Еще в 1911 г. F. Fulleborn высказал предположение о возможности паразитирования у человека несвойственных ему видов аскаридат с развитием аллергических реакций. В 1952 г. P. Beaver назвал феномен миграции личинок гельминтов животных у человека "larva migrans" (мигрирующие личинки) и утвердил этот термин как диагностическую единицу. "Larva migrans" - это большая группа зоонозных болезней, характеризующаяся следующими особенностями:

человек для их возбудителя - несвойственный хозяин;
возбудители в организме человека не достигают половозрелого состояния;
симтомокомплекс обусловлен миграцией личинок или взрослых гельминтов в коже или внутренних органах человека.

В зависимости от преобладающих симптомов выделяют кожную, висцеральную и глазную формы larva migrans. Позднее, в 1969 г., P. Beaver предложил в тех случаях, когда известен возбудитель, обозначать заболевание не расплывчатым термином "мигрирующая личинка", а конкретным названием, происходящим от названия возбудителя (дирофиляриоз, гнатостомоз, ангиостронгилез, капиляриоз, спарганоз и др.). Инвазию, вызываемую аскаридатами собак (Toxocara canis), он назвал токсокарозом.

В нашей стране внимание к токсокарозу человека привлекли работы И.Р. Дробинского (1961), Е.С. Лейкиной (1962), М.И. Алексеевой (1982) и др.читать дальше

CME/CE
News Author: Laurie Barclay, MD
CME Author: Charles Vega, MD, FAAFP

Disclosures

To earn CME credit, read the news brief along with the CME information that follows and answer the test questions.

Release Date: August 8, 2006; Valid for credit through August 8, 2007

August 8, 2006 — Longer needles for infant immunizations are associated with fewer local reactions but similar efficacy as shorter needles, according to the results of a randomized study reported in the August 4 Online First issue of the BMJ.

"Some local policies stipulate use of the larger diameter 23 gauge needle, drawing on anecdotal evidence that this enables the vaccine to dissipate over a wider space, reducing risks of localized redness and swelling," write Linda Diggle, MD, from the Oxford Vaccine Group at the University of Oxford, United Kingdom, and colleagues. "Others advise that a 16 mm needle adequately reaches anterolateral thigh muscle when inserted at 90° and using the intramuscular delivery technique recommended by the World Health Organization... Uncertainty has arisen because of insufficient data to define best practice."

At 18 general practices within 2 UK primary care trusts, 696 healthy infants were vaccinated at 2, 3, and 4 months of age, with follow-up to 5 months of age. Infants were randomized to immunization with combined diphtheria, tetanus, whole cell pertussis, and Haemophilus influenzae type b vaccine and a serogroup C meningococcal glycoconjugate vaccine administered using either a wide, long needle (23-gauge/0.6-mm diameter, 25 mm); a narrow, short needle (25-gauge/0.5-mm diameter, 16 mm); or a narrow, long needle (25 gauge, 25 mm).

Primary endpoints were local and general reactions recorded by parents for 3 days after each dose; and diphtheria, tetanus, and H. influenzae type b antibody concentrations and functional antibody against serogroup C Neisseria meningitides 28 to 42 days after the third dose.

Compared with narrow, short needles, use of wide, long needles was associated with significantly decreased local reactions to diphtheria, tetanus, whole cell pertussis, and H. influenzae type b vaccinations. At all 3 doses, 1 less infant for every 6 to 8 vaccinated experienced local reactions at days 1, 2, or 3. Significantly fewer infants vaccinated with the long needle had severe local reactions.

Noninferiority of the immune response using a wide, long needle compared with a narrow, short needle was demonstrated for serogroup C meningococcal glycoconjugate vaccine and for diphtheria, but not for H. influenzae type b or tetanus. However, there was no evidence of decreased immune response using a wide, long needle. In terms of local reaction or immune response, there was little difference between needles of the same length but different gauges.

"Long (25 mm) needles for infant immunizations can significantly reduce vaccine reactogenicity at each dose while achieving comparable immunogenicity to that of short (16 mm) needles," the authors write. "Our results suggest that consideration of needle size is advisable when planning clinical trials of vaccines and we repeat calls for this variable to be reported to facilitate comparisons between trials."

