Vitamin K, an update for the paediatrician

Abstract

Introduction  

This review summarizes current knowledge on vitamin K for the paediatrician. Vitamin K is a fat-soluble vitamin, present in plants as phylloquinone and produced by bacteria as menaquinone. It is acting as a co-factor for γ-glutamyl carboxylase. This enzyme is responsible for post-translational modification of some glutamate side chains to γ-carboxyglutamate. The majority of γ-carboxylated proteins function in blood coagulation; others play a role in calcium homeostasis.  

Data  Newborn babies are at particular risk of vitamin K deficiency, as placental transfer is limited and human milk is a poor source. Vitamin K prophylaxis at birth effectively prevents vitamin K deficiency bleeding (VKDB), formerly known as “haemorrhagic disease of the newborn”. Recent epidemiological studies provide data on the effectiveness of different administration routes and dosing schemes. Infants of mothers taking drugs that inhibit vitamin K are at risk of early VKDB and should receive 1 mg intramuscular (IM) as soon as possible after birth. Classic VKDB is prevented by intramuscular as well as by oral administration of 1 mg vitamin K. In exclusively breast-fed infants, single IM administration at birth is also effectively preventing (rare) late VKDB but single oral administration is not. If given orally, prophylaxis should be continued by either weekly administration of 1 mg till 12 weeks or repeating 2 mg at weeks 1 and 4. Daily administration of 25 μg offers insufficient protection. The only infants not fully protected in this way are those with yet unrecognised liver disease.

Conclusions  Further work is needed before firm recommendations can be made regarding dose in preterm infants and in patients with fat malabsorption/cholestasis or regarding the role of vitamin K in the prevention of osteoporosis.

Más información:

http://www.springerlink.com/content/jk222k38u1176kw8/fulltext.pdf?page=1

Grandparental and Parental Obesity Influences on Childhood Overweight: Implications for Primary Care Practice

Background: 

Community-based studies have suggested a multigenerational pattern of obesity affecting children’s risk of overweight, but no national data have substantiated such a pattern. 

Our objective was to examine the prevalence of overweight [body mass index (BMI) >95th percentile for age and sex] among children aged 5 to 19 in a national sample, stratified by the obesity status of their parents and grandparents.

Methods: We used a secondary analysis of the Panel Study of Income Dynamics, Child Development Supplement, a multigenerational, genealogical, prospective cohort study of the US population. Self-report height and weight data from adults and measured height and weight data for children were used to calculate BMI. The prevalence of child overweight was calculated for different possible combinations of parental and grandparental BMI status, including missing status.

Results: The sample included 2591 children aged 5 to 19 years, for whom parental BMI data were available for 94% and grandparental BMI data were available for 61%. Prevalence of childhood overweight (18.6%) in the sample was comparable with contemporaneous measured national data from other sources. Among children with normal-weight parents and normal-weight grandparents, 7.9% were overweight. In contrast, among children with overweight parents (BMI 25–29.9) and normal-weight grandparents, 17.9% were overweight, and among children with obese parents (BMI >30) and normalweight grandparents, 31.9% were overweight (P < .0001). Importantly, when parents were normal weight, if grandparents were obese, then the prevalence of child overweight was 17.4% (P < .0001). The prevalence of child overweight was similarly elevated (16.4%) when parents were normal weight and grandparental BMI was missing.

Conclusions: This is the first national study to find an association of child weight status with grandparental obesity, distinct from parental obesity. Primary care physicians may find it helpful to consider grandparents’ weight status in judging risk of childhood overweight for their patients, especially when parents’ weight is normal. (J Am Board Fam Med 2008;21:549 –54.)

Más información: 

http://www.jabfm.org/cgi/reprint/21/6/549

Guidelines Address HIV Testing, Prophylaxis to Prevent Mother-to-Child Transmission

"The American Academy of Pediatrics (AAP) has issued a policy statement to summarize the guidelines for HIV testing and prophylaxis to prevent mother-to-child transmission (MTCT) of HIV in the United States. This policy statement updates evidence supporting the current guidelines and suggests ways to continue improving the implementation of universal HIV testing of pregnant women during routine prenatal care.

