WHO | Arsenic in drinking water

Arsenic in drinking water
Arsenic may be found in water which has flowed through arsenic-rich rocks. Severe health effects have been observed in populations drinking arsenic-rich water over long periods in countries world-wide.

Source
Arsenic is widely distributed throughout the earth's crust.
Arsenic is introduced into water through the dissolution of minerals and ores, and concentrations in groundwater in some areas are elevated as a result of erosion from local rocks.
Industrial effluents also contribute arsenic to water in some areas.
Arsenic is also used commercially e.g. in alloying agents and wood preservatives.
Combustion of fossil fuels is a source of arsenic in the environment through disperse atmospheric deposition.
Inorganic arsenic can occur in the environment in several forms but in natural waters, and thus in drinking-water, it is mostly found as trivalent arsenite (As(III)) or pentavalent arsenate (As (V)). Organic arsenic species, abundant in seafood, are very much less harmful to health, and are readily eliminated by the body.
Drinking-water poses the greatest threat to public health from arsenic. Exposure at work and mining and industrial emissions may also be significant locally.

Effects
Chronic arsenic poisoning, as occurs after long-term exposure through drinking- water is very different to acute poisoning. Immediate symptoms on an acute poisoning typically include vomiting, oesophageal and abdominal pain, and bloody "rice water" diarrhoea. Chelation therapy may be effective in acute poisoning but should not be used against long-term poisoning.
The symptoms and signs that arsenic causes, appear to differ between individuals, population groups and geographic areas. Thus, there is no universal definition of the disease caused by arsenic. This complicates the assessment of the burden on health of arsenic. Similarly, there is no method to identify those cases of internal cancer that were caused by arsenic from cancers induced by other factors.
Long-term exposure to arsenic via drinking-water causes cancer of the skin, lungs, urinary bladder, and kidney, as well as other skin changes such as pigmentation changes and thickening (hyperkeratosis).
Increased risks of lung and bladder cancer and of arsenic-associated skin lesions have been observed at drinking-water arsenic concentrations of less than 0.05 mg/L.
Absorption of arsenic through the skin is minimal and thus hand-washing, bathing, laundry, etc. with water containing arsenic do not pose human health risk.
Following long-term exposure, the first changes are usually observed in the skin: pigmentation changes, and then hyperkeratosis. Cancer is a late phenomenon, and usually takes more than 10 years to develop.
The relationship between arsenic exposure and other health effects is not clear-cut. For example, some studies have reported hypertensive and cardiovascular disease, diabetes and reproductive effects.
Exposure to arsenic via drinking-water has been shown to cause a severe disease of blood vessels leading to gangrene in China (Province of Taiwan), known as 'black foot disease'. This disease has not been observed in other parts of the world, and it is possible that malnutrition contributes to its development. However, studies in several countries have demonstrated that arsenic causes other, less severe forms of peripheral vascular disease.
According to some estimates, arsenic in drinking-water will cause 200,000 -- 270,000 deaths from cancer in Bangladesh alone (NRC, 1998; Smith, et al, 2000).

Measurement
Accurate measurement of arsenic in drinking-water at levels relevant to health requires laboratory analysis, using sophisticated and expensive techniques and facilities as well as trained staff not easily available or affordable in many parts of the world.
Analytical quality control and external validation remain problematic.
Field test kits can detect high levels of arsenic but are typically unreliable at lower concentrations of concern for human health. Reliability of field methods is yet to be fully evaluated.

Prevention and control
The most important remedial action is prevention of further exposure by providing safe drinking- water. The cost and difficulty of reducing arsenic in drinking-water increases as the targeted concentration lowers. It varies with the arsenic concentration in the source water, the chemical matrix of the water including interfering solutes, availability of alternative sources of low arsenic water, mitigation technologies, amount of water to be treated, etc.

Control of arsenic is more complex where drinking-water is obtained from many individual sources (such as hand-pumps and wells) as is common in rural areas. Low arsenic water is only needed for drinking and cooking. Arsenic-rich water can be used safely for laundry and bathing. Discrimination between high-arsenic and low-arsenic sources by painting the hand-pumps (e.g. red and green) can be an effective and low cost means to rapidly reduce exposure to arsenic when accompanied by effective health education.

