Guidelines on Allergen Immunotherapy

The American College of Allergy, Asthma and Immunology has issued guidelines on allergen immunotherapy. The recommendations are available online at www.jcaai.org/Param/immunotherapy/index.htm.

According to the guidelines, patients who have symptoms of allergic rhinitis or allergic asthma and demonstrate specific IgE antibodies after exposure to allergic triggers (e.g., pollens, molds, dust mites, pet dander, insect stings), whose symptoms are not adequately controlled by medications, and who want to avoid or reduce long-term medication use should be considered for allergen immunotherapy. The decision to begin immunotherapy depends on the degree to which symptoms can be reduced by avoidance and medication, the amount and type of medication required to control symptoms, and the adverse effects of the medications.

Venom immunotherapy should be considered in patients with a history of systemic reaction to a Hymenoptera sting, especially if the reaction was associated with respiratory or cardiovascular symptoms.

AHRQ Report on Hospital Care of Women

Pregnancy and childbirth accounted for 4.4 million hospital admissions in 2000, or one of every four hospital stays, according to a new report from the Agency for Healthcare Research and Quality (AHRQ). The report, Care of Women in U.S. Hospitals, 2000, is available online at www.ahrq.gov.

According to the report, depression is the second leading reason for the hospitalization of younger women, leading to approximately 205,000 hospital stays per year. Physicians generally hospitalize women with more severe cases of depression, and many more women are treated for depression on an outpatient basis.

Among women older than 44 years, pneumonia and heart problems are among the top reasons for hospitalizations. Treatment for hip fractures and hip replacements are among the top 10 reasons why women older than 80 years are hospitalized.

Other leading reasons for admitting younger women to a hospital include the following:

• Fibroids of the uterus (139,000 admissions in 2000)

• Gallbladder disease (117,000 admissions)

• Back problems (85,000 admissions)

• Asthma (70,000 admissions)

The report includes data on why women of different ages are hospitalized, what happens to them in the hospital, what hospitals charge for their care, and who pays the bill. It is based on data from AHRQ's Nationwide Inpatient Sample, a database that is part of the Heath care Cost and Utilization Project, which provides national estimates based on a sample of approximately 1,000 hospitals and 7 million hospital discharges. The report is the third in a series of AHRQ publications that provide statistical information on different aspects of hospital care.

ACOG Guidelines on Perinatal Care

The American College of Obstetricians and Gynecologists (ACOG) has issued guidelines on perinatal care and counseling parents when an extremely preterm birth is anticipated. ACOG Practice Bulletin No. 38 appeared in the September 2002 issue of Obstetrics and Gynecology.

Although early preterm births and births of extremely low birth weight (less than 1 kg [2.2 lb]) newborns make up less than 1 percent of all births, they account for nearly one half of all cases of perinatal mortality. Recent information from large multi-center studies has made it possible to develop an evidence-based approach to managing extremely preterm and extremely low birth weight fetuses.

Parents of anticipated extremely preterm fetuses can be counseled that the neonatal survival rate for newborns increases from zero percent at 21 weeks' gestation to 75 percent at 25 weeks' gestation. The survival rate increases from 11 percent at 401 to 500 g (0.9 to 1.1 lb) to 75 percent at 701 to 800 g (1.5 to 1.8 lb). Girls generally have a better prognosis than boys.

Parents also can be counseled that infants delivered before 24 weeks' gestation are less likely to survive, and that those who do are likely to have disabilities. Disabilities in mental and psychomotor development, neuromotor function, or sensory and communication function are present in about one half of extremely preterm fetuses.

ACOG recommends moving the mother to a tertiary care center before delivery when possible. Women at risk of delivery between 24 and 34 weeks' gestation also should be considered to receive a single course of corticosteroids. Whenever possible, data specific to the age, weight, and gender of the fetus should be used to aid management decisions, and each member of the health care team should strive for consistency in discussions with family members about the assessment, prognosis, and recommendations for care.

Update on West Nile Virus Activity

West Nile virus (WNV) activity expanded substantially in the United States last year, with the number of reported human infections increasing more than 20-fold from the previous three years, according to provisional data from the Centers for Disease Control and Prevention (CDC). The report, “Provisional Surveillance Summary of the West Nile Virus Epidemic—United States, January-November 2002,” is available online at www.cdc.gov/mmwr/preview/mmwrhtml/mm5150a1.htm.

In 2002, there were 3,389 human cases of WNV-associated illness reported, compared with 149 cases reported between 1999 and 2001. West Nile meningoencephalitis (69 percent of WNV cases) was the most common illness, followed by West Nile fever (21 percent), and unspecified illness (10 percent). Onset of illness ranged from June 10 to November 4, and the epidemic peak occurred during the week that ended August 24.

WNV activity was reported in 44 states and the District of Columbia in 2002, compared with 27 states and the District of Columbia in 2001. Nearly two thirds of the WNV infections that affected humans last year were reported in Illinois, Michigan, Ohio, Louisiana, and Indiana.

The median age of persons infected with WNV was 55 years. Of the 2,354 persons with West Nile meningoencephalitis last year, 199 (9 percent) died; two (0.3 percent) persons with West Nile fever died.

