hicn medical news part cut here volume number april health info com network medical newsletter editor david dodell d m d north nd street suite scottsdale arizona usa telephone fax compilation copyright by david dodell d m d all rights reserved license is hereby granted to republish on electronic media for which no fees are charged so long as the text of this copyright notice and license are attached intact to any and all republished portion or portions the health info com network newsletter is distributed biweekly articles on a medical nature are welcomed if you have an article please contact the editor for information on how to submit it if you are interested in joining the automated distribution system please contact the editor e mail address editor internet david stat com fidonet bitnet atw h asuacad listserv mednews asuacad bitnet or internet mednews asuvm inre asu edu anonymous ftp vm nodak edu notification list hicn notify request stat com fax delivery contact editor for information t a b l e o f c o n t e n t s centers for disease control and prevention mmwr april rates of cesarean delivery malaria among u s embassy personnel fda approval of hib vaccine for children infants dental news workshop explores oral manifestations of hiv infection food drug administration news fda approves depo provera injectable contraceptive new rules speed approval of drugs for life threatening illnesses articles research promises preventing slowing blindness from retinal disease affluent diet increases risk of heart disease general announcments publications for health professionals from national cancer institute publications for patients available from national cancer institute aids news summaries aids daily summary for april to april aids statistics worldwide aids statistics hicnet medical newsletter page i volume number april centers for disease control and prevention mmwr rates of cesarean delivery united states source mmwr date apr cesarean deliveries have accounted for nearly million of the approximately million annual deliveries in the united states since table the cesarean rate in the united states is the third highest among reporting countries exceeded only by brazil and puerto rico this report presents data on cesarean deliveries from cdc s national hospital discharge survey nhds for and compares these data with previous years data on discharges from short stay nonfederal hospitals have been collected annually since in the nhds conducted by cdc s national center for health statistics for medical and demographic information were abstracted from a sample of inpatients discharged from participating hospitals the cesareans and vaginal births after a prior cesarean vbac presented in this report are based on weighted national estimates from the nhds sample of approximately women discharged after delivery the estimated numbers of live births by type of delivery were calculated by applying cesarean rates from the nhds to live births from national vital registration data therefore estimates of the number of cesareans in this report will not agree with previously published data based solely on the nhds stated differences in this analysis are significant at the confidence level based on the two tailed t test with a critical value of in there were cesareans per deliveries the same rate as in and similar to rates during table the primary cesarean rate i e number of first cesareans per deliveries to women who had no previous cesareans for also was stable ranging from to in the cesarean rate in the south was significantly p higher than the rates for the west midwest and northeast rates were higher for mothers aged greater than or equal to years than for younger women in proprietary hospitals than in nonprofit or government hospitals in hospitals with fewer than beds than in larger hospitals and for deliveries for which blue cross blue shield and other private insurance is the expected source of payment than for other sources of payment table the same pattern characterized primary cesarean deliveries since the early s the number and percentage of births to older women increased however if the age distribution of mothers in had remained the same as in the overall cesarean rate in would have been essentially the same as the observed based on the nhds of the approximately live births in an hicnet medical newsletter page volume number april estimated were by cesarean delivery of these an estimated births were repeat cesareans and were primary cesareans since approximately primary cesareans have been performed annually in of women who had a previous cesarean delivered vaginally compared with in of all cesareans in were associated with a previous cesarean with dystocia i e failure of labor to progress with breech presentation with fetal distress and with all other specified complications the average hospital stay for all deliveries in was days in comparison the hospital stay for a primary cesarean delivery was days and for a repeat cesarean days nearly twice the duration for vbac deliveries days or for vaginal deliveries that were not vbacs days in the average hospital stay for all deliveries was days for primary cesareans days for repeat cesareans days and for vbac and non vbac vaginal deliveries and days respectively reported by office of vital and health statistics systems national center for health statistics cdc editorial note the cesarean rate in the united states steadily increased from through however the findings in this report indicate that rates have been stable since because there is little evidence that maternal and child health status has improved during this time and because cesareans are