Alternative low-arsenic sources such as rain water and treated surface water may be available and appropriate in some circumstances. Where low arsenic water is not available, it is necessary to remove arsenic from drinking-water:

. The technology for arsenic removal for piped water supply is moderately costly and requires technical expertise. It is inapplicable in some urban areas of developing countries and in most rural areas world-wide.
. New types of treatment technologies, including co-precipitation, ion exchange and activated alumina filtration are being field-tested.
. There are no proven technologies for the removal of arsenic at water collection points such as wells, hand-pumps and springs.
. Simple technologies for household removal of arsenic from water are few and have to be adapted to, and proven sustainable in each different setting.
. Some studies have reported preliminary successes in using packets of chemicals for household treatment. Some mixtures combine arsenic removal with disinfection. One example, developed by the WHO/PAHO Pan American Center of Sanitary Engineering and Environmental Sciences in Lima, Peru (CEPIS), has proven successful in Latin America.

WHO's activities on arsenic
WHO's norms for drinking-water quality go back to 1958. The International Standards for Drinking-Water established 0.20 mg/L as an allowable concentration for arsenic in that year. In 1963 the standard was re-evaluated and reduced to 0.05 mg/L. In 1984, this was maintained as WHO's "Guideline Value"; and many countries have kept this as the national standard or as an interim target. According to the last edition of the WHO Guidelines for Drinking-Water Quality (1993):

* Inorganic arsenic is a documented human carcinogen.
* 0.01 mg/L was established as a provisional guideline value for arsenic.
* Based on health criteria, the guideline value for arsenic in drinking-water would be less than 0.01mg/L.
* Because the guideline value is restricted by measurement limitations, and 0.01 mg/L is the realistic limit to measurement, this is termed a provisional guideline value.

The WHO Guidelines for Drinking-water Quality is intended for use as a basis for the development of national standards in the context of local or national environmental, social, economic, and cultural conditions.

The summary of an updated International Programme on Chemical Safety Environmental Health Criteria Document on Arsenic published by WHO is available at http://www.who.int/pcs/pubs/pub_ehc_num.html. It addresses all aspects of risks to human health and the environment. The full text will be published in late 2001.

A UN report on arsenic in drinking-water has been prepared in cooperation with other UN agencies under the auspices of an inter-agency coordinating body (the Administrative Committee on Coordination's Sub-committee on Water Resources. It provides a synthesis of available information on chemical, toxicological, medical, epidemiological, nutritional and public health issues; develops a basic strategy to cope with the problem and advises on removal technologies and on water quality management. The draft of the report is available at http://www.who.int/water_sanitation_health/dwq/arsenic3/en/

Information on arsenic in drinking-water on a country-by-country basis is being collected and will be added to the UN report and made available on the web site.

As part of WHO's activities on the global burden of disease, an estimate of the disease burden associated with arsenic in drinking-water is in preparation. A report entitled "Towards an assessment of the socioeconomic impact of arsenic poisoning in Bangladesh" was released in 2000.

A United Nations Foundation grant for 2.5 million approved in July 2000, will enable UNICEF and WHO to support a project to provide clean drinking-water alternatives to 1.1 million people in three of the worst affected sub-districts in Bangladesh. The project utilizes an integrated approach involving communication, capacity building for arsenic mitigation of all stakeholders at subdistrict level and below, tube-well testing, patient management, and provision of alternative water supply options.

Urgent requirements
^Large-scale support to the management of the problem in developing countries with substantial, severely affected populations.
^Simple, reliable, low-cost equipment for field measurement.
^Increased availability and dissemination of relevant information.
^Robust affordable technologies for arsenic removal at wells and in households.

Global situation
The delayed health effects of exposure to arsenic, the lack of common definitions and of local awareness as well as poor reporting in affected areas are major problems in determining the extent of the arsenic-in-drinking-water problem.

Reliable data on exposure and health effects are rarely available, but it is clear that there are many countries in the world where arsenic in drinking-water has been detected at concentration greater than the Guideline Value, 0.01 mg/L or the prevailing national standard. These include Argentina, Australia, Bangladesh, Chile, China, Hungary, India, Mexico, Peru, Thailand, and the United States of America. Countries where adverse health effects have been documented include Bangladesh, China, India (West Bengal), and the United States of America. Examples are:

-Seven of 16 districts of West Bengal have been reported to have ground water arsenic concentrations above 0.05 mg/L; the total population in these seven districts is over 34 million (Mandal, et al, 1996) and it has been estimated that the population actually using arsenic-rich water is more than 1 million (above 0.05 mg/L) and is 1.3 million (above 0.01 mg/L) (Chowdhury, et al, 1997).
-According to a British Geological Survey study in 1998 on shallow tube-wells in 61 of the 64 districts in Bangladesh, 46% of the samples were above 0.010 mg/L and 27% were above 0.050 mg/L. When combined with the estimated 1999 population, it was estimated that the number of people exposed to arsenic concentrations above 0.05 mg/l is 28-35 million and the number of those exposed to more than 0.01 mg/l is 46-57 million (BGS, 2000).
-Environment Protection Agency of The United States of America has estimated that some 13 million of the population of USA, mostly in the western states, are exposed to arsenic in drinking- water at 0.01 mg/L, although concentrations appear to be typically much lower than those encountered in areas such as Bangladesh and West Bengal. (USEPA, 2001)

