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School-Based Telehealth Care: Is It an Option? Using the "plain old telephone system" and television monitors, researchers at two school sites were able to provide primary care and in some cases mental health care as well to children in urban and rural elementary schools in Kentucky. Reporting in the November issue of Pediatrics, journal of the American Academy of Pediatrics, researchers Thomas Young and Carol Ireson found that parents who might otherwise have had to take time from work to take children to distant providers were pleased with the telemedicine encounters, and the children seemed comfortable with televised images of doctors who asked about their symptoms. This suggests, they said, that the relatively low-cost school-based telephone option may be a useful way to provide basic care to children in remote or sparsely settled rural regions, or in cities where transportation is difficult or lacking. The school-based telehealth model in the Kentucky test used a full-time school nurse, a half-time mental health consultant, a pediatric practice, and a child psychiatrist, all linked by traditional telephone lines without computer enhancement. An electronic stethoscope; an ears, nose, and throat endoscope; and an otoscope were available. Of a combined 3,461 visits to school nurses at the two school sites during the two-year study period, slightly more than 4 percent (142) resulted in telehealth consultations, with the most common diagnoses being otitis media, pharyngitis, dermatitis, and upper respiratory infections. Thirteen children received psychiatric evaluations resulting in diagnoses of depression and attention deficit/hyperactivity, anxiety, and conduct disorders. The researchers concluded that: "Telehealth technology was effective in delivering pediatric acute care to children in these schools. Pediatric providers, nurses, parents, and children reported primary care school-based telehealth as an acceptable alternative to traditional health care delivery systems. The POTS ("plain old telephone system") technology helps to make this telehealth service a cost-effective alternative for improving access to primary and psychiatric health care for underserved children." Reprints of the Pediatrics article, "Effectiveness of School-Based
Telehealth Care in Urban and Rural Elementary Schools," which describes
the Kentucky initiative, are available from tlyoung@pol.net
How Adolescents Live--A Report on One-Fifth of the World’s Population The world now has the largest generation of adolescents in history, and how those young people experience the ages 10 to 19 will determine not only the course of their individual lives but the health and economic conditions of the world, the United Nations Population Fund said in a "State of World Population 2003" report that focuses on adolescent life, with special emphasis on sexual and reproductive health. Half the world’s population is now under the age of 25, and a fifth of the world’s population—1.2 billion people—is between 10 and 19, the report points out. As they grow up, adolescents are subject to cultural pressures, including poverty, that lead to early marriage and childbearing, incomplete education, and the threat of HIV/AIDS--half of all new HIV infections worldwide occur in people aged 15 to 24. "Within the framework of human rights established and accepted by the global community, certain rights are particularly relevant to adolescents and youth and the opportunities and risks they face," the report notes. "These include gender equality and the rights to education and health, including reproductive and sexual health information and services appropriate to their age, capacities, and circumstances." Addressing those challenges is "an urgent developmental priority," because reducing poverty requires progress in addressing adolescent reproductive health needs, the report concludes. Here are some of the facts about adolescence worldwide reported by the United Nations:
Wherever and however young people live, "Adolescence can neither be denied nor seen as ‘a time between,’" the report cautions. "The choices young people make and the opportunities they are offered are not just preparatory; they are an important and meaningful. Today’s adolescents and young people have diverse experiences, given the different political, economic, social, and cultural, realities they face in their communities. Yet there is a common thread running through all their lives, and that is the hope for a better future." The report, "State of the World Population 2003: Investing
in Adolescents’ Health and Rights," can be accessed online at
www.unfpa.org/swp/2003/english/ch1/index.htm