associated with an increased risk for complications of childbirth a national health objective for the year is to reduce the overall cesarean rate to or fewer per deliveries and the primary cesarean rate to or fewer per deliveries objective postpartum complications including urinary tract and wound infections may account in part for the longer hospital stays for cesarean deliveries than for vaginal births moreover the prolonged hospital stays for cesarean deliveries substantially increase health care costs for example in the average costs for cesarean and vaginal deliveries were and respectively the additional cost for each cesarean delivery includes for physician fees and for hospital charges if the cesarean rate in had been the year objective instead of the number of cesarean births would have decreased by versus resulting in a savings of more than billion in physician fees and hospital charges despite the steady increase in vbac rates since several factors may impede progress toward the year national health objectives for cesarean delivery for example vbac rates substantially reflect the number of women offered trial of labor which has been increasingly encouraged since of women who are offered a trial of labor could deliver vaginally a level already achieved by many hospitals trial of labor was routinely offered in of hospitals surveyed in the most recent year for which hicnet medical newsletter page volume number april national data are available when the vbac rate according to nhds data was the year objective specifies a vbac rate of based on all women who had a prior cesarean regardless of whether a trial of labor was attempted to reach the overall cesarean rate goal however increases in the vbac rate will need to be combined with a substantial reduction in the primary rate one hospital succeeded in reducing the rate of cesarean delivery by applying objective criteria for the four most common indications for cesarean delivery by requiring a second opinion and by instituting a peer review process other recommendations for decreasing cesarean delivery rates include eliminating incentives for physicians and hospitals by equalizing reimbursement for vaginal and cesarean deliveries public dissemination of physician and hospital specific cesarean delivery rates to increase public awareness of differences in practices and addressing malpractice concerns which may be an important factor in maintaining the high rates of cesarean delivery references notzon fc international differences in the use of obstetric interventions jama graves ej nchs summary national hospital discharge survey hyattsville maryland us department of health and human services public health service cdc advance data no taffel sm placek pj kosary cl u s cesarean section rates an update birth public health service healthy people national health promotion and disease prevention objectives full report with commentary washington dc us department of health and human services public health service dhhs publication no phs danforth dn cesarean section jama hospital insurance association of america table cost of maternity care physicians fees and hospital charges by census region based on consumer price index in source book of health insurance data washington dc hospital insurance association of america committee on obstetrics acog committee opinion no guidelines for vaginal delivery after a previous cesarean birth washington dc american college of obstetricians and gynecologists hicnet medical newsletter page volume number april rosen mg dickinson jc vaginal birth after cesarean a meta analysis of indicators for success obstet gynecol shiono ph fielden jg mcnellis d rhoads gg pearse wh recent trends in cesarean birth and trial of labor rates in the united states jama myers sa gleicher n a successful program to lower cesarean section rates n engl j med use of trade names and commercial sources is for identification only and does not imply endorsement by the public health service or the u s department of health and human services hicnet medical newsletter page volume number april malaria among u s embassy personnel kampala uganda source mmwr date apr the treatment and prevention of malaria in africa has become a challenging and complex problem because of increasing drug resistance although the risk of acquiring malaria for u s citizens and their dependents stationed overseas generally has been low this risk varies substantially and unpredictably during may the office of medical services department of state oms dos and cdc were notified of an increased number of malaria cases among official u s personnel stationed in kampala uganda a review of the health records from the embassy health unit ehu in kampala indicated that cases of malaria were diagnosed in official personnel from march through june compared with two cases during the same period in ehu oms dos and cdc conducted an investigation to confirm all reported malaria cases and identify potential risk factors for malaria among u s embassy personnel this report summarizes the results of the investigation malaria blood smears from of the reported case patients were available for review by oms dos and cdc a case of malaria was confirmed if the slide was positive for plasmodium sp of the persons were slide confirmed as having malaria a questionnaire was distributed to all persons served by the ehu to obtain information about residence activities use of malaria chemoprophylaxis and use of personal protection measures i e using bednets and insect repellents having window and door screens and wearing long sleeves and pants in the evening of the persons eligible for the survey