneumococcal carriage in children are largely unknown, although highly relevant in the context of subsequent herd effects," write Elske J.M. van Gils, MD, from Wilhelmina Children's Hospital, University Medical Center Utrecht in Utrecht, the Netherlands, and colleagues.

The goal of this study was to determine the effects of a 2-dose and 2 plus 1-dose PCV-7 schedule on nasopharyngeal pneumococcal carriage in infants vs those who did not receive the vaccine.

Between July 7, 2005, and February 14, 2008, in a general community in the Netherlands, 1003 healthy newborns, each with one of their parents, were enrolled, randomly selected to 1 of 3 groups, and followed up to age 24 months. The 3 study groups were 2 doses of PCV-7 at 2 and 4 months; 2 plus 1 doses of PCV-7 at 2, 4, and 11 months; or no dosage (control group). The primary endpoint of the study was rates of vaccine serotype pneumococcal carriage in infants in the second year of life.

After both PCV-7 schedules, vaccine serotype pneumococcal carriage was significantly decreased at 12 months. In the 2-dose and 2 plus 1-dose schedule groups, vaccine serotype pneumococcal carriage rates were 25% and 20%, respectively, vs 38% in the control group (both P < .001).

In the 2 plus 1-dose schedule group, vaccine serotype pneumococcal carriage had decreased further at 18 months to 16% and to 14% at 24 months both P < .001. In the 2-dose schedule group, however, vaccine serotype pneumococcal carriage was stable at 18 months 24%; but decreased further to 15% at 24 months. Vaccine serotype pneumococcal carriage in the control group remained approximately 36% to 38% until 24 months.

"The reduction of pneumococcal carriage obviously reduces the number of cases of invasive pneumococcal disease," said Fernando Artiles-Campelo, MD, a microbiologist in molecular epidemiology at Dr. Negrín University Hospital, Las Palmas de Gran Canaria, Canary Islands, Spain, told Medscape Pediatrics. "The fact that reduction occurs in both vaccination schedules is important in order to design a possible universal vaccination, because the total number of doses would be reduced if we use the 2-doses schedule."

JAMA. 2009;302:159-167.


note: PCV7 is not used in childhood vaccination in Malaysia

Tuesday, July 14, 2009

Chest Xrays in Wheezing Children?

Radiographic Pneumonia Uncommon in Children With Wheezing
by Laurie Barclay & Penny Murata

July 10, 2009 — Because radiographic pneumonia in children with wheezing but without fever is uncommon, the routine use of chest radiography in these children should be discouraged, according to the results of a prospective cohort study reported in the July issue of Pediatrics.

"The diagnosis of pneumonia in children with wheezing can be difficult, because the clinical history and auscultatory findings may be difficult to distinguish from those for children without pneumonia," write Bonnie Mathews, MD, from Children's Hospital Boston and Harvard Medical School in Boston, Massachusetts, and colleagues.

The study sample consisted of 526 individuals not older than 21 years who were seen in the ED, who had wheezing on clinical examination, and who underwent chest radiography because of possible pneumonia. Before learning the chest radiograph results, treating physicians obtained a medical history and performed and recorded a physical examination. Two blinded radiologists independently read the chest radiographs.

Factors linked to an increased risk for radiographic pneumonia were a history of fever at home; a history of abdominal pain, triage temperature of 38°C or higher, maximal temperature in the ED of 38°C or higher and triage oxygen saturation of less than 92%.

"Radiographic pneumonia among children with wheezing is uncommon," the study authors write. "Historical and clinical factors may be used to determine the need for chest radiography for wheezing children. The routine use of chest radiography for children with wheezing but without fever should be discouraged."

Pediatrics. 2009;124:e29-e36.