Study limitations include possible lack of generalizability to immunization in resource-poor countries with less well-nourished children.

"With increasing parental attention focused on the safety rather than the efficacy of vaccines, simple interventions that reduce local reactions, such as longer needles, should be welcomed," the authors conclude. "Vaccine manufacturers and national policymakers should consider needle size in recommendations for infant immunization."

The National Health Service Executive South East research and development project grant scheme funded this study. Additional support was provided by Becton Dickinson. Some of the authors have disclosed various financial relevant relationships with the National Coordinating Centre for Research Capacity Development, Wyeth Vaccines, Sanofi Pasteur MSD, Oxford University, Novartis Vaccines, GlaxoSmithKline, and/or Wyeth Vaccines. One of the authors is an inventor on a patent application in the area of meningococcal B vaccines.

BMJ. Published online August 4, 2006.

Disclosures

Release Date: May 8, 2006; Valid for credit through May 8, 2007

May 8, 2006 — An update of previous guidelines for emergency cardiovascular care (ECC) of the pediatric patient as well as cardiopulmonary resuscitation (CPR) and ECC of neonates has been issued.

The American Heart Association and the American Academy of Pediatrics published the updates in the May 2006 issue of Pediatrics.

The authors emphasize that the “new recommendations do not imply that care involving the use of earlier guidelines is unsafe.” Nonetheless, several changes were made on the basis of newly emerging evidence.

The major pediatric advanced life support (PALS) changes and neonatal resuscitation changes are summarized in about 20 key bulleted points at the beginning of the multipart report.

For the pediatric population, the authors urge caution with the use of endotracheal tubes and emphasize their correct placement. Also, a change from the use of cycles of CPR to continuous compressions “at a rate of 100/minute without pauses for ventilation” is made.

Additionally, the guidelines discourage the use of high-dose epinephrine and lidocaine in some settings and describe the use of inodilators and termination of resuscitative efforts.

Major neonatal resuscitation changes include the recommendation to use room air rather than 100% oxygen for initial resuscitation attempts. In addition, routine intrapartum oropharyngeal and nasopharyngeal suctioning for infants born to mothers with meconium staining of amniotic fluid, is no longer recommended. However, “endotracheal suctioning for infants who are not vigorous should be performed immediately after birth,” the authors suggest.

The report also recommends changes in ways to perform and assess ventilation attempts, to administer intravenous epinephrine, and to withhold and discontinue resuscitative efforts.

These recommendations “confirm the safety and effectiveness of many approaches, acknowledge that other approaches may not be optimal, and recommend new treatments that have undergone evidence evaluation,” the authors note.

They also point out that the guidelines “will not apply to all rescuers and all victims in all situations. The leader of a resuscitation attempt may need to adapt application of the guidelines to unique circumstances.”

Pediatrics. 2006;117:e989-e1038

The American Heart Association convened the 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations in January of 2005. In conjunction with the International Liaison Committee on Resuscitation and the American Academy of Pediatrics, the American Heart Association made recommendations based on the available evidence to improve survival rates following cardiac arrest and life-threatening cardiopulmonary events in children who require neonatal resuscitation, pediatric BLS, or PALS.

The current report is a summary of the American Heart Association 2005 guidelines for CPR and ECC of the pediatric patient (BLS and PALS) and the 2005 American Heart Association and American Academy of Pediatrics guidelines for CPR and ECC of the neonate. The new recommendations might need to be adapted by the resuscitation leader according to the circumstances.

