Background: Risk factors for severe respiratory syncytial virus (RSV) disease include prematurity, congenital heart disease, chronic lung disease, and immunocompromised states. There is no consensus concerning the most effective therapy for severe RSV infection in high-risk patients. Palivizumab is approved for prevention of RSV disease, and ribavirin is approved for treatment of RSV infections but its efficacy in high-risk patients has not been conclusively established.
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Nearly one third of sex-education teachers in an Illinois survey had not received sex-education training.
Although teenagers in the U.S. and other developed Western countries have similar rates of sexual activity, U.S. rates of teen pregnancy and abortion rank among the highest. More than 20 states mandate sex education programs in public schools, but just how comprehensively is sex education provided? To address this question, investigators surveyed more than 200 geographically representative sex education teachers from middle schools and high schools in Illinois.
Abstinence-only curricula were used by 74% of teachers; one third of them supplemented their material with “other” curricula. The most commonly covered topics were HIV/AIDS (97%), sexually transmitted diseases (96%), and abstinence (89%). The least-taught topics were emergency contraception (31%), sexual orientation (34%), condoms (34%), other contraceptives (37%), and abortion (39%). Nearly one third of teachers had not received formal training in sex education; trained teachers were nearly 2.5 times more likely to teach a comprehensive program. Availability of formal curricular materials had the greatest influence on the topics taught.
Comment: An editorialist notes the consequences associated with not educating youth about sexual health, including increased exposure to sexually transmitted infections, vulnerability to sexual assault, and unintended pregnancy. Yet we clearly fall short in training our teachers and in providing them with comprehensive teaching tools. Because sexual health is also important in adulthood, physicians should take the lead in rectifying these failings.
— Robert W. Rebar, MD
Published in Journal Watch General Medicine March 11, 2008
Citation(s):
Lindau ST et al. What schools teach our patients about sex: Content, quality, and influences on sex education. Obstet Gynecol 2008 Feb; 111:256.
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Phipps MG. Consequences of inadequate sex education in the United States. Obstet Gynecol 2008 Feb; 111:254.
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Screening all surgical admissions had little effect in a European hospital with a relatively low infection rate.
Faced with soaring rates of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infections, some experts recommend universal screening of all newly admitted hospital patients for MRSA carriage. In a giant prospective cohort crossover study that involved eight surgical services at a large Swiss teaching hospital, researchers evaluated the efficacy of this technique. During one 9-month period, each service screened all newly admitted patients for MRSA carriage; a second 9-month period provided control data. Throughout the study, MRSA carriers were treated with contact isolation, topical decolonization, and MRSA-directed emendation of the usual antibiotic protocols.
More than 10,000 patients were screened with rapid PCR-based analyses of swabs from nares, perineum, and other clinically indicated sites. Screening identified 515 MRSA carriers; most were not previously known to be colonized. However, screening made no difference in overall nosocomial MRSA infection rates nor in rates in any individual surgical service or in sites of infection. More than half of the 93 patients who acquired nosocomial MRSA infections during the screening periods had negative screens for MRSA on admission.
Comment: At 0.36 cases per 10,000 patient-days, this hospital’s rate of nosocomial MRSA infection is considerably lower than that of many other European and U.S. hospitals, and these results might not apply to hospitals with higher rates or to those in the midst of MRSA outbreaks. Still, editorialists remind us that MRSA, now germ-of-the-moment in the press, actually causes fewer than 10% of hospital-acquired infections in the U.S. and that more broadly directed infection-control interventions generally should be preferred over those directed against a single organism.
— Abigail Zuger, MD
Published in Journal Watch General Medicine March 11, 2008
Citation(s):
Harbarth S et al. Universal screening for methicillin-resistant Staphylococcus aureus at hospital admission and nosocomial infection in surgical patients. JAMA 2008 Mar 12; 299:1149.
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Diekema DJ and Climo M. Preventing MRSA infections. JAMA 2008 Mar 12; 299:1190.
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New strategies should be exhausted to protect infants.
March 2008
Mortality and morbidity associated with pertussis dropped dramatically with the introduction of the pertussis vaccine in the United States during the 1940s. By 1994, coverage for three or more doses of pertussis-containing vaccines reached at least 90% among children aged 19 to 35 months.
Despite this success, however, the number of pertussis cases in infants aged 3 months or younger that were reported to the national passive surveillance system increased between the 1980s and 1990s.
To examine the situation from 1993-2004, Margaret M. Cortese, MD, and colleagues conducted a study that compared results obtained from the national passive surveillance survey with the rates of infant pertussis hospitalizations obtained from databases that did not rely on passive reporting.
Their results were published in Pediatrics this month.
Article
Vikram Paralkar, M.D.
I know the color of that blood; it is arterial blood. I cannot be deceived in that color. That drop of blood is my death warrant. I must die.
The British Romantic poet John Keats, trained as a physician and licensed by the Society of Apothecaries, gave himself this accurate prognosis in 1820 after an episode of hemoptysis. He realized that he had contracted tuberculosis, and tragically, he died soon afterward at the age of 25.
Article
Richard E. Chaisson, M.D., and Neil A. Martinson, M.B., B.Ch., M.P.H.
Africa is facing the worst tuberculosis epidemic since the advent of the antibiotic era. Driven by a generalized human immunodeficiency virus (HIV) epidemic and compounded by weak health care systems, inadequate laboratories, and conditions that promote transmission of infection, this devastating situation has steadily worsened, exacerbated by the emergence of drug-resistant strains of tuberculosis.