Arsenic in Bangladesh
In Bangladesh, West Bengal (India) and some other areas, most drinking-water used to be collected from open dug wells and ponds with little or no arsenic, but with contaminated water transmitting diseases such as diarrhoea, dysentery, typhoid, cholera and hepatitis. Programmes to provide "safe" drinking-water over the past 30 years have helped to control these diseases, but in some areas they have had the unexpected side-effect of exposing the population to another health problem - arsenic.

Arsenic in drinking-water in Bangladesh is attracting much attention for a number of reasons. It is a new, unfamiliar problem to the population, including concerned professionals. There are millions of people who may be affected by drinking arsenic-rich water. Last, but not least, fear for future adverse health effects as a result of water already consumed.

Background

.In recent years, extensive well drilling programme has contributed to a significant decrease in the incidence of diarrhoeal diseases.
.It has been suggested that there are between 8-12 million shallow tube-wells in Bangladesh. Up to 90% of the Bangladesh population of 130 million prefer to drink well water. Piped water supplies are available only to a little more than 10% of the total population living in the large agglomerations and some district towns.
.Until the discovery of arsenic in groundwater in 1993, well water was regarded as safe for drinking.
.It is now generally agreed that the arsenic contamination of groundwater in Bangladesh is of geological origin. The arsenic derives from the geological strata underlying Bangladesh.

Situation

* The most commonly manifested disease so far is skin lesions. Over the next decade, skin and internal cancers are likely to become the principal human health concern arising from arsenic.
* According to one estimate, at least 100,000 cases of skin lesions caused by arsenic have occurred and there may be many more (Smith, et al, 2000).
* The number of people drinking arsenic-rich water in Bangladesh has increased dramatically since the 1970s due to well-drilling and population growth.
* The impact of arsenic extends from immediate health effect to extensive social and economic hardship that effects especially the poor. Costs of health care, inability of affected persons to engage in productive activities and potential social exclusion are important factors.
* The national standard for drinking-water in Bangladesh is 0.05 mg/L, same as in India.
* District and sub-district health officials and workers lack sufficient knowledge as to the identification and prevention of arsenic poisoning.
* The poor availability of reliable information hinders action at all levels and may lead to panic, exacerbated if misleading reports are made. Effective information channels have yet to be established to those affected and concerned.

Remedial actions

- Within Bangladesh, a number of governmental technical and advisory committees have been formed and a co-ordinating mechanism established among the interested external support agencies. These committees include the Governmental Arsenic Co-ordinating Committee headed by the Minister of Health & Family Welfare (MHFW) and several technical committees. One of the positive outcomes of this collaboration (including work with local institutes) has been the testing of new types of treatment technologies.
- So far, many initiatives have focused on water quality testing and control with a view to supplying arsenic-free drinking-water, thereby reducing the risk of further arsenic-related disease. The amount of testing required and the need to provide effective feedback to those using well water, suggest use of field testing kits.
- Only a few proven sustainable options are available to provide safe drinking-water in Bangladesh. These include: obtaining low-arsenic groundwater through accessing safe shallow groundwater or deeper aquifers (greater than 200 m); rain water harvesting; pond-sand-filtration; household chemical treatment; and piped water supply from safe or treated sources.

For more information contact:


WHO Media centre
Telephone: +41 22 791 2222
E-mail: mediainquiries@who.int

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WHO | Arsenic in drinking water

El componente acetabular tiene tanta importancia como el femoral - DiarioMedico.com

Manel Ribas (1 de 2)
Manel Ribas, del Instituto Universitario Dexeus, de Barcelona. (Covadonga Díaz)

Diariomedico.com
ESPAÑA
SU PRINCIPAL VENTAJA ES QUE TIENE UNA MENOR AGRESIVIDAD
La selección de pacientes candidatos a artroplastia debe ser muy precisa
La mesa de redonda titulada Artroplastias de superficie de cadera: ¿pasado o futuro?, celebrada dentro de los Encuentros en Asturias en Cirugía Ortopédica, en Oviedo, ha sido el lugar donde se han debatido las ventajas e inconvenientes de las artroplastias de superficie de cadera. Una cosa está clara: la selección de candidatos debe ser muy precisa.

Covadonga Díaz. Oviedo - Martes, 1 de Diciembre de 2009 - Actualizado a las 00:00h.

