PedSPAM August 1998

Welcome to a slightly delayed PedSPAM for August. Here are some more things from my update reading that might interest you.

In the News

The rapid increase in drug-resistant head lice in the US has led to new approaches to handle recalcitrant infestations. A five-step plan outlined by Harvard researchers suffocates the lice and helps in eliminating them from the head of the victim. When ordinary olive oil, either used alone or as a supplement to pediculicidal products, is applied to active head lice the lice are literally drowned by the oil after several hours.

The first step is to use permethrin or pyrethrum-based pediculicides (Nix® cream rinse)
The second step: olive oil is applied liberally to the scalp and hair shortly before bedtime, with the victim donning a shower cap to prevent any oil from rubbing off while sleeping.
Step three is the most important step in the battle because before the oil is washed out, the hair must be methodically combed using a special metal nit comb. The lice are stymied by the oil and are easier to comb out.
The fourth step is making sure the surrounding environment is clear of the lice. The weapons researchers recommend people use in preventing any reappearance are the vacuum cleaner and dryer. Dry heat is a very effective against lice, so instead of washing an infested item use the dryer. Vacuuming the home after infestation is important to pick up any shed hairs or stray vestiges that could still be still lurking in the carpet.
The fifth step is visually checking close to the scalp for any nits with a metal nit remover. The infested person should be checked over a three-week period. The lice can be pulled off by a fingernail, placed on a tissue and thrown away.

The Journal of the American Medical Association reports that the US rate of prone infant sleep position is declining. The researchers called for redoubled efforts to educate mothers about the importance of back sleeping, especially among low income minority families. African-American grandmothers were highly likely to be resistant to back-sleeping. The benefits of back-sleeping are now irrefutable in study after study around the world. Remember: Back To Sleep!

Even if written records are available, blood tests for immunity show that vaccine records of foreign-born adopted children are questionable, concluded Margaret K. Hostetter, M.D. It is wise to repeat the whole series for adopted children from China, Russia and Eastern Europe.

In determining the ratio of good therapeutic effects to undesirable side effects, inhaled steroids for asthma differ widely in "bioavailability" and thus side effects. Harold S. Nelson, M.D. of the National Jewish Medical and Research Center in Denver (a hospital specializing in asthma care) stated "You don't want a high (bioavailability) percentage because the agent is not contributing to any clinical effect, but only contributing to the side effect."

triamcinolone (Nasacort, Rhone-Poulenc Rorer), flunisolide (Aerobid, Forest) and beclomethasone (Beclovent, Glaxo Wellcome) are three inhaled corticosteroids with about a 20% rate of bioavailability
budesonide (Pulmicort, Astra) has about 11%
fluticasone (Flovent, Glaxo Wellcome) less than 1%.

Complications of inhaled steroids in higher doses include growth delay among prepubertal children, although it is not clear this growth delay leads to permanent loss of adult height. Steroids have also been linked to osteoporosis, thinning of the skin and bruising easily, cataracts and glaucoma (increased pressure within the eye). Bioavailability for causing these complications is reduced dramatically by

using a spacer device ( such as Aerochamber® or Inspirease®)
rinsing the mouth (swish and spit) after inhalation.

The Texas Department of Health reports an outbreak of invasive group A streptococcal infections, leading to 36 deaths. Official causes of death for the majority of cases included streptococcal toxic shock syndrome, pneumonia and necrotizing fasciitis. In children, the most common predisposing condition was chickenpox. Comment: VACCINATE.

A study from the Yale University School of Medicine of patients referred with a diagnosis of Lyme disease found that adult patients and to some degree their physicians freak out about the disease, with resultant over-diagnosis and overtreatment.

Lyme disease is a tick-borne illness caused by the bacterium Borrelia burgdorferi (technically a "spirochete" in the same general family as syphilis). The researchers say that patients suspected of having the disease receive excessive numbers of blood tests, and are often over-treated with antibiotics in repeated courses (one round of the right antibiotic is almost always curative) or which they actually don't need at all (60% of the patients referred to the specialty study center did not have Lyme disease). Patients given a diagnosis of Lyme disease often (40%) suffer depression as a result - even though 60% don't even have the disease at all.

Lyme disease often produces vague symptoms that are also found with other diseases such as non-specific fatigue-arthralgia-myalgia syndrome, depression, rheumatoid arthritis, bursitis and myasthenia gravis. The researchers noted that many times diagnosis and treatment of the patients's actual illness is delayed by the focus on Lyme disease as the explanation. Current endemic areas for Lyme disease include the northeastern coast of the United States, the upper Midwest and northern California into Oregon. Annals of Internal Medicine 1998:128;354-62.

A report in the August electronic edition of Pediatrics demonstrated fecal impactions with fecal soiling (encopresis) in two four-year-olds caused by swallowing large amounts of chewing gum. A 4 year old boy had a two year history of constipation with chronic fecal soiling in his pants. His lower colon was found to be full of a large mass of old chewing gum. This boy always swallowed his gum after chewing five to seven pieces each day. A 4 year old girl had a very similar history with a similar outcome: fecal soiling caused by a large rectal mass of gum. The authors warn that chewing gum should not be swallowed and not given to children who cannot understand this point.

According to a recent study, children and adolescents with chronic fatigue have a syndrome that is similar to that described in adults, but younger patients seek medical attention earlier in the course of the illness and have a more optimistic outcome. In contrast to adults with the syndrome, most are improved or cured within a few years.

A study in the American Journal of Epidemiology suggests that multivitamin intake by smoking mothers, may reduce fetal death caused by maternal smoking. The effect was greatest for mothers who smoked the most. Vitamin intake had no effect on the risk of fetal death for nonsmoking women.

The July issue of The Journal of Pediatrics reports that intrauterine growth retardation is not associated with long-term deficits in intelligence or functional development, according to the investigators. They also found no evidence that overfeeding growth retarded infants will lead to improved "catch-up" growth.

A retrospective study at St Louis Regional Medical Center in Missouri found that the C-section rate was not increased by epidural analgesia, as some have intimated in the past.

A comprehensive study reported in the July issue of Archives of Pediatrics & Adolescent Medicine called for eliminating the backyard trampoline. Because neither warning labels, public education, nor adult supervision have effectively prevented widespread and often serious injuries to children who use backyard trampolines, the authors recommended that trampolines no longer be sold for private recreational use. In their emergency-room study they saw on average, one significant trampoline-related injury every 3 days. Limb fractures and lacerations were most common. They note:

More than half of all children and nearly three-fourths of those under age 6 years were supervised by an adult at the time of injury
A large majority of parents acknowledged knowing ahead of time about the potential dangers,
One in ten children had previously been injured on a trampoline
More than half the children had continued using a trampoline after being injured

At least in adults, if eradication of Helicobacter pylori (the causative bacterium of humanpeptic ulcer disease) is successful, gastric acid suppression is unnecessary for ulcer healing. Another study showed that if the H. pylori antibody blood test was negative one year later, the patient could be considered cured.

About 80% of Down's syndrome pregnancies can be detected during the first trimester by ultrasound (August 1st issue of The Lancet). This was done by comparing neck skinfold thickness observed on ultrasound to certain standard measurements.

About 40% of surveyed severe asthmatics are not receiving the recommended anti-inflammatory drugs, according to a report in the July Annals of Allergy Asthma and Immunology. This despite current emphasis on inhaled anti-inflammatory drugs as the mainstay of asthma treatment. Patients need to be aware of the guidelines for asthma treatment to receive the best care possible.

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