Study Highlights
BLS Highlights
Steps for unresponsive infants (<1 year) and children (1 year to puberty): open airway; give 2 breaths if not breathing; begin compressions if no pulse; activate EMS system, use automated external defibrillator (AED) after 5 cycles of CPR in children; if rhythm shockable, give 1 shock and resume CPR for 5 cycles; if rhythm not shockable, resume CPR and check rhythm every 5 cycles until response or PALS providers intercede.
For sudden collapse in child, activate EMS and get AED before CPR.
Barrier devices do not reduce infection risk and might increase resistance to air flow.
Bag-mask ventilation is as effective as endotracheal intubation for short periods; use 100% oxygen until more information known.
If definite pulse, give 12 to 20 breaths/minute (1 breath every 3 - 5 seconds) and check pulse every 2 minutes; if no pulse or if pulse < 60 beats/minute with poor perfusion, begin chest compressions at 100 per minute.
Cycle consists of 30 compressions (1 rescuer) or 15 compressions (2 rescuers) per 2 breaths. Ideal ratio unknown, but previously recommended 5:1 ratio resulted in less than 60 compressions/minute.
If rescuer unable to ventilate patient, chest compressions alone are recommended vs no resuscitation.
Changing rescuer every 2 minutes will maintain good compressions (forceful, fast, full chest recoil, minimal interruptions).
For severe foreign body airway obstruction, perform subdiaphragmatic abdominal thrusts (child) or 5 back blows alternating with 5 chest thrusts (infant).
For drowning victims, ventilation, but not compressions, can be started in the water if it does not prolong removal from water.
PALS Revisions
Laryngeal mask airways can be used with caution.
Cuffed endotracheal tubes can be used if inflation pressure < 20 cm.
Verify endotracheal tube placement.
When advanced airway in place, perform 100 compressions/minute and 8 to 10 breaths/minute (1 breath every 6 - 8 seconds) continuously instead of cycles.
During pulseless arrest, timing of 1 shock, CPR, and drug treatment is same as in advanced cardiac life support.
Epinephrine is recommended in standard dose, not routine high dose.
Lidocaine can be used for ventricular fibrillation or pulseless ventricular tachycardia if amiodarone not available.
Consider induced hypothermia if persistent coma.
Inodilators can enhance postresuscitation cardiac output.
Family members prefer to be present during resuscitation.
Guidelines for resuscitation termination are unreliable as patients can survive prolonged efforts; witnessed collapse, bystander CPR, and early professional treatment are associated with successful resuscitation.
Neonatal Resuscitation Revisions
If no improvement within 90 seconds on room air, use supplementary oxygen or positive-pressure ventilation with room air.
Intrapartum oropharyngeal and nasopharyngeal suctioning not needed in infants of mothers with meconium-stained amniotic fluid; endotracheal suctioning not needed for vigorous meconium-stained infants.
Self-inflating bag, flow-inflating bag, or T-piece can be used for ventilation.
Primary sign of improved ventilation is increased heart rate; endotracheal tube placement can be confirmed by exhaled CO2 detection if heart rate does not increase.
Recommended epinephrine dose is 0.01 to 0.03 mg/kg/dose intravenously vs alternative 0.1 mg/kg/dose via endotracheal tube.
Resuscitation might be withheld if neonatal condition linked with early mortality or high morbidity.
Stopping resuscitation could be justified if there are no signs of life after 10 minutes of resuscitation, which is linked with high rate of mortality or severe neurodevelopmental disability.
Pearls for Practice
Pediatric CPR cycle consists of 30 compressions (1 rescuer) or 15 compressions (2 rescuers) per 2 breaths with compression rate of 100 per minute; when advanced airway is in place, compressions and ventilation (1 breath every 6 - 8 seconds) should be delivered continuously rather than in cycles.
In performing BLS for unresponsive infants and children, 5 cycles of CPR can be initiated before or concurrently with EMS system activation and AED retrieval.

September 5, 2006 — The Advisory Committee on Immunization Practices (ACIP) has issued recommendations for treating and preventing rotavirus gastroenteritis in children and infants using rotavirus vaccine. The new guidelines are published in the August 11 issue of the Morbidity and Mortality Weekly Report.

"Rotavirus is the most common cause of severe gastroenteritis in infants and young children worldwide," write Umesh D. Parashar, MBBS, and colleagues from the National Center for Immunization and Respiratory Diseases. "Rotavirus gastroenteritis results in relatively few childhood deaths in the United States (approximately 20 - 60 deaths per year among children aged < 5 years). However, nearly every child in the United States is infected with rotavirus by age 5 years, and the majority will have gastroenteritis, resulting in approximately 410,000 physician visits, 205,000 - 272,000 emergency department (ED) visits, and 55,000 - 70,000 hospitalizations each year and direct and indirect costs of approximately $1 billion."