La cirugía ortopédica acumula una experiencia en todo el mundo en lo que a realización de artroplastias de superficie de cadera se refiere que permite efectuar un balance adecuado. Su utilización suscita consenso en algunos aspectos y controversia en otros. Mientas que algunos hospitales han renunciado a esta técnica, otros especialistas la prefieren sobre otras. Su principal ventaja frente a las prótesis clásicas es la menor agresividad. Lo que está claro es que la dificultad para el cirujano con esta técnica es notablemente mayor y que la selección de pacientes candidatos debe ser muy precisa.

Una mesa redonda celebrada en Oviedo en el marco de los Encuentros en Asturias en Cirugía Ortopédica, organizados por Daniel Hernández Vaquero, jefe del Servicio de Traumatología del Hospital San Agustín, en Avilés, y profesor de la Universidad de Oviedo, ha servido para explicar los argumentos de las corrientes que defienden una y otra posición. En ella han participado, entre otros, Manel Ribas, jefe de la Unidad de Cadera del Departamento de Cirugía Ortopédica y Traumatología Clínica del Instituto Universitario Dexeus, de Barcelona, y firme defensor de las prótesis de superficie de cadera, y Enrique Gil Garay, jefe de Sección de Cirugía Ortopédica y Traumatología del Hospital La Paz, de Madrid, quien no cree que la técnica tenga indicaciones y defiende otras alternativas.

Ribas acumula una experiencia de más de 700 artroplastias de superficie de cadera "y sólo en cuatro casos he tenido que recurrir después a la prótesis convencional". Las ventajas para este especialista son que "podemos actuar sobre la artrosis de pacientes jóvenes proporcionándoles una calidad de vida aceptable; de otro modo tendrían que esperar a un implante tradicional o prótesis total". Ribas ha insistido en que "la prótesis total es de amputación, mientras que ésta es de superficie porque sólo cambiamos la superficie articular dando mejor contorno a la cabeza femoral sobre el acetábulo".

Otra de las ventajas, según este especialista, es que el riesgo de luxación se acerca a cero, mientras que con las convencionales es del 2 por ciento. "Algunas revistas científicas sobre medicina deportiva incluso han publicado artículos que demuestran que pacientes con prótesis de superficie son más activos e incluso se involucran en actividades que exigen algo de impacto".

Respecto a las indicaciones de la prótesis de superficie, Ribas citó adultos jóvenes, varones de menos de 65 años, y mujeres de menos de 55, con tomodensitometría normal. Las contraindicaciones son insuficiencia renal, osteoporosis, tumores y pacientes con deformidades extremas.

En el lado opuesto se ha situado Enrique Gil Garay, precisando inicialmente que su servicio no recibe en general el tipo de pacientes que requiere este tipo de técnica. "Se trata de una alternativa técnicamente muy exigente, con una curva de aprendizaje muy larga, sobre la que se me plantea un problema casi de tipo moral, en el sentido de que si sé que unas prótesis funcionan bien resulta frustrante colocar otras que sé que en algunos casos van a ir mal. Corremos el riesgo de llevar a pacientes jóvenes por un camino que puede no dar los resultados que buscamos, al menos, al principio".

La vía de abordaje en las intervenciones quirúrgicas sobre la cadera no influye en los resultados obtenidos

Una cuestión que suscita consenso entre los cirujanos es que la vía de abordaje en intervenciones sobre la cadera no influye en los resultados y que el especialista puede y debe utilizar el acceso al que esté más acostumbrado. Con respecto a las prótesis de superficie es importante que el abordaje permita una exposición óptima del cuello femoral en su totalidad. Enrique Moro, del Servicio de Traumatología y Cirugía Ortopédica del Hospital Clínico San Carlos, de Madrid, ha ofrecido una ponencia sobre trucos y vías de acceso en la que se ha referido a la importancia de la colocación de los componentes en la orientación correcta, sobre todo del componente femoral. Otro de los aspectos sobre los que ha llamado la atención es la necesidad de tener en cuenta que la aplicación de la aguja guía tiene poco margen de error.

La planificación preoperatoria es inexcusable en la colocación de las prótesis de superficie, con una exhaustiva medición previa y observación precisa "para ajustarse a los detalles técnicos de cada instrumental de modelo de prótesis". En la misma línea, Daniel Hernández Vaquero, del Hospital San Agustín, en Avilés, ha señalado que se trata de una técnica "muy cuidadosa que requiere una buena preparación del hueso".

