Sexual Risk Behaviors in High School Students

The percentage of American teenagers who are practicing abstinence or who use condoms is increasing, according to a survey from the Centers for Disease Control and Prevention (CDC) published in the June 4, 1999, issue of Morbidity and Mortality Weekly Report. The CDC analyzed data from 1991 to 1997 that were obtained from over 40,000 public high school students in eight major cities and found that students in most cities reported a significant decrease in at least one sexual risk behavior related to human immunodeficiency virus (HIV). The cities were Boston; Chicago; Dallas; Fort Lauderdale, Fla.; Jersey City, N.J.; Miami; Philadelphia; and San Diego.

The self-administered survey asked students if they ever had sexual intercourse, their number of sex partners and how frequently they used condoms. Sexual experience was defined as ever having had sexual intercourse, multiple sex partners as having four or more in one's lifetime, current sexual activity as having had sexual intercourse in the past three months and condom use as having used a condom at last sexual intercourse.

The proportions of sexually experienced students decreased significantly from previous surveys in Chicago, Dallas and Fort Lauderdale from 1991 to 1997, while data from students in Boston showed a significant decrease from 1993 to 1997. The percentage decrease in these cities ranged from 7 percent in Dallas to 16 percent in Chicago.

Condom use in currently sexually active students increased significantly in Chicago, Dallas, Fort Lauderdale, Jersey City, Miami and Philadelphia from 1991 to 1997. The percentage of increase ranged from 25 percent in Dallas to 52 percent in Jersey City.

The decrease in the percentage of urban students reporting sexual experience and multiple sex partners represents a reversal of the increasing trend that occurred nationally during the 1970s and 1980s. The CDC credits the improved statistics with the effectiveness of educational programs in these cities. However, the report emphasizes that while the numbers reflect a positive trend, more education is needed to help all students avoid the risk of HIV infection, and teacher in-service education on HIV prevention needs to be increased.

Astemizole Withdrawn from the Market

The antihistamine astemizole (Hismanal) has been voluntarily withdrawn from the market by the manufacturer. Since the approval of the drug by the U.S. Food and Drug Administration (FDA) in 1988, new adverse reaction data have required labeling changes and warnings. Adverse effects included rare serious cardiovascular events. The drug could not be used in combination with some antibiotics, protease inhibitors, certain antidepressants and even grapefruit juice. Because of the availability of new antihistamines and the risk–benefit profile of astemizole, the FDA supported the decision by the manufacturer to withdraw the product.

AAP Statement on Use of Trampolines

A revised policy statement from the American Academy of Pediatrics (AAP), published in the May 1999 issue of Pediatrics, recommends that trampolines not be used at home—either indoors or outdoors. The AAP states that, during anticipatory guidance, physicians should advise parents never to allow children to use a home trampoline. In addition, the AAP recommends that trampolines not be part of routine physical education classes in schools and believes that the trampoline has no place on playgrounds and should never be regarded as play equipment.

The following data collected by the Consumer Product Safety Commission's (CPSC) National Electronic Injury Surveillance System is taken from the report:

• Trampoline-related injuries increased 140 percent from 1990 to 1996.

• An estimated 83,000 trampoline-related injuries requiring an emergency department visit occurred in 1996.

• Thirty percent of trampoline-related injuries were fractures, often resulting in hospitalization and surgery.

• Catastrophic cervical spine injuries are rare; however, head and neck injuries make up a notable number of the more serious injuries requiring hospitalization.

• Since 1990, the CPSC has received reports of six deaths involving trampolines. The victims were aged three years to 21 years. Most of the deaths occurred when victims fell from the trampoline, and most injuries involved the spinal cord.

Guidelines on the design of trampolines and on behavior while using trampolines on a limited basis in supervised training programs are included in the statement.

Recommendations for Inactivated Poliovirus Vaccine

To eliminate the risk of contracting vaccine-associated paralytic poliomyelitis (VAPP) from the oral poliovirus vaccine (OPV) itself, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) has recommended the exclusive use of inactivated poliovirus vaccine (IPV) in children. IPV does not cause VAPP. ACIP has concluded that the benefits of OPV no longer outweigh the potential risks.