In February 2006, a live, oral, human-bovine reassortant rotavirus vaccine (RotaTeq, Merck & Co) was licensed by the US Food and Drug Administration (FDA) for use among US infants. The ACIP recommends routine vaccination of US infants with 3 doses of this rotavirus vaccine given by mouth at ages 2, 4, and 6 months. The first dose should be administered between ages 6 to 12 weeks; the following 2 doses should be administered at 4- to 10-week intervals; and all 3 doses should be given by age 32 weeks.

Rotavirus vaccine can be given together with other childhood vaccines. The rotavirus vaccine is contraindicated for infants with a serious allergic reaction to any vaccine component or to a previous vaccination.

Although rotavirus infects nearly all children by age 5 years, severe, dehydrating gastroenteritis affects primarily children aged 3 to 35 months. Rotavirus gastroenteritis may range from mild, watery diarrhea of short duration to severe diarrhea with vomiting and fever, resulting in dehydration with shock, electrolyte imbalance, and even death. Up to one third of patients have a fever with a temperature higher than 102°F (> 39°C).

Rotaviruses are transmitted primarily by the fecal-oral route, both through close person-to-person contact and through fomites, as well as by fecally contaminated food and water and respiratory droplets.

Confirmation of rotavirus infection by laboratory testing of stool specimens is necessary for reliable rotavirus surveillance and can facilitate clinical decisions about the use of antimicrobial agents. The most widely available testing method is antigen detection in the feces by enzyme immunoassay. Serologic methods detecting a rise in serum antibodies have also been used to confirm recent infections.

The guidelines note several reasons to adopt vaccination of infants as the primary public health measure for prevention of severe rotavirus disease in the United States.

"First, rates of rotavirus illness among children in industrialized and less-developed countries are similar, indicating that clean water supplies and good hygiene have little effect on virus transmission; therefore, further improvements in water or hygiene are unlikely to have a substantial impact on disease prevention," the authors write. "Second, in the United States, a high level of rotavirus morbidity continues to occur despite available therapies... Third, studies of natural rotavirus infection indicate that initial infection protects against subsequent severe gastroenteritis, although subsequent asymptomatic infections and mild disease might still occur."

Breast-fed infants and infants with transient, mild illnesses with or without low-grade fever can receive rotavirus vaccine. Rotavirus vaccine can be administered together with diphtheria and tetanus antigens in the diphtheria, tetanus, and pertussis (DTaP) vaccine, Haemophilus influenzae type b conjugate vaccine, inactivated poliovirus vaccine, hepatitis B vaccine, and pneumococcal conjugate vaccine without interfering with the immune response.

Precautions involving rotavirus vaccination include considering the specific benefits and risks in the following situations: altered immunocompetence; moderate-to-severe illness, including acute gastroenteritis; chronic gastrointestinal disease; and history of intussusception.

Other special patient groups mandating clinical judgment as to whether rotavirus vaccine should be administered include premature infants (aged < 37 weeks), infants living in households with immunocompromised persons, infants living in households with pregnant women, regurgitation of vaccine, and children hospitalized after vaccination. However, infants living in households with pregnant women and immunocompromised persons and clinically stable preterm infants being discharged from hospital can receive the vaccine. Future research should address these issues.

"The success of a rotavirus vaccination program depends on the acceptance and enthusiasm of physicians and other healthcare providers who care for children and caretakers of infants," the authors note. "In light of the experience with the withdrawal of RRV-TV [rhesus-based tetravalent rotavirus] vaccine because of its association with intussusception, some health-care providers and parents might have concerns about vaccination with current rotavirus vaccine."

"Vaccination program personnel will benefit from education about rotavirus disease and rotavirus vaccine," the authors conclude. "Parental education on rotavirus gastroenteritis and on the vaccine will be essential to establish and maintain public confidence in this vaccine and to avoid confusion caused by cases of gastroenteritis in early childhood resulting from nonrotaviral etiologies and not preventable by rotavirus vaccine."

Individuals from the FDA and Merck & Co, the maker of the rotavirus vaccine, reviewed and contributed to sections of this report.

Morb Mortal Wkly Rep. 2006;55(RR-12):1-11.