"Continuing technologic and medical advances in the diagnosis, prevention, and treatment of pediatric HIV infection require ongoing assessment and review of recommendations relating to pediatric HIV infection, including recommendations regarding prenatal and perinatal HIV counseling and testing," write Peter L. Havens, MD, and colleagues from the 2007-2008 Committee On Pediatric AIDS. "Current guidelines are consistent in their recognition of the importance of universal HIV testing of pregnant women in the United States as the key to prevention of...MTCT (also referred to as vertical or perinatal transmission) of HIV. The...AAP continues to support these guidelines."

Specific recommendations in the new guidelines are as follows:

• As part of a comprehensive prenatal program of healthcare, pregnant women should routinely receive information about HIV infection, prevention of MTCT of HIV, and HIV antibody testing.
• All pregnant women in the United States should undergo documented, routine HIV antibody testing, in a manner consistent with state and local laws, after being notified that testing will be performed. However, the patient may decline HIV testing (opt-out consent or right of refusal).
• Healthcare professionals in states where laws and regulations require written informed maternal consent for testing should endeavor to change these laws or regulations to allow opt-out consent.
• All programs designed to detect HIV infection in pregnant women and their infants should undergo periodic monitoring of the proportion of women who do not receive HIV antibody testing. Those programs in which an unacceptably high proportion of women are not tested should assess the reasons and modify the program as indicated.
• In the third trimester, preferably before 36 weeks of gestation, repeated HIV antibody testing is recommended for the following groups:
  
  • Women aged 15 to 45 years in states with high HIV prevalence.
  • Women delivering in hospitals in which HIV prevalence is 1 or more in 1000 pregnant women screened.
  • Women with risk factors for HIV infection, such as diagnosis of a sexually transmitted infection during pregnancy, use of injection drugs or being a partner of an injection drug user, exchanging sex or money for drugs, being a sex partner of someone who is HIV-infected, having a new or multiple sex partners during pregnancy, or signs or symptoms of acute HIV infection.
• Some experts recommend repeated HIV screening for all pregnant women in the third trimester. The rationale is that prevalence-based testing may be difficult to implement, evaluation of individual risk is unreliable, and the risk for MTCT of HIV is increased in women who first acquire HIV infection during pregnancy.
• Maternal HIV antibody testing with opt-out consent, with use of a rapid HIV antibody test, is recommended for women in labor when HIV-infection status during the current pregnancy is undocumented.
• When the mother's HIV serostatus is unknown, the newborn infant's healthcare professional should order rapid HIV antibody testing for the mother or the newborn, with appropriate consent as required by state or local law.
• To facilitate appropriate care and testing of the newborn infant, maternal HIV serostatus should promptly be disclosed to the healthcare professional for that infant.
• When results of HIV rapid antibody test are positive, the mother and newborn infant should receive antiretroviral prophylaxis without waiting for results of confirmatory HIV testing.
• Although women with positive results of HIV rapid antibody test should not breast-feed, they should be offered assistance with immediate initiation of hand and pump expression to stimulate milk production, in the event that confirmatory test results may be negative. If this proves to be the case, prophylaxis should be stopped and breast-feeding may be started.
• All facilities with an obstetric unit and/or newborn nursery of any level should have rapid HIV antibody testing available on a 24-hour basis.
• Infant medical records should document maternal HIV-infection status, and this documentation should be a standard measure of the adequacy of hospital care for the mother and infant.
• Although prophylaxis is most effective within 12 hours of birth, it may still be effective when started as late as 48 hours of life.
• Before hospital discharge, the full 6-week course of infant antiretroviral prophylaxis should be arranged and the family should be carefully instructed regarding administration. All third-party payers should pay for the prophylaxis.
• Infants should not breast-feed if either the mother or the infant has a positive test result for HIV antibody.
• The newborn infant should be tested for HIV antibody, preferably within the first 12 hours of life, in the absence of parental availability for consent. State and local jurisdictions should develop policies to ensure rapid assessment and testing of the infant.
• To guide appropriate care and follow-up testing if indicated, infants of unknown HIV exposure status at the first health supervision visit should undergo HIV antibody testing with appropriate consent.
• Specialists in obstetric and pediatric HIV infection should be consulted regarding care of the mother, fetus, newborn, and child with perinatal exposure to HIV.