The recommendations will go into effect next year, and children will begin receiving IPV for all four doses of poliovirus vaccine. Currently, the recommendation from the CDC is for children to receive two doses of IPV at two months and four months of age followed by two doses of OPV administered at six to 18 or 12 to 18 months of age and at four to six years of age.

Richard Zimmerman, M.D., M.P.H., University of Pittsburgh (Pa.), is the liaison from the American Academy of Family Physicians (AAFP) to ACIP. For more information on current recommendations for the poliovirus vaccine, see the January 1, 1999, issue of American Family Physician, which includes an article by Dr. Zimmerman on the poliovirus vaccine and also contains the 1999 Harmonized Childhood Immunization Schedule from ACIP, the AAFP and the American Academy of Pediatrics.

New Therapy for Urinary Control

A new treatment for patients with severe urinary control problems has been approved by the U.S. Food and Drug Administration. The InterStim therapy for urinary control is indicated for the treatment of urinary urge incontinence and urinary retention, as well as for significant symptoms of urgency frequency.

InterStim therapy uses neurostimulation to send mild electrical pulses to the sacral nerves in the lower back that control bladder function. The small neurostimulator is placed under the skin of the abdomen.

In clinical trials of the therapy for 12 months, 82 percent of patients with urgency-frequency experienced increased volumes of urine voided with the same or a reduced degree of urgency. After six months, 77 percent of patients with urinary urge incontinence reported that they no longer experienced unexpected, heavy wetting episodes. After six months of therapy, 53 percent of patients with urinary retention no longer needed a catheter.

Risks associated with the therapy include the risk of the surgical procedure itself and infection. Possible side effects include pain, infection and lead migration. More information can be obtained by calling 800-664-5111, ext. 3000, or by visiting the InterStim Web site at http://www.interstim.com.

Treatment of Depression

The newer antidepressant drugs known as selective serotonin reuptake inhibitors (SSRIs) are as effective in treating depression and dysthymia as older-generation antidepressants, such as tricyclics, according to a new evidence report prepared for the Agency for Health Care Policy and Research (AHCPR). The report is one of a series of evidence reports and technology assessments sponsored by the AHCPR 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.

No trials evaluating the effectiveness of two herbal preparations, kava kava and valeriana, in the treatment of depression were found, and evidence about the effectiveness of St. John's wort is unclear. However, the researchers noted that the literature suggests St. John's wort shows promise for the treatment of mild to moderate depression and may have fewer adverse effects than older antidepressants.

The researchers said that the discontinuation rates of the older and newer antidepressant medications because of adverse effects are similar. The report noted that, when selecting an antidepressant, clinicians should consider both newer and older anti-depressants, taking into account such factors as cost, dropout rates, the lack of information about relative benefits compared with alternative therapies, and the individual patient's preferences and tolerance of particular adverse effects.

A summary of the report, “Treatment of Depression: Newer Pharmacotherapies: Summary,” is on the AHCPR Web site at http://www.ahcpr.gov. The full report (Evidence Report/Technology Assessment No. 7, AHCPR publication 99-E013) may be obtained from the AHCPR Publications Clearinghouse by calling 800-358-9295.

Prevention of Varicella

The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) now recommends that states require all children entering child care facilities and elementary schools to have received the varicella (chickenpox) vaccine or have evidence of immunity to varicella. In addition, recommendations for adult vaccination have been strengthened for persons at high risk for exposure and now include adolescents and adults who live in households with children.

The recommendations were published in the May 28, 1999, issue of the CDC's reports and recommendations series of Morbidity and Mortality Weekly Report (MMWR Morb Mortal Wkly Rep 1999;48(RR6):1–5). The report also covers use of the vaccine following exposure and for outbreak control, use of the vaccine for some children infected with the human immunodeficiency virus and other persons with altered immunity, vaccination of adults and adolescents at high risk for exposure and transmission, and adverse reactions to the vaccine. New information on varicella vaccine postlicensure safety data is also included.