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Washington Times (03.12.08):: Cheryl Wetzstein
Speaking Tuesday at CDC’s 2008 National STD Prevention Conference, the director of the agency’s Division of STD Prevention called expedited partner therapy, in which women with curable STDs are given drugs to treat their male partners, a “promising approach.”
“In this way, men who may not have a physician, or who may be reluctant to seek health care because they themselves don’t have symptoms, can get treated without having to visit a doctor themselves,” said Dr. John M. Douglas Jr. The female patients should be retested in about three months, he added, to check for reinfection.
In addition, CDC recommends “routine HIV testing for all individuals, male and female, ages 13 to 64, regardless of perceived risk,” Douglas said. “HIV remains an incurable disease, and infection with an [STD] can significantly facilitate HIV transmission and acquisition.”
Three cases in Minnesota and North Dakota are the first reported cases of ciprofloxacin-resistant meningococcal disease in North America.
Close contacts of an index case of meningococcal disease have a 500- to 800-fold higher risk for disease than the general population, and 1% to 3% of household contacts develop the disease if no prophylaxis is provided. Antibiotic prophylaxis can markedly decrease carriage rates and should be given to close contacts within the first 24 hours after the identification of an index case. Previously, CDC-recommended prophylaxis regimens included rifampin, ceftriaxone, and ciprofloxacin. However, three recent case reports of fluoroquinolone-resistant Neisseria meningitidis in North Dakota and Minnesota have led to a regional change in these recommendations.
The three cases involved a child who attended day care, an adult, and a college student. Meningococcal isolates from these patients were serogroup B, had indistinguishable pulsed-field gel electrophoreses patterns and multilocus sequence typing, and possessed the same gyr A sequence that confers fluoroquinolone resistance. To ensure adequate antibiotic prophylaxis for close contacts of infected patients, the CDC has issued the following interim recommendation: Fluoroquinolones should not be used for prophylaxis in close contacts in certain North Dakota and Minnesota counties. Rifampin, ceftriaxone, and azithromycin are acceptable alternatives, and ciprofloxacin can still be used for prophylaxis in adults in other regions.
Comment: The interim recommendations are limited to a small geographic area at this time, but the three cases serve as an important reminder of the importance of providing antibiotic prophylaxis to close contacts as soon as possible. One half of secondary cases occur within the first week of disease onset in the index case and 70% within 2 weeks. The prevention of secondary cases in close contacts is as critical as the care of an index case. The prophylaxis regimen should be based on local sensitivity patterns and availability of antibiotic agents. Clinicians should encourage laboratories to perform sensitivity testing on all Neisseria isolates and to report resistant strains to local health departments.
— Peggy Sue Weintrub, MD
Published in Journal Watch Pediatrics and Adolescent Medicine March 5, 2008
Citation(s):
Centers for Disease Control and Prevention (CDC). Emergence of fluoroquinolone-resistant Neisseria meningitidis — Minnesota and North Dakota, 2007–2008. MMWR Morb Mortal Wkly Rep 2008 Feb 22; 57:173.
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Segmental paresis affects 3% to 5% of patients with cutaneous herpes zoster. This retrospective case report describes three patients with cutaneous zoster followed within several days by segmental weakness involving limb muscles. The authors also reviewed the literature and found 135 additional cases to illustrate the clinical characteristics of this syndrome.
The three cases involved the proximal arm (two cases) and the proximal leg (one case). All three patients received oral antiviral therapy, and two were subsequently treated with intravenous acyclovir and methylprednisolone, followed by oral prednisolone. All patients had good functional recovery, even though one refused steroids and intravenous antivirals.
These three cases are similar to most: weakness starting within 2 weeks of cutaneous eruption, involving proximal muscles slightly more commonly, varying from severe to mild, and limited to two or three myotomes. Electrodiagnostic studies are abnormal and helpful because pain may hinder examination for weakness. Nerve conduction studies show reduced amplitudes of action potentials in sensory and compound motor nerves. Needle electromyography 2 weeks to 3 months after onset commonly reveals abnormal spontaneous activity in weak muscles and, if done later, reinnervation with prolonged and polyphasic motor unit potentials. Paraspinal muscles are also usually abnormal. Prognosis is generally good; patients usually recover most function, and more than half recover completely. The role of antiviral therapy remains incompletely studied.
Comment: The authors contend that segmental zoster paresis is an underrecognized syndrome. They may be right, though they offer no data to support that contention. Whether failure to diagnose affects prognosis is unknown. Oral antiviral treatment for zoster may reduce the incidence of segmental paresis, but it’s unclear whether additional intravenous antiviral or steroid treatment is beneficial once paresis occurs. These three cases do not provide further clarity.
— James M. Gilchrist, MD
Dr. Gilchrist is Professor and Associate Chairman of Neurology, Brown Medical School, and Vice Chairman of Neurology, Rhode Island Hospital, Providence.
Published in Journal Watch Neurology January 15, 2008
Citation(s):
Kawajiri S et al. Segmental zoster paresis of limbs. Report of three cases and review of literature. Neurologist 2007 Sep; 13:313.
Medline abstract (Free)
Wall Street Journal (03/12/08) P. D7
An analysis of national survey data from 2003 and 2004 by the Centers for Disease Control and Prevention (CDC) reveals that 26 percent of girls between the ages of 14 and 19 years, or approximately 3.2 million, have a sexually transmitted disease. Of these, about 18 percent had human papillomavirus (HPV), 4 percent had chlamydia, 2.5 percent had trichomoniasis, and 1.9 percent had herpes simplex virus 2. While a vaccine is available to safeguard against certain strains of HPV, the CDC says it probably has not yet affected HPV prevalence rates in teenage girls much.
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