Enrique Gil Garay (2 de 2)
Enrique Gil Garay, del Hospital La Paz, de Madrid. (Covadonga Díaz)

Diariomedico.com
ESPAÑA
ES DETERMINANTE
El componente acetabular tiene tanta importancia como el femoral
La experiencia acumulada en el Hospital Clínico de Barcelona desde el año 2003 incluye una serie, si no muy amplia de pacientes, sí con un periodo de evolución que permite sacar conclusiones y revisar los pros y contras de las prótesis de superficie a través de su aprendizaje.

Redacción - Martes, 1 de Diciembre de 2009 - Actualizado a las 00:00h.

Uno de los aspectos sobre los que Xavier Gallart, de dicho centro, ha querido llamar la atención es la necesidad de dar más importancia de la que actualmente recibe al componente acetabular.

Desde su experiencia, este componente determina que "la prótesis vaya bien o mal, por lo que no debe ser descuidado, y eso no siempre se tiene en cuenta", ha explicado Gallart, y ha añadido que "nos centramos mucho en el componente acetabular y en ocasiones es una deficiente colocación del acetábulo la causa por la que fracasa el implante".

Este especialista ha señalado que "la orientación del componente, es decir, el ángulo, es fundamental".

El balance que realiza Gallart respecto a las prótesis de superficie es que, "tras el boom inicial, seguramente ahora su utilización va a ir en descenso, sobre todo porque es una opción muy técnico-dependiente y porque los pacientes deben estar muy bien seleccionados. Si el cirujano no tiene una notable pericia en la técnica y la indicación no está muy bien establecida, fracasará".

La técnica Notes permite extirpar un cáncer de recto a través del ano - DiarioMedico.com

Anastomosis del colon

Diariomedico.com
ESPAÑA
A CARGO DE CIRUJANOS DE BARCELONA Y DE BOSTON
La técnica Notes permite extirpar un cáncer de recto a través del ano
El sistema Notes sigue dando sorpresas: ayer, cirujanos del Hospital Clínico de Barcelona y del Hospital de Massachusetts de Boston informaron de que han realizado con éxito el primer caso mundial de extracción de un cáncer de recto a través del ano, apoyándose también en la técnica TEM. Consideran que este nuevo enfoque tiene grandes ventajas.

Redacción - Lunes, 30 de Noviembre de 2009 - Actualizado a las 00:00h.


Introducción instrumental (2 de 6)Introducción instrumental quirúrgico a través del ano. (DM)


La cirugía mínimamente invasiva Notes (Natural Orifice Transluminal Endoscopy Surgery), un innovador abordaje quirúrgico que permite operar a partir de orificios naturales del cuerpo, sigue avanzando: un equipo de cirujanos del Hospital Clínico de Barcelona y el Hospital General de Massachusetts- Universidad de Harvard, en Boston, Estados Unidos, acaba de informar de que ha realizado la primera extracción mundial de un cáncer de recto a través del ano.

La boca y la vagina han sido las vías más utilizadas para el Notes hasta el momento, pero en esta nueva técnica destaca la vía escogida: la transrectal (a través del ano), mucho menos explorada. La intervención se realizó el día 9 de noviembre, con el abordaje Notes y la técnica TEM (cirugía transanal-Transanal Endoscopic Microsurgery), y resultó exitosa, en buena parte gracias al trabajo conjunto del equipo de Cirugía Gastrointestinal del Clínico de Barcelona, que lidera Antonio María de Lacy, y un equipo de cirujanos del Boston, encabezados por Patricia Sylla.


(3 de 6) Localización del tumor que se extirpará. (DM)


Según ha informado el equipo catalán, ésta es la primera vez en el mundo que una intervención en el tratamiento de un cáncer de recto se realiza mediante una cirugía en la que la cavidad de salida del tumor es el propio ano.La paciente, una mujer de 76 años de edad diagnosticada de un tumor maligno en el recto, fue dada de alta el pasado 14 de noviembre (tan sólo cinco días después de la intervención), y se fue a casa sin ninguna complicación y con una recuperación postoperatoria excelente.

Durante la intervención todos los instrumentos quirúrgicos se introdujeron a través del ano para evitar incisiones abdominales dolorosas.Esta nueva técnica ha sido desarrollada para alcanzar mejores resultados que la cirugía laparoscópica, técnica mínimamente invasiva que garantiza numerosas ventajas: disminución de dolor, menor estancia hospitalaria y mejores resultados oncológicos.



(4 de 6) La línea punteada muestra la disección que se hace del recto. (DM)


La innovadora cirugía aplicada en este caso supone un paso más y permitirá en adelante operar con éxito un cáncer de recto sin dejar cicatrices, a diferencia de la laparoscopia, cuyas cicatrices se reducen a 4 ó 5 mínimas incisiones.