The most frequently reported adverse event was rash (37 per 100,000 vaccine doses). Most rash events occurring within two weeks of vaccination were caused by wild-type virus. Reports of serious adverse events have included encephalitis, ataxis, erythema multiforme, Stevens-Johnson syndrome, pneumonia, thrombocytopenia, seizures, neuropathy and herpes zoster. The CDC states that adverse event rates following vaccinations are substantially lower than rates following the natural disease. In most cases, data are insufficient to determine a causal association.

As of April 28, 1999, Colorado, Maryland, Massachusetts, Michigan, Oklahoma, Oregon, Rhode Island, Tennessee, Texas, Virginia, and the District of Columbia, have passed regulations requiring varicella vaccination or evidence of immunity for children entering elementary school or child care centers.

FDA Advisory on the Use of Trovan

The U.S. Food and Drug Administration (FDA) has issued an advisory to physicians concerning liver toxicity associated with the use of trovafloxacin (Trovan), an oral antibiotic, and alatrofloxacin (Trovan-IV), the intravenous formulation. Trovan was approved in 1998 for use in the treatment of a broad range of infections, from minor skin infections to severe infections in hospitalized patients. The FDA now recommends that Trovan be reserved only for use in patients who meet all of the following criteria:

• Patients who have at least one of several specific infections, such as nosocomial pneumonia, that are considered to be life- or limb-threatening.

• Patients who begin their therapy in in-patient health care facilities.

• Patients for whom the benefit of use of Trovan outweighs the potential risks.

The FDA recommends that patients receive the medication for no longer than 14 days and that patients who meet the treatment criteria for Trovan be started on the intravenous form of the drug. After the patient has stabilized, the oral dosage may be started.

The FDA has received 14 reports of cases of acute liver failure that it believes are strongly associated with the drug. Six of these patients died.

More information about Trovan is available on the FDA Web site at http://www.fda.gov/ and from the manufacturer of the drug at 800-438-1985.

Availability of Updated HIV Treatment Guidelines

An updated version of the “Guidelines for the Use of Antiretroviral Agents in HIV-infected Adults and Adolescents” has been made available on the AIDS Treatment Information Service Web site at http://www.hivatis.org. Developed by the Panel on Clinical Practices for the Treatment of HIV, a joint effort of the Department of Health and Human Services and the Henry J. Kaiser Family Foundation, the guidelines have been updated several times since first publication in Morbidity and Mortality Weekly Report in 1998. The most recent changes contain information about the newly licensed nucleoside reverse transcriptase inhibitor, abacavir (Ziagen).

The panel notes that the potential advantages of using abacavir in a treatment regimen include ease of administration (two pills twice daily), and the opportunity to save other classes of potent anti-HIV drugs for later use. The revised guidelines include a hypertext link to a brief discussion of the controversy surrounding the use of the drug hydroxyurea in the treatment of HIV infection. In addition, tables and charts have been updated and reorganized.

The guidelines were constructed as a “living document” and are updated frequently by the panel. Changes from the previous document are highlighted in the text. The guidelines can also be obtained by calling 800-448-0440 or by faxing a request to 301-519-6616.

Report on Treatment of Acute Ischemic Stroke

The Health Technology Advisory Committee (HTAC) has published a report on the treatment of acute ischemic stroke (brain attack). HTAC was established in 1992 by the Minnesota state legislature. It is an independent, nonpartisan advisory body that evaluates new and emerging health care technologies based on existing scientific research and technology assessments.

The report provides information on the safety and effectiveness of a recombinant tissue plasminogen activator (t-PA) in the treatment of brain attack. T-PA is the only treatment for brain attack approved by the U.S. Food and Drug Administration. Discussions in the report include those on the issues involved in the use of t-PA including cost, unresolved issues in the treatment of brain attack and how the incidence of brain attack can be decreased. An accompanying brochure includes answers to questions commonly asked by patients regarding brain attack.

This report (document no. 980501) and others published by HTAC may be obtained by calling 651-282-6374; e-mail: htac@health.state.mn.us/. There is no charge for the reports. All HTAC reports are also available through the World Wide Web at http://www.health.state.mn.us/htac/index./htm.