Update on Elevated Blood Lead Levels in Adults

The findings in a report from the Centers for Disease Control and Prevention (CDC), published in the March 19, 1999, issue of Morbidity and Mortality Weekly Report, document the continuing hazard of lead exposure as an occupational health problem. The report presents prevalence data from 27 states for elevated blood lead levels in the second and third quarters of 1998 and compares them with corresponding quarters in 1997. Laboratory-reported blood lead levels are monitored by the CDC's Adult Blood Lead Epidemiology and Surveillance (ABLES) program. The ABLES program defines an adult as a person aged 16 years and older and an elevated blood lead level in adults as 25 μg per dL (1.20 μmol per L), although in this report lead level threshold varied among the 27 reporting states.

Of the approximately 20,000 persons tested for blood lead whose levels were reported to the ABLES each quarter, approximately 4,000 persons had elevated blood lead levels. These figures indicate a decrease in elevated blood lead levels in persons reported for the same quarters in 1997.

Ninety to 95 percent of adult lead exposures occur at work. Occupations known to expose workers to lead include radiator repair, battery manufacture and recycling, smelting, and construction or remodeling involving lead-based paint. The CDC notes that lead exposure can be prevented by engineering controls, good housekeeping, use of personal protective equipment and fastidious hygiene. Medical removal from a lead-exposed job is required by the Occupational Safety and Health Administration when a worker's blood lead level is 50 μg per dL (2.40 μmol per L) or more.

Use of Restraints in Nursing Home Patients

The Council on Scientific Affairs of the American Medical Association (AMA) examined issues associated with the use of restraints for patients in nursing homes and released a report on the subject published in the March/April 1999 issue of the Archives of Family Medicine. The report discusses the background of restraint use, the risks and benefits of restraint use, system problems associated with restraints, and measures to reduce the use of restraints. The AMA reports that data show restraint use can cause more adverse outcomes than it prevents. In recent years, restraint use has decreased by 20 percent.

The AMA notes that while regulations governing the use of restraints in long-term care facilities are in place, the regulations are subject to variable interpretation. Widespread educational programs about the use of restraints are needed for health care professionals, families and patients to better understand the risks and benefits of restraint use.

The AMA also recommends further research to determine when the use of restraints results in improved outcomes and to evaluate the effects of the restraint regulations on the health and well-being of patients in nursing homes.

AAP Statement on Violence and Children

Following a two-year analysis of violence and its effects on children in the United States, the American Academy of Pediatrics (AAP) has issued a policy statement recommending measures to prevent violence and violent injuries among children. The statement, published in the January 1999 issue of Pediatrics, notes that while there has been an overall decrease in homicides nationwide, violence and violent injuries among children have not declined.

Homicide and suicide have become the second and third leading causes of deaths in teenagers. In addition, teenagers are more likely to die of gunshot wounds than all natural causes combined. The AAP outlined recommendations for physicians to help prevent and manage violence by focusing on four key areas: clinical practice, advocacy, education and research.

Risk factors for morbidity and mortality in children caused by violence include substance abuse problems, history of mental illness, family stresses, and exposure to violence at home and in the media. In addition to promoting a safe family and community environment, physicians should assess high-risk situations and behaviors and offer appropriate referrals and treatment when necessary. The AAP also recommends that violence-prevention counseling and screening be started during prenatal visits and continued into young adulthood.

Update on Treating Acute Bacterial Sinusitis

Inexpensive antibiotics, such as amoxicillin and folate inhibitors, are just as effective as newer and more expensive antibiotics, such as third-generation cephalosporins, in the treatment of uncomplicated acute bacterial sinusitis, according to a study sponsored by the Agency for Health Care Policy and Research (AHCPR) under its evidence-based practice program. However, the report indicates that in many patients with acute sinusitis, symptoms will resolve without antibiotic treatment.

The research, conducted at the New England Medical Center, is the ninth in a series of evidence reports and technology assessments to provide comprehensive, science-based information on common, costly conditions and health care technologies. The report's conclusions are based on a systematic review of the best available evidence from published research.