Internet Sales of Cigarettes to Minors If you are underage and smoking, how do you get your cigarettes? Previous studies have shown that convenience stores often fail to card young customers, or clerks may ask for a card, thereby technically meeting the law, but simply not bother to calculate age from birth date. And many teens say their older siblings, or their parents, buy cigarettes for them. With the growth of the Internet, there is suspicion that another source of cigarettes may now be available to minors. To test whether underage young people can buy tobacco products on the Internet, a trio of North Carolina researchers, with the consent of state officials, set up a project in which adolescents aged 11 to 15 years attempted to purchase cigarettes from 55 Internet vendors in 12 states, paying by credit card or money order. The researchers found that the youngsters received cigarettes 93.6 percent of the time in their credit card purchase attempts and in most of their money order purchases. At no point in any of the deliveries was an attempt made by the vendors to verify age. In total, the underage adolescents received 1,650 packs of cigarettes. All compliance checks were conducted between April and July 2001. Each adolescent worked with a member of the research staff for each purchase attempt. Staff provided the website address or URL for each internet vendor and the adolescents then ordered the minimum number of cartons required by the vendor of Marlboro cigarettes, the leading brand among adolescents, or the cheapest brand available if the site did not sell Marlboros. For sites allowing credit card purchases, adolescents were given a prepaid, reloadable Visa card made out to the teenagers. One, who was younger than 13, the minimum age for this card, used her parents’ credit card for her 12 purchases. The adolescents typed in all of the ordering information at the website, including whether they were of legal age to purchase tobacco products. If asked for birth date, they used fake dates that made them seem 18 to 21 years old. If a driver’s license number was requested, a fake one was provided, as were e-mail addresses and telephone numbers. The procedure with money orders was even easier. When teenagers were escorted by adults to post offices or grocery stores to buy money orders, none was ever asked for age identification or the purpose of the money order, which was sold blank. The teen then simply filled in the name of the vendor and sent the money order along with an order form to the vendor. The adolescents answered the door for the cigarette deliveries as much as possible, giving the package to parents for safe storage. Staff then retrieved the packages and recorded whether they were marked as containing tobacco products, whether the return label identified the sender as a tobacco vendor, whether the package was marked "Adult signature required for delivery," or whether the package featured a code that would prompt the delivery person to verify the age of the recipient. In none of the 76 successful deliveries was the age of the recipient verified, and often packages were left on the doorstep without any contact with the recipients. Many of the vendors included complimentary packs of cigarettes in the adolescents’ orders, plus free promotional items such as pens, ashtrays, or lighters with the vendor’s logo and contact information. Some included their business cards. What Was Learned, But Do Not Try This at Home It is, in fact, not only possible but easy for adolescents to buy cigarettes on the Internet, the researchers concluded, even when state laws ban tobacco sales to minors or make it illegal for minors to misrepresent their ages when making purchases. (As part of the research project, research staff received written immunity from North Carolina law which bans tobacco sales to minors and makes it a crime for adults to aid minors in purchasing tobacco products.) New methods need to be devised for verifying the age of an Internet purchaser, the researchers concluded, as well as ways to make sure that vendors require such verifications. With enforcement of tobacco purchasing now left to the states, the researchers also concluded that federal legislation may be the most effective policy strategy. The report, "Internet Sales of Cigarettes to Minors,"
appeared in the September 10, 2003, issue of the Journal of the American
Medical Association. Reprints are available at kurt_ribisl@unc.edu
A New Way to Prevent Influenza: All You Ever Wanted to Know about LAIVs They are in use in Russia and have been in development in the United States since the 1960s, but this year is the first time Americans ages 5 to 49 can receive an "intranasal, trivalent, cold-adapted, live, attenuated" vaccine, known as LAIV, as immunization against influenza. Previously, only inactivated influenza vaccine administered by injection was available for use in the Unite States, but in 2003 the Food and Drug Administration (FDA) approved the nasal form, marketed by MedImmune, Inc., of Gaithersburg, Maryland, under the name FluMist. In some respects, the two vaccines are alike. Both LAIV and inactivated influenza vaccine contain the strains of influenza virus that are expected to be prevalent in the current year. Viruses for both are grown in eggs. Both should be administered annually to provide protection against the flu. Where they differ, however, is that one—the familiar injected flu shot—contains killed viruses, while LAIV contains attenuated viruses still capable of replication. LAIV is administered by nasal spray, whereas the inactivated vaccine is administered by intramuscular injection. LAIV is more expensive than inactivated vaccine, and it is so far approved for use only among healthy persons aged 5 to 49 years—which includes most school-age children. By comparison, the traditional injected vaccine can be given to children as young as 6 months, and to elderly persons, including those with chronic medical conditions. Recommendations for Using LAIV The Centers for Disease Control and Prevention has issued the following recommendations for using the new nasal vaccine:
Care of the Vaccine LAIV, the nasal vaccine, must be stored at minus-15 degrees Centigrade or colder and should not be refrozen after thawing. It’s supplied in prefilled, single-use sprayers containing 0.5 mL of vaccine and is sprayed into the first nostril while the patient is in an upright position. The second half of the dose is then sprayed into the other nostril. Children ages 5 to 8 previously unvaccinated with either LAIV or inactivated influenza vaccine should receive two doses of LAIV separated by six to eight weeks. Children 5 to 8 who were previously vaccinated at any time require only one dose of LAIV, as do all persons aged 9 to 49 years. In 20 pre-licensure clinical trials, the signs and symptoms most often reported among vaccine recipients were runny noses or nasal congestion, headaches, fever, vomiting, and abdominal pain, but all of these were self-limiting. A supplemental recommendation of the Advisory Committee on Immunization
Practice, "Using Live, Attenuated Influenza Vaccine for Prevention
and Control of Influenza," is available online at www.cdc.gov/mmwr
WORTH NOTING Ipecac No Longer Recommended for Child Poisoning Treatment It has been a standard part of the treatment recommended when a child ingests a poisonous substance, but the effectiveness of ipecac, which induces vomiting, in removing poisons from a child’s system was never really proven, says the American Academy of Pediatrics. The Academy is now recommending that ipecac no longer be used routinely, and it suggests that existing stocks in homes or centers be disposed of safely. Nowadays, the Academy says, child-resistant closures, safer medications, and public education campaigns have made accidental poisonings less likely, and the best advice for caregivers if a child does ingest a substance is to call the poison control center. The universal telephone number in the United States is 800-222-1222; calls are routed to the local poison control center. Trends in Utilization/Costs of Psychotropic Medications for Children, Adolescents Between 1997 and 2000, overall use of psychotropic medication by persons 17 years old and younger increased by almost 5 percent, to an average of 33.7 children or adolescents per 1,000 of population, with the largest increases in utilization seen for atypical antipsychotics, atypical antidepressants, and selective serotonin reuptake inhibitors. Almost half of the $2.7 million gross sales differential was accounted for by three of 39 psychotropic drugs identified—amphetamine compound, risperidone, and setraline. Seventy-five percent of the increase was due to increases in prescriptions for those three plus buproprion, paroxetine, venlafaxine, and citalopram. The average prescription price increased by 17.6 percent or $7.90 per prescription, a change attributed to a shift to costlier medications within a given category and to inflation. Researchers reporting in the October issue of Archives of Pediatrics and Adolescent Medicine suggested that the impact of managed care and pharmaceutical marketing on these trends "warrants further investigation." Study Identifies Puberty Gene A study funded by the National Institute of Child Health and Human Development (NICHD) and other agencies in the National Institutes of Health and published in the October 23 issue of the New England Journal of Medicine reported that researchers have identified a gene that appears to be a crucial signal for the beginning of puberty in human beings. The gene, known as GPR54 is believed to be a "gatekeeper for puberty," which begins when a substance known as gonadotropin-releasing hormone is secreted from the hypothalamus of the brain. Individuals may fail to reach puberty because of inherited or spontaneous mutations of the gatekeeper gene, the researchers said. Bibliography of Dietary Supplement Research The Office of Dietary Supplements (ODS) in the National Institutes of Health (NIH) has released the fourth issue of its annual Bibliography of Significant Advances in Dietary Supplement Research. The issue covers research reported in the year 2002 and includes research findings on antioxidants, vitamins, minerals, amino and fatty acids, botanicals, fiber, and soy. The bibliography will be available on the ODS website, http://ods.od.nih.gov October News Alerts The following information appeared during the month of October in the News Alerts section of this website. Government Cites Diabetes in Report on Health of Americans In its 27th annual report on the overall health of Americans released October 3, the National Center for Health Statistics devoted an entire section to troubling gains in the incidence of diabetes, noting that 6.5 percent of adults were diagnosed with diabetes in 2002, compared with 5.1 percent in 1997, possibly bringing the total number of adults with diabetes to 12 million. An additional 5 million are believed to have the condition but don’t know it, and 12 million have impaired fasting glucose tolerance that may go on to become diabetes unless changes are made in diet and physical activity. The report includes the following data on children’s health:
The report, "Health United State 2003," is available online at www.cdc.gov/nchs States Differ in Mental Health Care Available to Children, Study Finds A study of mental health care needs and service use in 13 states found that where a child lives may be as important as socio-economic characteristics in determining whether a child or adolescent receives needed mental health care. State policies and health care market characteristics differ widely, researchers found, and those geographic differences are a factor in disparities in the services available to children. "Regarding the use of any services, the effect of state of residence exceeds the effects of either race/ethnicity or income," RAND researchers reported in the October issue of the journal Pediatrics. Nationally, an average of 64.7 percent of children ages 6 to 17 with mental health care needs receive no treatment, but in the 13 states examined by RAND (Alabama, California, Colorado, Florida, Massachusetts, Michigan, Minnesota, Mississippi, New Jersey, New York, Texas, Washington, and Wisconsin) unmet needs ranged from just over 50 percent to almost 80 percent. Reporting those variations is only a first step toward eliminating them, the researchers conceded, but states that find themselves at the low end of the spectrum may want to focus attention on access issues and potential barriers to care. The full report, "Geographic Disparities in Children’s Mental Health Care," appeared in the October 2003 issue of the journal Pediatrics. Effects of Ozone Levels on Asthmatic Children Children with severe asthma—defined as needing daily medication—are susceptible to even very slight increases in ozone and particulates in the air they breathe, researchers reported in today’s issue of the Journal of the American Medical Association. Even when air pollution remained below the standard set by the Environmental Protection Agency, children living in southern New England suffered more chest tightness, wheezing, coughing, and shortness of breath when ozone and fine particle levels increased, the researchers found. The study followed 271 children younger than 12 years with physician-diagnosed active asthma from April through September 2001. The article, "Association of Low-Level Ozone and Fine Particles with Respiratory Symptoms in Children with Asthma," is available free at website http://jama.ama-assn.org Revised Standards for Child and Adolescent Immunization Practices Standards for health care professionals to follow in vaccination delivery have been updated by the National Vaccine Advisory Committee to reflect changes in the health care delivery system. The revised guidelines focus on making vaccines readily accessible; properly assessing patient vaccination status; effectively communicating with patients; ensuring that vaccines are properly stored, administered, and documented; and developing strategies to improve vaccination rates and reach target populations. The revised guidelines are available at www.cdc.gov/nip/recs/rev-immz-stds.htm NIDA Launches New Drug Education Program for Teens The National Institute on Drug Abuse October 22 announced a major new drug education program geared specifically for adolescents aged 11 to 15. The program includes an interactive website, NIDA for Teens: The Science Behind Drug Abuse, at www.teens.drugabuse.gov, and a series of educational materials available free of charge to teachers, plus the recently updated publication "Preventing Drug Abuse among Children and Adolescents: A Research-Based Guide for Parents, Educators, and Community Leaders." Materials are available online at www.backtoschool.drugabuse.gov or by telephone from the National Clearinghouse for Alcohol and Drug Information at 1-800-729-6686. NIH Aims to Reduce Health Disparities Despite medical advances and improved public health in America in recent decades, African Americans, Hispanics, American Indians, Alaska Natives, Asian and Pacific Islanders, and other medically underserved communities "continue to suffer an unequal burden of illness, premature death, and disability," according to the National Center on Minority Health in the National Institutes of Health. To reduce and ultimately eliminate these disparities, the NIH October 30 asked for public input into plans for biomedical research aimed at improving health for all Americans. Comments may be submitted by e-mail to NIHHealthDisparitiesPlan@mail.nih.gov and should include contact information. International Partnerships To Look at Traditional Medicine Eighty percent of the world’s population uses plants to meet primary health care needs, and use of alternative medicines is growing in the United States. To try to determine how traditional medicines emerged in the places they are now used, and whether the medicines meet modern research criteria for effectiveness, the National Center for Complementary and Alternative Medicine (NCCAM) in the National Institutes of Health is making grants to universities and schools of medicine in the United States to collaborate with organizations in countries including China, India, Japan, and Korea. The partnerships will evaluate remedies traditionally used for women’s reproductive disorders, nervous disorders, and other illnesses, to try to determine the origins and potential value of indigenous remedies. Background information on alternative medicine is currently available on the NCCAM website at www.nccam.nih.gov
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