Clinical Context

In children with wheezing, underlying pneumonia can be difficult to diagnose. In the July 1999 issue of Clinical Pediatrics, a retrospective study by Mahabee-Gittens and colleagues found that in wheezing children younger than 18 months, the factors associated with radiographic pneumonia were a history of fever, a temperature of at least 38.4°C, and crackles by examination. A prospective study by Mahabee-Gittens in the July 2000 issue of Clinical Pediatrics noted that in wheezing children younger than 18 months, the factors associated with radiographic pneumonia were grunting and oxygen saturation less than 94% but not fever or tachypnea.

This prospective cohort study of wheezing children who undergo chest radiography in the ED evaluates which historical and examination features are associated with pneumonia.

Clinical Implications

•In children with wheezing in the ED, the rate of radiographic pneumonia is 4.9%.
•In children with wheezing in the ED, the risk for pneumonia is increased by fever at home, at triage, and in the ED, as well as by a history of abdominal pain and triage oxygen saturation less than 92%. The rate of pneumonia in afebrile, wheezing children is 2.2%.

Friday, July 3, 2009

HPV Vaccination Is Not Cost-Effective in the Netherlands

From Medscape Medical News
Roxanne Nelson

July 2, 2009 — Vaccination against the human papillomavirus (HPV) is not cost-effective in the Netherlands, even under favorable assumptions that include lifelong protection against 70% of all cervical cancers, administration to all women regardless of their risk for cervical cancer, and no adverse effects.

According to a report published online July 1 in the Journal of the National Cancer Institute, in order for the HPV vaccine to become cost-effective among Dutch women, the price would have to be considerably reduced, depending on the long-term effectiveness of the vaccine.

Cost Effectiveness Tied to Declining Incidence

As in many industrialized nations, cervical-cancer–associated mortality has dramatically declined in the Netherlands, due to efficient and widespread screening programs. In 2005 it was 1.6 per 100,000 woman-years [World Standardized Rate (WSR)] in the Netherlands, and this rate is lower than the WSR of 2.5 per 100,000 woman-years in the United States for the period 2001–2005 and 1.9 in the United Kingdom in 2005, according to the authors.

A number of analyses have concluded that HPV vaccination should be cost-effective, but this conclusion is primarily dependent on the incidence and mortality rates of cervical cancer. Low incidence and mortality rates might limit the cost-effectiveness of adding HPV vaccination to a screening program, the researchers comment.

The team, led by Inge M.C.M. de Kok, from the department of public health at Erasmus MC University Medical Center, in Rotterdam, the Netherlands, examined the effect of adding HPV vaccination to the current Dutch cervical-cancer screening program..

Using a microsimulation screening analysis (MISCAN) model, the researchers estimated costs and effects of adding HPV vaccination to the current screening protocol in the Netherlands and examined the impact of changes in the price of vaccination, number of booster vaccinations, vaccination attendance rate, vaccination efficacy, cervical-cancer incidence level, and quality-of-life assumptions on the cost-effectiveness of HPV vaccination.

Cost Efficacy Lower Under Less Favorable Assumptions

There were limitations to the analysis, the researchers note. For example, the impact of herd or community immunity was underestimated, and the impact of the vaccine on other types of HPV-related diseases was also not taken into account.

While long-term adverse effects are not yet known and only a small number of adverse events have been reported in women between the ages of 15 to 26 years, most countries intend to vaccinate 12-year-old girls. Both safety and efficacy have not been tested in the age group, the researchers note, and since cervical cancer is a relatively rare disease in the Netherlands, adverse events due to vaccination will also influence the risk/benefit ratio of vaccination. This highlights the importance of future studies that will evaluate adverse effects among vaccinated 12-year-old girls, primarily for safety and also for cost-effectiveness estimates.

“In conclusion, many uncertainties still exist about the effects of HPV vaccination on HPV-related diseases,” the authors write. “Our cost-effectiveness analysis shows that in the Netherlands, a country with low cervical-cancer incidence and mortality, HPV vaccination is not cost-effective.”

GlaxoSmithKline provided funding for the study, to the department of public Health of the Erasmus University Medical Center. The authors made no disclosures.

J Natl Cancer Inst. Published online July 1, 2009.

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