Statement on Tobacco, Alcohol and Other Drugs

Physicians should include discussions of substance abuse as a part of the routine health care of their pediatric patients. Discussions should start with the prenatal visit and continue as a part of ongoing anticipatory guidance, according to a new policy statement from the American Academy of Pediatrics (AAP). The statement points out that one in 10 eighth graders and nearly one in four high school seniors smoke daily. “Daily use of tobacco . . . among young people is at an epidemic level,” says the statement, published in the January 1998 issue of Pediatrics. In addition, the statement also addresses alcohol and other drugs of abuse, noting that they are a major cause of death and injury in adolescents and young adults.

The AAP believes that it is important for physicians to know about the extent and nature of tobacco, alcohol and other drug use in their communities as well as the physical, psychologic and social consequences. The AAP recommends that physicians be alert for signs and symptoms suggestive of substance abuse in their patients and in their patients' families and be able to identify those children and adolescents exhibiting behaviors that may place them at high risk for subsequent use of tobacco, alcohol and other drugs (see table). Physicians are reminded in the report that although patient consent should generally be obtained before testing for drugs of abuse, patient consent can be waived if the patient's mental status or judgment is impaired.

FDA Warning on Use of Astemizole

The U.S. Food and Drug Administration (FDA) has issued a warning to consumers and health care professionals about new safety information regarding the antihistamine astemizole (Hismanal). The warning was issued in conjunction with the addition of more information in the product label about cardiovascular adverse events, potentially serious drug interactions and rare reports of anaphylaxis.

According to the FDA, use of astemizole has been associated with a risk of death caused by irregular heart rhythms when taken with certain other drugs and when used at higher than the recommended dosage on the label. A specific warning is given against using astemizole at the same time as other types of drugs such as the antihypertensive mibefradil (Posicor) and the antibiotics clarithromycin (Biaxin) and troleandomycin (TAO).

The new labeling provides additional precautions concerning the use of astemizole with human immunodeficiency virus (HIV) protease inhibitors, such as indinavir (Crixivan), ritonavir (Norvir), saquinavir (Invirase) and elfinavir (Viracept); selective serotonin reuptake inhibitors, such as fluoxetine (Prozac), fluvoxamine (Luvox), sertraline (Zoloft), nefazodone (Serzone) and paroxetine (Paxil); and the antiasthma medication zileuton (Zyflo). Also, the label now recommends that astemizole not be taken with grapefruit juice. It also emphasizes that patients with liver disorders should not take astemizole.

Health care professionals are asked to report any adverse events associated with the use of astemizole to the manufacturer, Janssen Pharmaceuticals, at 800-JANSSEN (526-7736). Adverse events can also be reported to FDA MedWatch by telephone at 800-FDA-1088, by fax at 800-FDA-1078 or by writing to the following address: FDA, HF-2, 5600 Fishers Lane, Rockville, MD 20857.

Cultural Competency in Health Care

The American College of Obstetricians and Gynecologists (ACOG) has published a report on cultural competency in health care (ACOG committee opinion no. 201).

According to ACOG, “during every health care encounter, the culture of the patient, the culture of the physician and the culture of medicine converge and impact upon the patterns of health care utilization, compliance with recommended medical interventions and health outcomes.” To provide good care to an increasingly diverse patient population, ACOG encourages physicians to develop the knowledge and skills to understand individuals from other cultures.

ACOG believes that cultural competency is particularly relevant in maternity care. Individual family traditions must be incorporated into prenatal care to help strengthen family ties and provide a medically safe birth experience for the mother and infant, with support from the family. ACOG recommends the use of a “birth plan” as one way for a physician to accommodate a pregnant woman's cultural preferences into her delivery experience. The patient writes down her ideas about how she wants the birth of her child to be handled.

ACOG believes that a health care system with cultural competency values diversity. As the cultural makeup of the country diversifies, physicians must develop appropriate methods to ensure access to services. Cultural competency in health care is an ongoing and interactive process, based on respect of others' customs, beliefs and values. ACOG stresses that physicians must be sensitive to the unique needs of all of the women in their communities. The impact of this increased sensitivity will be felt positively by physicians and their patients.

For more information on ACOG committee opinions, contact ACOG, 409 12th St., S.W., P.O. Box 96920, Washington, D.C. 20090; telephone: 800-762-2264.

Statement on Exercise and the Common Cold

The American College of Sports Medicine (ACSM) has issued a statement concerning the effects of exercise on the common cold. According to the ACSM, resting, drinking plenty of hot fluids and using over-the-counter and prescription cold remedies is still all that can be done to alleviate symptoms of most colds. The ACSM reports that most clinical authorities in the area of immunology recommend the following considerations for athletes with cold symptoms:

• If an athlete has common cold symptoms without fever or general body aches and pains, intensive exercise training may be safely resumed a few days after the resolution of symptoms.

• Mild-to-moderate exercise (e.g., walking) does not appear to be harmful for individuals with common cold symptoms.

• With a symptom complex of fever, extreme tiredness, muscle aches and swollen lymph glands, two to four weeks should probably be allowed before resumption of intensive training.

• In general, if the symptoms affect areas from the neck up, moderate exercise is probably acceptable and, possibly, beneficial, while bed rest and a gradual progression to normal training are recommended when the illness is systemic.

The ACSM supports the view that moderate physical activity exerts less stress on the immune system than does prolonged and intense exercise. Regular and moderate exercise lowers the risk of respiratory infections.

Dihydroergotamine Nasal Spray for Migraine

Dihydroergotamine mesylate (Migranal Nasal Spray) has been approved by the U.S. Food and Drug Administration for the acute treatment of migraine headaches with or without aura. It is a migraine-specific serotonin agonist that works at multiple receptor sites.