The AHCPR report focuses on the diagnosis and treatment of uncomplicated, community-acquired, acute bacterial sinusitis in children and adults. The investigators of the study report the following findings:

• More patients recovered, and more recovered earlier, when treated with antibiotics as compared with placebo; however, two thirds of the patients receiving placebo recovered without the use of antibiotics.

• More research is needed to identify simple, inexpensive, diagnostic methods to help distinguish patients requiring treatment with antibiotics from those not requiring antibiotics or further evaluation.

• Children need to be the specific focus of clinical research to determine proper methods of diagnosing and treating sinusitis.

• Future studies should examine the connection between treatment and relapse rates or the development of recurrent sinusitis. Studies also should address the optimal length of antibiotic treatment, the role of patient preferences in clinical decision-making and the issue of emerging antibiotic resistance.

A four-page summary of “Diagnosis and Treatment of Acute Bacterial Rhinosinusitis” (AHCPR99-EO15) is available from the AHCPR's Web site (http://www.ahcpr.gov/clinic/sinussum.htm). Complete copies are available from the AHCPR Publications Clearinghouse by writing to P.O. Box 8547, Silver Spring, MD 20907, or by calling 800-358-9295.

Confusion Surrounding the Name of Celebrex

The Institute for Safe Medication Practice (ISMP) has issued a warning to health care professionals and consumers to be careful when prescribing, dispensing and using celecoxib (Celebrex) and other products whose names look and sound like Celebrex. The warning was published in the April 2, 1999, issue of ISMP Medication Safety Alert.

Since being released on the market, around 50 documented medication errors have resulted from confusion surrounding the name Celebrex, a new COX2 inhibitor. The errors occur primarily from the fact that its brand name looks and sounds like two other existing drugs. These two drugs are citalopram (Celexa) and fosphenytoin (Cerebryx).

ISMP recommends the following actions to ensure safe use of celecoxib and the similar-sounding products:

• Prescribers should always include the purpose of the medication on the prescription order for all three of these drugs, and the prescription should be printed clearly.

• Use both the generic and brand names of these drugs, because the generic names are less likely to be misinterpreted.

• Add alerts to the pharmacy/hospital computer system warning pharmacists and other health professionals to question the indication for the drug if it is not clearly stated on the order.

• Pharmacy staff and other health professionals should confirm the drug's indication if the order is not clearly stated.

• Pharmacists, nurses and other health professionals should repeat verbal orders back to the prescriber and clearly communicate the drug's indication.

• Patients who receive any of these three drugs should always double check with the pharmacist to make sure they have received the correct medication.

• Pharmacists should counsel patients on the use of these three medications before giving the medication to the patient.

In addition, the ISMP requested the manufacturer of celecoxib and the U.S. Food and Drug Administration (FDA) to reconsider use of the Celebrex trademark. Discussions between the manufacturer and the FDA are under way regarding potential methods to avoid the drug mixups that have occurred. For more information on this and other safe medication practices, consult the Web site of the ISMP at http://www.ismp.org.

Synthetic Conjugated Estrogen Approval

The U.S. Food and Drug Administration has approved the use of synthetic conjugated estrogens, A (Cenestin) tablets in the treatment of women with hot flushes, night sweats and other moderate to severe vasomotor symptoms associated with menopause. Cenestin is synthesized 100 percent from soy and yam plants. It is available in two dosage strengths—0.625 mg and 0.9 mg.

Cenestin was shown to be safe and effective in a double-blind, placebo-controlled randomized trial that included 120 women. A statistically significant reduction was reported in the number of moderate to severe hot flushes at four weeks of therapy in the group receiving Cenestin, compared with the women receiving placebo.

Response to Cenestin did not vary significantly among races; 68 percent of the women were white, 28 percent were black and 4 percent were of other races. The most frequently reported adverse events were headache and insomnia, which also occurred with similar frequency in the women receiving placebo. More information is available from the manufacturer by calling 800-543-3763.