responded risk for malaria was not associated with sex or location of residence in kampala although the risk for malaria was higher among children aged less than or equal to years than among persons greater than years this difference was not significant relative risk rr confidence interval ci eighty two percent of the cases occurred among persons who had been living in kampala for years compared with those living there less than year travel outside of the kampala area to more rural settings was not associated with increased risk for malaria four malaria chemoprophylaxis regimens were used by persons who participated in the survey mefloquine chloroquine and proguanil chloroquine alone and proguanil alone in addition persons who responded were not using any malaria chemoprophylaxis the risk for malaria was significantly lower among persons using either mefloquine or chloroquine and proguanil than among persons using the other regimens or no prophylaxis rr ci twelve persons not using prophylaxis reported side effects or fear of possible side effects as a reason the risk for malaria was lower among persons who reported using bednets hicnet medical newsletter page volume number april all or most of the time than among persons who sometimes or rarely used bednets rr ci the risk for malaria was also lower among persons who consistently used insect repellent in the evening compared with those who rarely used repellent rr upper confidence limit risk for malaria was not associated with failure to have window or door screens or wear long sleeves or pants in the evening as a result of this investigation ehu staff reviewed with all personnel the need to use and comply with the recommended malaria chemoprophylaxis regimens ehu staff also emphasized the need to use personal protection measures and made plans to obtain insecticide impregnated bednets and to provide window and door screens for all personnel reported by u s embassy health unit kampala uganda office of medical svcs dept of state washington d c malaria br div of parasitic diseases national center for infectious diseases cdc editorial note in uganda the increase in malaria among u s personnel was attributed to poor adherence to both recommended malaria chemoprophylaxis regimens and use of personal protection measures during a period of increased malaria transmission and intensified chloroquine resistance in sub saharan africa the findings in this report underscore the need to provide initial and continued counseling regarding malaria prevention for persons living abroad in malaria endemic areas preventive measures that are also important for short term travelers to such areas mefloquine is an effective prophylaxis regimen in africa and in most other areas with chloroquine resistant p falciparum however in some areas e g thailand resistance to mefloquine may limit its effectiveness in africa the efficacy of mefloquine compared with chloroquine alone in preventing infection with p falciparum is mefloquine is safe and well tolerated when given at mg per week over a year period the risk for serious adverse reactions possibly associated with mefloquine prophylaxis e g psychosis and convulsions is low i e episodes per users while the risk for less severe adverse reactions e g dizziness gastrointestinal complaints and sleep disturbances is similar to that for other antimalarial chemoprophylactics doxycycline has similar prophylactic efficacy to mefloquine but the need for daily dosing may reduce compliance with and effectiveness of this regimen chloroquine alone is not effective as prophylaxis in areas of intense chloroquine resistance e g southeast asia and africa in africa for persons who cannot take mefloquine or doxycycline chloroquine and proguanil is an alternative although less effective regimen chloroquine should be used for malaria prevention in areas only where chloroquine resistant p falciparum has not been reported country specific recommendations for preventing malaria and information hicnet medical newsletter page volume number april on the dosage and precautions for malaria chemoprophylaxis regimens are available from health information for international travel i e yellow book or hours a day by telephone or fax references lobel ho miani m eng t et al long term malaria prophylaxis with weekly mefloquine in peace corps volunteers an effective and well tolerated regimen lancet world health organization review of central nervous system adverse events related to the antimalarial drug mefloquine geneva world health organization publication no who mal pang l limsomwong n singharaj p prophylactic treatment of vivax and falciparum malaria with low dose doxycycline j infect dis pang l limsomwong n boudreau ef singharaj p doxycycline prophylaxis for falciparum malaria lancet cdc health information for international travel atlanta us department of health and human services public health service dhhs publication no cdc hicnet medical newsletter page volume number april fda approval of use of a new haemophilus b conjugate vaccine and a combined diphtheria tetanus pertussis and haemophilus b conjugate vaccine for infants and children source mmwr date apr haemophilus influenzae type b hib conjugate vaccines have been recommended for use in infants since and their routine use in infant vaccination has contributed to the substantial decline in the incidence of hib disease in the united states vaccines against diphtheria tetanus and pertussis during infancy and childhood have been administered routinely in the united states since the late s and has been associated with a greater than reduction in morbidity and mortality associated with