Diabetes in the School and Day Care Setting

Diabetes is one of the most common chronic diseases of childhood, affecting about 125,000 persons 19 years or younger in the United States. Because the majority of these young persons attend school and/or some type of day care, a knowledgeable staff is required to provide a safe school environment. The American Diabetes Association (ADA) has issued a position statement on the management of children with diabetes in school and day care settings. The position statement appears in a January 2000 supplement to Diabetes Care.

The ADA reports that studies have shown that the majority of school personnel do not adequately understand diabetes and that parents of children with diabetes lack confidence in the ability of teachers to effectively manage their children's diabetes. Because of this, diabetes education should be targeted at day care providers, teachers and other school personnel who interact with the child, including school administrators, coaches, school nurses, bus drivers and school secretaries.

According to the ADA statement, an individualized diabetes care plan should be developed by the parent/guardian, the child's diabetes care team and school personnel or the day care provider. The plan should address the specific needs of the child and provide specific instructions for each of the following areas:

• Blood glucose monitoring, including the frequency and circumstances that require testing.

• Insulin administration, if necessary, including the dosages and injection times prescribed for specific blood glucose values and the storage of insulin.

• Meals and snacks, including food content, amounts and timing.

• Symptoms and treatment of hypoglycemia, including the administration of glucagon, if appropriate.

• Symptoms and treatment of hyperglycemia.

• Testing for ketones and appropriate actions to take for abnormal ketone levels.

The ADA position statement also discusses responsibilities of the various caregivers and expectations of the child in diabetes care.

Use of Rifamycins in HIV-Infected Patients

Guidelines for managing drug interactions that can result when patients with human immunodeficiency virus (HIV) infection and tuberculosis are treated simultaneously with protease inhibitors, nonnucleoside reverse transcriptase inhibitors (NNRTIs) and rifamycins were previously published in Morbidity and Mortality Weekly Report. Protease inhibitors and NNRTIs are antiretroviral agents that are substrates that may inhibit or induce cytochrome P-450 isoenzymes (CYP450), while rifamycins are antituberculosis agents that induce CYP450 and may substantially decrease blood levels of the antiretroviral agents. Drug-drug interactions occur because each type of drug affects the action of the other. Updated information regarding drug-drug interactions among these agents is provided in a notice to readers, which appears in the March 10, 2000 issue of Morbidity and Mortality Weekly Report.

Drug regimens that include rifabutin instead of rifampin were previously suggested as the preferred alternative for the treatment of active tuberculosis among patients taking protease inhibitors or NNRTIs. New data indicate that rifampin can be used for the treatment of active tuberculosis in the following situations: (1) in patients whose antiretroviral regimen includes the NNRTI efavirenz and two nucleoside reverse transcriptase inhibitors (NRTIs); (2) in patients whose antiretroviral regimen includes the protease inhibitor ritonavir and one or more NRTIs; or (3) in patients whose antiretroviral regimen includes the combination of two protease inhibitors, ritonavir and either saquinavir hard-gel capsule or saquinavir soft-gel capsule.

The updated guidelines also recommend substantially reducing the dosage of rifabutin (150 mg two or three times per week) when it is administered to patients who are taking ritonavir (with or without saquinavir) and increasing the dosage of rifabutin to 450 mg or 600 mg per day or 600 mg two or three times per week when rifabutin is used concurrently with efavirenz.

Copies of the guidelines are available by writing the National Center for HIV, STD and TB Prevention of the Centers for Disease Control and Prevention, 1600 Clifton Rd., N.E., Mailstop E-06, Atlanta, GA 30333. The guidelines are also posted on the Web at http://www.cdc.gov.

New Indication for Levofloxacin

The U.S. Food and Drug Administration (FDA) has approved a new indication for levofloxacin (Levaquin). It is the first antimicrobial agent indicated for the treatment of penicillin-resistant Streptococcus pneumoniae in community-acquired pneumonia.

The safety and efficacy of levofloxacin in children, adolescents, pregnant women and nursing mothers are unknown. Persons who have a history of hypersensitivity to levofloxacin, quinolone antimicrobial agents or any other components of the medication should not use levofloxacin. Common adverse effects related to the use of levofloxacin include nausea (1.3 percent), diarrhea (1.1 percent), dizziness (0.4 percent) and insomnia (0.3 percent). Serious and occasionally fatal hypersensitivity and/or anaphylactic reactions have been reported in patients receiving levofloxacin, often following the first dose.