Physicians and Psychosocial Implications of Disasters

Physicians have important roles in preparing for natural and human-caused disasters, as well as acting in the community's behalf during and after such events, according to a statement by the American Academy of Pediatrics (AAP). The statement, published in the February 1999 issue of Pediatrics, recommends that physicians educate themselves about available resources provided by professional organizations and local specialists concerning disasters. As part of anticipatory guidance at health care visits, physicians can help families by reviewing how to help their children understand what to do for the types of disasters they are likely to encounter and what resources to contact.

The AAP emphasizes that during a disaster, the physician should be a source of information for patients and families; counsel families experiencing acute psychosocial problems; treat injured children and adolescents; and design local public service announcements and help establish a community hotline addressing concerns of parents. After a disaster, physicians should educate parents about the range of normal reactions they may expect from their children; help evaluate children at school and child care facilities, and educate school and child care staff about acute and normal delayed reactions to disasters.

Biologic for Von Willebrand's Disease

The U.S. Food and Drug Administration (FDA) has approved a new indication for the antihemophilic factor/von Willebrand factor complex, human (Humate-P). It has been approved to manage patients with severe or hard-to-treat cases of von Willebrand's disease. Previously, Humate-P was approved by the FDA in the treatment of patients with hemophilia A. According to the FDA, Humate-P is the only approved plasma-derived treatment for von Willebrand's disease.

In a clinical trial of both children and adults with von Willebrand's disease, approximately 95 percent of participants reported excellent or good response to Humate-P when used to control episodes of bleeding. The FDA points out that the efficacy of Humate-P to prevent excessive bleeding associated with surgery in these patients has not been evaluated.

ISMP Warning About Syringe Tip Caps

The tip caps on syringes pose a potential choking hazard to small children and should be properly discarded before administration of the medication, according to a warning issued by the Institute for Safe Medication Practices (ISMP). The report was published in the March 9, 1999, issue of ISMP Medication Safety Alert.

The ISMP emphasizes that proper removal and disposal of syringe tip caps before administration of medication is essential to prevent accidental ingestion or asphyxiation by children. The ISMP recommends that the caps be properly discarded in a secured sharps disposal container before administering any medication. In addition, the ISMP reminds physicians and pharmacists to alert parents and other caregivers to the potential for ingestion or asphyxiation of caps for oral solutions or oral syringes in the community setting. Because oral syringes may be reused, parents should receive instructions about removing the cap before administration and storing the recapped syringe in a child-proof location.

For more information on this and other safe medication practices, consult the ISMP Web site at http://www.ismp.org.

AAP Guidelines on Teenage Pregnancy

The American Academy of Pediatrics (AAP) has issued a policy statement that includes new guidelines to help physicians in the management of pregnant adolescents. The statement, published in the February 1999 issue of Pediatrics, discusses adolescent sexual activity, contraceptive use, trends in childbearing among adolescents, medical risks and psychosocial complications of adolescent pregnancy, the fathers of infants born to adolescent mothers and adolescent pregnancy prevention.

The birth rate among single female adolescents has been increasing steadily for the past 30 years. Birth rates for unmarried adults have also risen dramatically, so births to unmarried adolescents reflect a larger societal trend toward single parenthood.

The AAP notes that teenagers under 17 years of age who are pregnant experience higher medical risks than adult pregnant women. In particular, the incidence low-birth-weight infants among adolescent mothers is double the rate in adult women, and the neonatal death rate is three times higher for infants born to adolescent mothers. Adolescent mothers also may need to spend more time in the hospital after delivery than adult mothers, according to the AAP.

The AAP recommends that physicians encourage adolescents to postpone early coital activity and promote abstinence. However, current data show that 56 percent of girls and 73 percent of boys have had sexual intercourse before 18 years of age. Physicians should help ensure that all adolescents who are sexually active know about and have access to contraceptives.

Physicians should encourage and participate in community efforts to prevent first and subsequent adolescent pregnancies. The AAP concludes that parents, schools, religious institutions, physicians, social agencies, government and adolescents all play critical roles in successful adolescent pregnancy prevention programs.