El equipo del Clínico barcelonés cree que utilizar la vía transanal presenta dos grandes ventajas: una, la posibilidad de utilizarla en ambos sexos (a diferencia de la vía transvaginal, que queda reducida a la mitad de la población); y la otra, la apertura y cierre del colon o recto con visión directa.



(5 de 6) Colocación del punto a nivel del recto durante la cirugía. (DM)



Esto se ha conseguido utilizando técnicas que se han desarrollado para el tratamiento local de lesiones en el recto (el TEM), consistentes en la realización de una endoscopia a través del recto, por donde se introduce un proctoscopio especial conectado a un sistema de insuflación de CO2 que dilata las paredes del recto. De esta forma se crea un espacio de trabajo que permite introducir los instrumentos para seccionar y disecar el recto afectado.


(6 de 6) Anatomía del recto previo a la intervención. (DM)

Los niños precisan ensayos de anti-VIH con arreglo a su edad - DiarioMedico.com

María Ángeles Muñoz

Diariomedico.com
ESPAÑA
LAS CARACTERÍSTICAS ENTRE LOS DE 2 AÑOS DIFIEREN DE LAS QUE SE DAN ENTRE LOS 3 Y 6 AÑOS
Los niños precisan ensayos de anti-VIH con arreglo a su edad
Los niños no son adultos en pequeño, por lo que necesitan ensayos farmacológicos con antirretrovirales específicos a sus franjas de edad. Actualmente, la población pediátrica se beneficia, por uso compasivo, de fármacos de adultos, pero los ensayos deben ser más específicos.

Raquel Serrano - Martes, 1 de Diciembre de 2009 - Actualizado a las 00:00h.

La infección por VIH sigue afectando a recién nacidos (RN), niños y adolescentes, pero cada vez se consigue mayor control en este grupo, a excepción de la población de países no desarrollados, en los que las cifras siguen siendo dramáticas.

La transmisión vertical ha disminuido significativamente. En los países industrializados se ha reducido a menos del 2 por ciento y suelen ser partos no controlados. En España aproximadamente hay entre 700-800 niños infectados, la mayoría en tratamiento antirretroviral, aunque desde la introducción de la Targa, el número de nuevas infecciones madre-hijo se ha reducido. Los casos de nuevas infecciones se deben a madres que acuden en el momento del parto al hospital, partos no controlados y niños que vienen infectados de otros países, ha explicado a DM María Ángeles Muñoz, del Laboratorio de Inmuno-Biología Molecular del Hospital Gregorio Marañón, de Madrid, y coordinadora de una jornada sobre VIH en neonatos niños que hoy se celebra en Madrid.

Uso compasivo
Con respecto a los fármacos que se están utilizando en niños, ha indicado que son los que se usan en adultos, aunque es muy difícil utilizar nuevas familias en los niños "porque no hay ensayos y no se conoce la farmacocinética y farmacodinámica en este grupo. Por supuesto su uso es compasivo". Hasta el momento, hay unos 25 antirretrovirales aprobados por la FDA para el tratamiento de la infección por el VIH en adultos y 17 en pediatría. Son nuevos inhibidores de la proteasa, con mayor potencia antirretroviral, o nuevas familias como inhibidores de la integrasa o anti-CCR5. "Los niños pueden disponer de los antirretrovirales por uso compasivo y no de forma rutinaria como los adultos. Por otra parte, el término niño es muy amplio. Así, los menores de 2 años tienen características muy diferentes a los niños de entre 3-6 años o a los adolescentes y son en los que hay menos estudios".

Sin embargo, con la aprobación de la Regulación Pediátrica, en el año 2007 en Europa, aumentarán los estudios específicos, ya que "es obligatorio y las dosis y formulaciones tendrán que ser las adecuadas a la edad".

La evolución del sida pide nuevos esfuerzos - DiarioMedico.com

Nuevas transmisiones según su vía de contagio en Europa occidental y Norteamérica (1977-2006)

Diariomedico.com
ESPAÑA
ADAPTACIÓN DE LOS PROGRAMAS DE PREVENCIÓN
La evolución del sida pide nuevos esfuerzos
La epidemia del sida ha cambiado en los últimos años. Por un lado, las vías de transmisión están variando, lo que exige una adaptación de los programas preventivos y para la detección precoz de la infección. Por otra parte, el perfeccionamiento de los tratamientos antirretrovirales ha logrado, sobre todo en las sociedades occidentales, que el paciente seropositivo sea un enfermo crónico, expuesto a las patologías propias de su edad.