In clinical trials, self-administration of the nasal spray resulted in significant pain relief and decreased pain intensity and nausea, compared with placebo. Patients began to feel headache relief as early as 30 minutes after treatment with dihydroergotamine. As many as 60 percent of patients responded within two hours, and up to 70 percent responded within four hours, following a single 2-mg dose. Most of the patients in the clinical trials did not need additional medications for their migraine headaches during the 24-hour period following a single 2-mg dose.

According to the manufacturer, dihydroergotamine nasal spray is non-narcotic, non-habit forming and non-sedating. Side effects are usually mild and transient. In clinical trials, the most common side effects were rhinitis, altered sense of taste, dizziness, nausea, vomiting and application site reaction.

Serious Bilateral Hearing Impairment in Children

A substantial number of children born with serious bilateral hearing impairment are not diagnosed early enough to benefit fully from intervention to minimize delays in the acquisition of speech and language skills and, possibly, reduce the occurrence of other disabilities associated with hearing impairments, according to a report from the Metropolitan Atlanta Developmental Disabilities Surveillance Program (MADDSP) published in the November 14, 1997, issue of Morbidity and Mortality Weekly Report. MADDSP of the Centers for Disease Control and Prevention monitors the prevalence of serious hearing impairment among children three to 10 years of age living in the Atlanta area.

From 1991 to 1993, an estimated 263,000 children in this age group resided in the Atlanta area. Of these children, 413 were identified as having hearing impairment. The average annual prevalence rate was 1.1 cases per 1,000 children in this age group. Approximately two thirds of these children (283, or 69 percent) had a sensorineural hearing loss that did not result from a postnatal cause and was presumed to be present at birth. Additional analysis showed that of a subgroup of 173 children, 13 (8 percent) had hearing impairment diagnosed during the first year of life and 81 (47 percent) were not diagnosed until the age of three years or later. The mean age at earliest known diagnosis was 2.9 years. Because MADDSP focuses only on serious hearing impairment, the actual magnitude of delayed diagnosis may be underestimated, according to the report.

Recent recommendations from the 1994 Joint Committee on Infant Hearing specify universal newborn screening by age three months and the initiation of appropriate intervention by age six months. The children in the MADDSP study were born from 1981 to 1990, before these recommendations were published. The report notes that the surveillance findings emphasize the importance of the development and evaluation of universal newborn hearing screening programs in all communities.

Substance Abuse and Domestic Violence

A panel of experts convened by the Center for Substance Abuse Treatment (CSAT) in the Health and Human Services' Substance Abuse and Mental Health Services Administration has concluded that there is a statistical association between domestic violence and substance abuse.

The report, “Substance Abuse Treatment and Domestic Violence,” is a part of CSAT's Treatment Improvement Protocol (TIP) series and recommends that professionals who treat alcohol and drug abusers and victims of domestic violence move toward more linked systems of delivering intervention in order to provide more effective care. The TIP provides diagnostic tools to help clinicians recognize when patients are victims or perpetrators of domestic violence, and to recognize drug and alcohol addiction.

The panel focused on men who abuse their female partners and women who are battered by their male partners. Research was identified showing that from one fourth to one half of men who commit acts of domestic violence also have substance abuse problems and that at least 30 percent of female trauma patients not involved in traffic accidents have been victims of domestic violence. The panel emphasizes that if a substance-abusing woman is being battered, the safety of the women needs to come first, before addressing the issue of an addiction treatment program. “Professionals in both addiction treatment and domestic violence treatment need to understand the connections between the problems and how the problems feed on one another,” says David J. Mactas, director of CSAT.

The panel recommendations are in volume 25 of the TIP series. TIPs are available on the CSAT Web page (http://www.samhsa.gov) or they can be ordered by contacting the National Clearinghouse for Alcohol and Drug Information at 800-729-6686.

ACEP Clinical Policy on Acute Blunt Trauma

The American College of Emergency Physicians (ACEP) has published a clinical policy on the initial approach to patients presenting with acute blunt trauma. The policy, published in the March 1998 issue of the Annals of Emergency Medicine, is a revision of ACEP's original policy on management of acute blunt trauma published in 1993. Developed by ACEP's Clinical Policies Committee and Subcommittee on Acute Blunt Trauma, it is intended for use in patients aged 12 years and older who have sustained blunt trauma.

The document is presented in a table format and includes guidelines that cover soliciting and recording a history, conducting and recording a physical examination and implementing actions based on the findings for a number of variables. Specific considerations relating to the pregnant woman with acute blunt trauma and to the transfer of the unstable patient are addressed in appendexes at the end of the clinical policy.

The guidelines are recommended by ACEP to be actions that may be considered depending on the patient, the circumstances or other factors. The following aspects to be considered when soliciting the history of a person with acute blunt trauma have been excerpted from the policy document:

• Mechanism and time of injury, nature and magnitude of forces, damage to structures surrounding patient (e.g., damaged steering column), mitigating factors (e.g., use of air bags), extrication problems, injuries sustained by other persons in the same event.

• Events preceding the injury, including any previous symptoms (e.g., chest pain).

• Recent alcohol use or other drug use.

• Location and character of any pain, including onset, severity, quality, constancy, radiation, referral to other sites, relationship to respiration or movement.

• Other current symptoms and complaints, including shortness of breath, numbness, weakness.

• History of blood loss before arrival.

• Prehospital course and treatment.

• Previous illnesses, injuries or surgery, current medications, allergies, tetanus immunizations, last menstrual period/pregnancy, last oral intake.