"Identification of HIV infection early in pregnancy allows the greatest ability to treat the pregnant woman for her HIV infection for her own health and to prevent MTCT of HIV," the study authors conclude. "Rapid HIV antibody testing allows for timely identification of HIV infection in women even late in pregnancy, during labor, or in the immediate postpartum period as well as HIV exposure in their newborn infants. The results can be available quickly enough to implement successful ARV [antiretroviral] interventions that can reduce MTCT of HIV when administered to the mother started later in pregnancy or in labor or to the infant when administered within the first few hours of life."

Pediatrics. 2008;122:1127-1134.

Más información:

http://www.medscape.com/viewarticle/582922?src=mpnews&spon=34&uac=95257CJ

Psoriasis in dermatological practices.

Low prescription rate for systemic treatments in the management of severe psoriasis vulgaris and psoriatic arthritis in dermatological practices in Berlin and Brandenburg, Germany: results from a patient registry

Abstract:

Background 

Many treatment options are available for the management of psoriasis vulgaris. However, detailed data on prescription behaviour in Germany, especially with regard to the use of new treatment options (e.g. biologics) in private practices, are lacking. 

Objective 

To assess the treatment choices being made in the management of psoriasis vulgaris and psoriatic arthritis in private dermatological practices. Methods 

We established a patient registry that documented the treatment decisions taken during 4797 patient visits between January 2006 and September 2006 with regard to disease activity and concomitant psoriatic arthritis. 

Results 

Corticosteroids were the most frequently prescribed topical treatment, and methotrexate and fumaric acid esters were the most frequently prescribed systemic treatments. Biologics were prescribed in only 2% of patient visits. Systemic treatments were prescribed in only 31% of visits made by patients suffering from moderate to severe psoriasis (which was diagnosed in 48% of all patient visits) and in only 58% of visits made by patients suffering from psoriatic arthritis (which was diagnosed in 12% of all patient visits). 

Conclusions 

Anti-psoriatic treatment was too often limited to topical agents. The rather small percentage of patients with moderate to severe psoriasis or psoriatic arthritis who received systemic therapy indicates that the use of systemic treatments in our sample was too restrictive. Novel therapeutic options such as biologics were rarely used in private practices. New strategies to improve the quality of care provided to patients suffering from severe psoriasis are needed.

Mas información: http://www.ingentaconnect.com/content/bsc/jdv/2008/00000022/00000011/art00008

Cerrando la brecha en una generación: la equidad en salud a través de la acción sobre los determinantes sociales de la salud

Resumen

La comisión sobre los Determinantes sociales en Salud, creado para supervisar la evidencia sobre lo que se puede hacer para promover equidad en salud y crear un movimiento global para alcanzarlo. Es una colaboración global de los encargados de crear políticas,investigadores, y sociedad civil , comandado por los comisionados con una única mezcla de experiencias políticas, académicas y de promoción. El foco de atención esta en los países a todos los niveles de renta y de desarrollo. La comisión elaboro este reporte final en Agosto28, 2008. Este documento resume los hallados y recomendaciones principales; la lista completa esta en el reporte final.

Introducción

La espectativa de vida difieren ampliamente dependiendo el lugar onde las personas nacieron y crecieron. Una persona quien nació y vivió en el Japón o Suecia puede tener una expectativa de vida mas de 80 años, en Brasil , 72 años; India , 63 años; y en varios países africanos , menos de 50 años de edad. Dentro de los países , las diferencias en las espectativas de vida son también diferentes. 

Las personas más pobres tienen altos niveles de enfermedad y mortalidad prematura. A todos los niveles de renta , salud y enfermedad sigue un gradiente social: la menor posición socio economica , la peor en salud.

Si las diferencias sistemáticas en salud para diferentes grupos son evitables por medio de acciones razonables, su existencia es, simplemente injusto. Nosotros llamamos esta diferencia como inequidad en salud. La injusticia social esta matando personas en gran escala, y la reducción de las inequidades en salud , entre y dentro de los países , es una acción ética imperativa.

Traducción : Dr. Carlos Vinicio Erazo

Mas Información: 

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)61690-6/abstract?_eventId=logout