Sonia Moreno - Martes, 1 de Diciembre de 2009 - Actualizado a las 00:00h.

llaves conceptuales:
1. Los factores de riesgo cardiovascular inciden en la población seropositiva con más fuerza que en la general, por lo que es clave evitarlos
2. Las nuevas familias farmacológicas y los estudios para reducir la terapia antirretroviral a un fármaco perfeccionarán el tratamiento
3. Uno de los problemas es que el 30 por ciento de la población en Europa occidental que está infectada por el virus del sida lo desconoce

La epidemia de sida en España se mantiene estable, con tasas de incidencia en la población general que han variado entre el 0,5 y el 0,8 por ciento en los últimos años. No obstante, la incidencia de los casos notificados de sida ha bajado; atendiendo al registro nacional, en 2008 se comunicaron 1.170, lo que supone un descenso del 80 por ciento con respecto a 1996, cuando se instauraron los tratamientos antirretrovirales de gran eficacia.

Estos datos indican que si bien no ha disminuido la incidencia de la transmisión del VIH en sí misma, la enfermedad aparece mucho más tarde, gracias a los tratamientos. De hecho, la edad media de los pacientes en el momento de recibir el diagnóstico de sida ha aumentado, alcanzando los 40 años, según comenta Juan González Lahoz, presidente de la Fundación de Investigación y Educación en Sida (IES) y jefe del Servicio de Enfermedades Infecciosas del Hospital Carlos III, de Madrid. Con motivo del Día Mundial del Sida, la Fundación IES organiza hoy un acto, con la Fundación del Colegio de Médicos de Madrid, donde se pondrá de relieve este cambio de la evolución de la enfermedad. "Gracias a los tratamientos antirretrovirales (TAR) las personas seropositivas tienen mayor esperanza de vida, pero eso conlleva la aparición de otras enfermedades, como las hepatitis víricas y los trastornos cardiovasculares". Respecto a los virus de la hepatitis, hay novedades terapéuticas que probablemente transformarán el tratamiento en los pacientes coinfectados.

"En cuanto al riesgo cardiovascular, la posibilidad de que un paciente con VIH muera de infarto, algo implanteable antes, se ha incrementado ahora. Los factores de riesgo de enfermedad cardiaca (tabaquismo, HTA, diabetes, hipercolesterolemia, etc.) inciden en los pacientes seropositivos con más fuerza que en la población general. Ello es debido primero a la propia infección por el virus del sida, que genera alteraciones en el endotelio vascular y, en parte, a ciertos antirretrovirales". González Lahoz explica que los análogos de nucleósidos son los que más riesgo aportan en cuanto a cardiotoxicidad, al igual que los inhibidores de la proteasa, debido a los trastornos metabólicos. "Plantean menos problemas desde el punto de vista cardiovascular los no análogos, así como los últimos antirretrovirales desarrollados: inhibidores de la integrasa e inhibidores de los correceptores". Con todo, el mayor peso en el riesgo cardiovascular lo tienen los factores comunes a toda la población general, por encima de la propia infección; de ahí la importancia de fomentar hábitos preventivos, tales como evitar el consumo del tabaco y controlar la hipertensión y el colesterol.Asimismo, según destaca González Lahoz, para favorecer el intercambio de conocimiento entre ambas áreas -sida y cardiovascular- se iniciará un proyecto en colaboración con Valentín Fuster, del Hospital Mount Sinai, en Nueva York, en el que gracias a los métodos de diagnóstico por imagen se podría adelantar la detección del riesgo cardiaco en los pacientes seropositivos.

Pere Domingo, secretario del Grupo de Estudio de Sida (Gesida), de la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (Seimc), entidad que agrupa a la mayoría de los médicos que atienden a personas con VIH/sida en España, también alude al desarrollo de los antirretrovirales alcanzado desde el punto de inflexión, en 1996: "El actual arsenal terapéutico, que incluye 25 fármacos, ha hecho que, convenientemente aplicados, la mayoría (un 90 por ciento) de pacientes que reciben tratamiento efectivo se hallen en buen estado de salud y activos desde el punto de vista social y laboral". La llegada de dos nuevas familias farmacológicas -los inhibidores de la integrasa y los antagonistas del CCR5- ha ayudado a aumentar las opciones para el paciente, así como los estudios encaminados a reducir la terapia a un solo fármaco, y que lideran los grupos españoles de Federico Pulido, en el Hospital 12 de Octubre, y de José Ramón Arribas, en el Hospital La Paz, ambos en Madrid, contribuyen a perfeccionar el régimen terapéutico.