AHRQ Releases New Clinical Preventive Services Guidebook

The Agency for Healthcare Research and Quality (AHRQ) has released the third edition of its Guide to Clinical Preventive Services. This third edition is a compilation of new and updated recommendations from the U.S. Preventive Services Task Force (USPSTF) on clinical preventive services, including screenings, immunizations, and counseling for behavior changes.

The guide is available on a subscription basis for $60. Subscribers will receive semiannual installments of recently released recommendations and their summaries of evidence; USPSTF background, history, and methods articles; and two three-ring binders to collect and store the installments. The subscription is for a five-year term.

The AHRQ also has released its new Step-by-Step Guide to Delivering Clinical Preventive Services: A Systems Approach. This book is designed to help physicians integrate USPSTF recommendations into their practice and describes how to develop a formal system for delivering clinical preventive services. The Step-by-Step Guide is available free of charge. Health risk profiles and flow sheet packets also are available for purchase through the Step-by-Step Guide.

To subscribe to the Guide to Clinical Preventive Services, or to order the Step-by-Step Guide, call the AHRQ Publications Clearinghouse at 800-358-9295.

CDC Guidelines on Testing for Anti-HCV

The Centers for Disease Control and Prevention (CDC) has issued new guidelines for laboratory testing and result reporting of antibody to hepatitis C virus (anti-HCV). The recommendations are available online at www.cdc.gov/mmwr/preview/mmwrhtml/rr5203a1.htm.

According to the guidelines, anti-HCV testing should include an antibody screening assay and, for screening test-positive results, a more specific supplemental assay. Verifying the presence of anti-HCV minimizes unnecessary medical visits and psychologic harm for persons who test falsely positive by screening assays. It also ensures that proper counseling, medical referral, and evaluation are targeted for patients with serologically confirmed HCV infection.

There is substantial variation among laboratories in reflex supplemental testing. Despite previous recommendations for supplemental testing of all anti-HCV screening test-positive results, the majority of laboratories report positive anti-HCV results based only on a positive screening assay. The new recommendations address this problem by expanding the recommended anti-HCV testing algorithm to include an option for more specific testing based on the signal-to-cut-off (s/co) ratios of screening test-positive results. This testing can be implemented without substantial increases in testing costs.

FDA Approvals

• Ezetimibe. The U.S. Food and Drug Administration (FDA) has approved ezetimibe (Zetia) for cholesterol reduction. Ezetimibe is the first in a new class of cholesterol-lowering agents that inhibits the intestinal absorption of cholesterol. The dosage of ezetimibe is 10 mg once daily. It can be used by itself or in combination with statins in patients with high cholesterol in order to reduce LDL cholesterol and total cholesterol levels. The patient also should follow an appropriate diet and exercise program.

Ezetimibe should not be taken by people who are allergic to any of its ingredients. When combined with a statin, ezetimibe should not be taken by anyone with active liver disease or unexplained persistent liver enzyme elevations. In addition, liver function tests should be performed at the start of therapy and after that in accordance with the label for the particular statin. Liver function tests are not required when ezetimibe is used alone.

Ezetimibe is not recommended for patients with moderate or severe hepatic insufficiency.

The most frequent adverse events reported in clinical trials were back pain, abdominal pain, and arthralgia, according to the manufacturer.

• Teriparatide. The FDA has approved teriparatide (rDNA origin) injection (Forteo) for the treatment of osteoporosis in postmenopausal women at high risk for fractures. The drug also was approved for use by men with primary or hypogonadal osteoporosis who are at high risk for fractures.

Teriparatide is the first drug in a new class of bone formation agents that work primarily by increasing the number and action of osteoblasts. The drug will be available in a disposable pen device that patients can use for self-injection. Teriparatide should be taken for up to two years.

In clinical trials, teriparatide appeared to increase leg cramps and dizziness. The most frequent treatment-related adverse events were mild, similar to placebo, and did not require discontinuation of therapy.

CDC Toolkit for Prevention and Treatment of Brain Injuries

The Centers for Disease Control and Prevention (CDC) has developed a new toolkit for physicians to raise awareness about mild traumatic brain injury (MTBI), and to improve treatment for patients with MTBI. Heads Up: Brain Injury in Your Practice is available by e-mailing the CDC at jpmcdonald@cdc.gov.

MTBI, also known as concussion, is one of the most common neurologic disorders. Approximately 1.5 million people incur traumatic brain injuries in the United States every year. Of those, approximately 1.1 million, or 75 percent, incur an MTBI. Many are released from medical care without hospitalization or never receive medical care at all. An unknown portion of those who are not hospitalized may experience long-term disability such as persistent headache, confusion, pain, memory problems, fatigue, difficulties with sleep patterns, mood changes, or vision or hearing problems.

The kit provides physicians with clinical information on incidence, prevention strategies, diagnosis, and treatment; patient education materials including tips on preventing brain injuries and a booklet for patients already diagnosed with a brain injury; and a CD-ROM with relevant scientific articles and download-able kit materials.