infection by these organisms because of the increasing number of vaccines now routinely recommended for infants a high priority is the development of combined vaccines that allow simultaneous administration with fewer separate injections the food and drug administration fda recently licensed two new products for vaccinating children against these diseases the haemophilus b conjugate vaccine tetanus toxoid conjugate acthib trademark for vaccination against hib disease only and a combined diphtheria and tetanus toxoids and whole cell pertussis vaccine dtp and hib conjugate vaccine tetramune trademark a combination of vaccines formulated for use in vaccinating children against diphtheria tetanus pertussis and hib disease acthib trademark on march the fda approved a new haemophilus b conjugate vaccine polyribosylribitol phosphate tetanus toxoid conjugate prp t manufactured by pasteur merieux serum et vaccins and distributed as acthib trademark by connaught laboratories inc swiftwater pennsylvania this vaccine has been licensed for use in infants in a three dose primary vaccination series administered at ages and months previously unvaccinated infants months of age should receive two doses months apart previously unvaccinated children months of age should receive one dose a booster dose administered at months of age is recommended for all children previously unvaccinated children months of age should receive a single dose and do not require a booster more than of infants receiving a primary vaccination series of acthib trademark consecutive doses at and months of age develop a geometric mean titer of anti haemophilus b polysaccharide antibody greater than ug ml this response is similar to that of infants who receive recommended series of previously licensed haemophilus b conjugate vaccines for which efficacy has been demonstrated in prospective trials two u s efficacy trials of prp t were terminated early because of the concomitant licensure of other haemophilus b conjugate vaccines hicnet medical newsletter page volume number april for use in infants in these studies no cases of invasive hib disease were detected in approximately infants vaccinated with prp t these and other studies suggest that the efficacy of prp t vaccine will be similar to that of the other licensed hib vaccines tetramune trademark on march the fda approved a combined diphtheria and tetanus toxoids and whole cell pertussis vaccine dtp and haemophilus b conjugate vaccine tetramune trademark available from lederle praxis biologicals pearl river new york combines two previously licensed products dtp triimmunol registered manufactured by lederle laboratories pearl river new york and haemophilus b conjugate vaccine hibtiter registered manufactured by praxis biologics inc rochester new york this vaccine has been licensed for use in children aged months years for protection against diphtheria tetanus pertussis and hib disease when indications for vaccination with dtp vaccine and haemophilus b conjugate vaccine coincide based on demonstration of co mparable or higher antibody responses to each of the components of the two vaccines tetramune trademark is expected to provide protection against hib as well as diphtheria tetanus and pertussis equivalent to that of already licensed formulations of other dtp and haemophilus b vaccines the advisory committee for immunization practices acip recommends that all infants receive a primary series of one of the licensed haemophilus b conjugate vaccines beginning at months of age and a booster dose at age months the acip also recommends that all infants receive a four dose primary series of diphtheria and tetanus toxoids and pertussis vaccine at and months of age and a booster dose at years a complete statement regarding recommendations for use of acthib trademark and tetramune trademark is being developed reported by office of vaccines research and review center for biologics evaluation and research food and drug administration div of immunization national center for prevention svcs meningitis and special pathogens br div of bacterial and mycotic diseases national center for infectious diseases cdc references adams wg deaver ka cochi sl et al decline of childhood haemophilus influenzae type b hib disease in the hib vaccine era jama broadhurst le erickson rl kelley pw decrease in invasive haemophilus influenzae disease in u s army children through jama murphy tv white ke pastor p et al declining incidence of haemophilus influenzae type b disease since introduction of vaccination jama hicnet medical newsletter page volume number april fritzell b plotkin s efficacy and safety of a haemophilus influenzae type b capsular polysaccharide tetanus protein conjugate vaccine j pediatr acip haemophilus b conjugate vaccines for prevention of haemophilus influenzae type b disease among infants and children two months of age and older recommendations of the immunization practices advisory committee acip mmwr no rr acip diphtheria tetanus and pertussis recommendations for vaccine use and other preventive measures recommendations of the immunization practices advisory committee acip mmwr no rr acip pertussis vaccination acellular pertussis vaccine for reinforcing and booster use supplementary acip statement recommendations of the immunization practices advisory committee acip mmwr no rr acip pertussis vaccination acellular pertussis vaccine for the fourth and fifth doses of the dtp series update to supplementary acip statement recommendations of the immunization practices advisory committee acip mmwr no rr use of trade names and commercial sources is for identification only and does not imply