The European Commission formally withdrew marketing permission on 28 June 2012.On 21 June 2012, the European Medicines Agency (EMA) issued a positive first opinion on Hexaxim for use outside the EU, in cooperation with the World Health Organization (WHO), but later withdrew the opinion.On 17 April 2013, marketing approval in the EU was granted to Hexyon and to Hexacima.On 15 February 2016, marketing approval in the EU was granted to Vaxelis. US approval
On 21 December 2018, the U.S. Food and Drug Administration (FDA) licensed a hexavalent combined diphtheria and tetanus toxoids and acellular pertussis (DTaP) adsorbed, inactivated poliovirus (IPV), Haemophilus influenzae type b (Hib) conjugate (meningococcal protein conjugate) and hepatitis B (HepB) (recombinant) vaccine, DTaP-IPV-Hib-HepB (Vaxelis), for use as a three-dose series in infants at ages two, four, and six months. On 26 June 2019, the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) voted to include DTaP-IPV-Hib-HepB in the federal Vaccines for Children Program (VFC). == References ==
Spinal or neurogenic
Spinal or neurogenic claudication is not due to lack of blood supply, but rather it is caused by nerve root compression or stenosis of the spinal canal, usually from a degenerative spine, most often at the "L4-L5" or "L5-S1" level. This may result from many factors, including bulging disc, herniated disc or fragments from previously herniated discs (post-operative), scar tissue from previous surgeries, osteophytes (bone spurs that jut out from the edge of a vertebra into the foramen, the opening through which the nerve root passes). In most cases neurogenic claudication is bilateral, i.e. symmetrical. Jaw
Jaw claudication is pain in the jaw or ear while chewing. This is caused by insufficiency of the arteries supplying the jaw muscles, associated with giant cell arteritis. Diagnosis
Differential diagnosis
Vascular (or arterial) claudication typically occurs after activity or ambulation for a distance with resultant vascular insufficiency (lack of blood flow) where the muscular demands of oxygen outweighs the supply. Symptoms are lower extremity cramping. Resting from activity even in a standing position may help relieve the symptoms. Spinal or neurogenic claudication may be differentiated from arterial claudication based on activity and position. In neurogenic claudication, positional changes lead to increased stenosis (narrowing) of the spinal canal and compression of nerve roots and resultant lower extremity symptoms. Standing and extension of the spine narrows the spinal canal diameter. Sitting and flexion of the spine increases spinal canal diameter. A person with neurogenic claudication will have worsening of leg cramping with standing erect or standing and walking.