“I recommend that physicians consider a fluoroquinolone with enhanced activity against penicillin-resistant S. pneumoniae if this organism is suspected,” said John Bartlett, M.D., Division of Infectious Diseases, Johns Hopkins University. “The resistance of S. pneumoniae to penicillin is increasing globally. It is the result of misuse, and calls attention to the need for the proper use of Levaquin and all other antimicrobials.”

Levofloxacin was approved by the FDA in 1997. It is also indicated for the treatment of mild to severe community-acquired pneumonia caused by other pathogens, acute maxillary sinusitis, acute bacterial exacerbation of chronic bronchitis, mild to moderate uncomplicated skin infections and skin structure infections, complicated urinary tract infections, acute pyelonephritis and uncomplicated urinary tract infections.

Consensus Statement on Chronic Tracheostomy

Although children with a chronic tracheostomy are especially at risk for devastating airway compromise, no standards for their care have been published and little research has been done. The Pediatric Assembly of the American Thoracic Society (ATS) funded a working group with input from several disciplines to develop a consensus statement about the care of these children. In the absence of scientific data, the panel made recommendations for treatment and further research by consensus. The statement appears in the January 2000 issue of American Journal of Respiratory and Critical Care Medicine.

The ATS consensus statement covers selection and care of a tracheostomy tube, suctioning, humidification, speech development, caregiver education, medications, monitoring, decannulation procedures and complications.

The areas that were identified as particularly in need of or amenable to research include the following:

• The relationship of the frequency of tracheostomy tube change to the incidence of airway infection or granulation tissue, and the ability of caregivers to deal with emergencies such as accidental decannulation.

• The factors involved in the development of increasing stiffness in polyvinyl chloride tubes, and the development of cracks, leaks and tears.

• The comfort, convenience, safety and complications of tracheostomy ties and the optimal frequency of tie changes.

• The cleaning and reuse of suction catheters.

• The optimal use of humidification, the complications associated with inadequate humidification and the best technology to use in particular situations.

• The pharmacokinetics of medications inhaled through a tracheostomy, particularly in spontaneously breathing patients.

• The use and timing of surveillance endoscopies.

• The role of home monitoring devices.

FDA Approves New Blood Glucose Device

The U.S. Food and Drug Administration (FDA) recently cleared a new blood glucose monitor called FreeStyle that allows patients with diabetes to obtain blood samples from places other than fingertips. The product is designed to cause much less pain than the usual fingertip testing.

FreeStyle uses a fraction of the blood sample currently required by other tests on the market to give patients a quick and accurate blood glucose value. Because the test is nearly pain free, the device may improve the management of diabetes by reducing this common barrier to testing. According to the results of a study by the National Institute of Health, tighter control of blood glucose levels could dramatically reduce the long-term effects of diabetes, such as eye, kidney and nerve disease.

More information on the FreeStyle monitor may be obtained by writing the manufacturer at TheraSense, 1360 S. Loop Rd., Alameda, CA 94502 or by calling 510-749-5400. The information is also available on the Web (http://www.TheraSense.com).

Injuries and Violence Among Older Adults

Among adults 65 years and older in the United States, injuries and violence are major causes of disability and morbidity. Injuries can impair the quality of life of older adults and may result in billions of dollars in health care expenses each year. A report on injuries and violence among older adults appears in the December 17, 1999 issue of the Surveillance Summary series of Morbidity and Mortality Weekly Report. The report reviews data on fall-related deaths, hospitalizations for hip fracture, injuries from motor vehicle crashes, suicides and homicides.

According to the report, to keep the burden of injuries and violence from increasing among older adults, persons who have frequent contact with older adults must be aware of the extent of the problem and prevention strategies must be improved. Interventions should be multifaceted and older adults who are able to take an active role in risk reduction should do so. The surveillance summary recommends that the following interventions be implemented:

• To prevent fall-related injuries and hip fractures, interventions should promote behavioral and environmental changes as well as the development of safety products.

• To prevent motor vehicle-related injuries, interventions should focus on improving the design of motor vehicles, changing traffic and pedestrian environments to improve safety, and changing the behavior of older drivers, passengers and pedestrians.

• To prevent suicide among older adults, interventions should educate health care professionals and care-givers about the extent of the problem and risk factors for suicide among older adults.

• To prevent homicide and violence against older adults, a variety of disciplines (e.g., criminal justice, social services, education, community advocacy and public health) must be integrated.

“Surveillance for Injuries and Violence Among Older Adults” is available on the CDC Web site at http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/ss4808a3.htm.