endorsement by the public health service or the u s department of health and human services hicnet medical newsletter page volume number april dental news international workshop explores oral manifestations of hiv infection nidr research digest written by jody dove march national institute of dental research at the second international workshop on the oral manifestations of hiv infection held january february in san francisco participants explored issues related to the epidemiology basic molecular virology mucosal immunology and oral clinical presentations of hiv infection the workshop was organized by dr john greenspan and dr deborah greenspan of the department of stomatology school of dentistry university of california san francisco an international steering committee and scientific program committee provided guidance the conference drew more than scientists from countries including asia africa europe central america south america as well as the united states and canada support tor the workshop was provided by the national institute of dental research the national cancer institute the national institute of allergy and infectious diseases the nih office of aids research and the procter and gamble company among the topics discussed were the epidemiology of hiv lesions ethics professional responsibility and public policy occupational issues provision of oral care to the hiv positive population salivary hiv transmission and mucosal immunity opportunistic infections pediatric hiv infection and women s issues recommendations recommendations emerged from the workshop to define the association between the appearance of oral lesions and rate of progression of hiv to establish a universal terminology for hiv associated oral lesions to look for more effective treatments for oral manifestations to expand molecular biology studies to understand the relationship between hiv infection and common oral lesions and to study the effects of hiv therapy on oral lesions epidemiology since the first international workshop on oral manifestations of hiv infection was convened five years ago the epidemiology of hiv infection has hicnet medical newsletter page volume number april radically changed in hiv infection was detected and reported largely in homosexual and bisexual males intravenous drug users and hemophiliacs today more hiv infection is seen in heterosexual males and females and in children and adolescents while the predominant impact of hiv infection has been felt in africa a major increase in infection rate is being seen in southeast asia as well five hundred thousand cases have been reported to date in this region and more are appearing all the time researchers are continuing to document the epidemiology of oral lesions such as hairy leukoplakia and candidiasis they also are beginning to explore the relationships between specific oral lesions and hiv disease progression and prognosis social political issues discussion on the social and political implications of hiv infection focused on changing the public s attitude that aids is retribution for indiscriminate sexual behavior and drug use speakers also addressed health care delivery for hiv infected patients and the need to educate the public about what aids is and how it is acquired saliva and salivary glands conference speakers described transmission issues and the hiv inhibitory activity of saliva the strength of which varies among the different salivary secretions whole saliva has a greater inhibitory effect than submandibular secretions which in turn have a greater inhibitory effect than parotid secretions research has shown that at least two mechanisms are responsible for salivary inhibitory activity they attributed the hiv inhibitory effect of saliva to the aggregation agglutination of hiv by saliva which may both promote clearance of virus and prevent it reaching a target cell and direct effects on the virus or target cells other topics discussed were the manifestation of salivary gland disease in hiv infected persons and current research on oral mucosal immunity pediatric issues pediatric aids recently has emerged as an area of intense interest with early and accurate diagnosis and proper treatment the life expectancy of hiv infected children has tripled the prevention of transmission of hiv from mother to child may be possible in many cases particularly if the mother s sero status is known prior to giving birth periodontal and gingival tissue disease hicnet medical newsletter page volume number april oral health researchers continue to explore periodontal diseases and gingivitis found in individuals with hiv infection recommendations made at the workshop include the standardization of terminology refinement of diagnostic markers standardization of study design and proper consideration of confounding variables resulting from periodontal therapy occupational and treatment issues occupational issues surrounding the treatment of hiv infected individuals and treatment rendered by hiv infected health care professionals still command considerable attention factors under consideration include the cost benefit of hiv testing patient to health care provider transmission of hiv infection and the reverse and the use of mainstream versus dedicated facilities for the treatment of hiv infected patients conference participants anticipate that a third international workshop on the oral manifestations of hiv infection will be held in five years or less proceedings from the second workshop will be published by the quintessence company in late end of part internet david stat com fax bitnet atw h asuacad fidonet amateur packet ax wb tpy wb tpy az usa na