A corto y medio plazo
Pero es obvio que existen retos no alcanzados, al menos uno a corto plazo y otro a largo plazo, continúa Pere Domingo. "A corto plazo, lo más importante sería identificar a la población que está infectada y que todavía no lo sabe (25-30 por ciento de los infectados en países occidentales). Con ello, y la aplicación de las medidas preventivas y terapéuticas adecuadas, se conseguiría que dichos pacientes no infecten a otros sujetos y también prevenir en ellos la progresión de la enfermedad. A medio-largo plazo, el reto es la consecución de una vacuna preventiva, para lo cual existe un enorme esfuerzo investigador que incluye también a nuestro país", en alusión al trabajo que dirige Mariano Esteban, del Centro Nacional de Biotecnología, con un prototipo de vacuna y que se concretó en un ensayo con voluntarios el pasado enero. Para González Lahoz, la consecución de la vacuna contra el VIH/sida es un reto difícil de alcanzar por la gran variabilidad del virus, aunque ve con más optimismo la llegada de vacunas terapéuticas. Mientras llegan, se concentran esfuerzos en la prevención y educación, como destaca González Lahoz de la labor de la fundación que preside.

Asimismo, Domingo alude a la importancia capital de detectar las personas infectadas que desconocen su situación y apuesta por una mayor oferta de pruebas de determinación del VIH, "como las de tipo opt-out (inclusión/exclusión voluntarias) a las mujeres que acuden a los servicios de obstetricia; a los pacientes que solicitan tratamiento de infecciones de transmisión sexual; a las mujeres que acuden a centros de interrupción voluntaria del embarazo; a los pacientes que efectúan programas de dependencia de drogas, y a los que reciben tratamiento para la tuberculosis, la hepatitis B y C o linfomas. Una opción similar, pero expandida, sería realizar la prueba a todos los ciudadanos cuando tengan contacto con el sistema público de salud. No obstante, se requieren estudios de coste/beneficio preliminares sobre estas estrategias e incluso podrían necesitar modificaciones en el actual marco legal".


CAMBIOS
El informe de Onusida muestra un cambio en el cariz de la epidemia que no se refleja en otro en la dirección de los esfuerzos para la prevención. Por ejemplo, en Europa oriental y Asia central la epidemia, que en algún momento se caracterizó por el uso de drogas inyectables, se está propagando a los compañeros sexuales de estos usuarios. En España, el Ministerio de Sanidad destaca que en 2008 la categoría de transmisión heterosexual fue la más frecuente, con un 41,8 por ciento de los casos, seguida de las relaciones homosexuales entre hombres (38,8 por ciento) y, por último, los casos de usuarios de drogas por vía parenteral (9,2 por ciento). Por otro lado, el cambio en la evolución de la enfermedad gracias a la TAR es un hecho en nuestro país, con el 80 por ciento de descenso de las notificaciones.

WHO | Rapid advice: use of antiretroviral drugs for treating pregnant women and preventing HIV Infection in infants

30 November 2009
Rapid advice: antiretroviral therapy for HIV infection in adults and adolescents

On the eve of World AIDS Day, the World Health Organization (WHO) is releasing new recommendations on treatment, prevention and infant feeding in the context of HIV, based on the latest scientific evidence.

WHO now recommends earlier initiation of antiretroviral therapy (ART) for adults and adolescents, the delivery of more patient-friendly antiretroviral drugs (ARVs), and prolonged use of ARVs to reduce the risk of mother-to-child transmission of HIV. For the first time, WHO recommends that HIV-positive mothers or their infants take ARVs while breastfeeding to prevent HIV transmission.

Rapid advice - English [pdf 306kb] 27 páginas [NEW]
http://www.who.int/hiv/pub/arv/rapid_advice_art.pdf


Key messages [NEW WHO RECOMMENDATIONS]- English [pdf 259kb] 5 páginas |
http://www.who.int/hiv/pub/arv/art_key_mess.pdf


Nouvelles recommandations de l’OMS :
Traitement antirétroviral de l’adulte et de l’adolescent
French [pdf 270kb] idem before
http://www.who.int/hiv/pub/arv/art_key_mess_fr.pdf

Related Rapid advice documents
Rapid advice: use of antiretroviral drugs for treating pregnant women and preventing HIV infection in infants
http://www.who.int/hiv/pub/mtct/rapid_advice_mtct.pdf

Key
New WHO recommendation s:
Preventing mother-to-child transmissionhttp://www.who.int/hiv/pub/mtct/mtct_key_mess.pdf

French
http://www.who.int/hiv/pub/mtct/rapid_advice_mtct_fr.pdf

Nouvelles recommandations de l’OMS :
Prévenir la transmission mère enfant
http://www.who.int/hiv/pub/mtct/mtct_key_mess_fr.pdf

Rapid advice: infant feeding in the context of HIV
http://www.who.int/child_adolescent_health/documents/hiv_if_principles_recommendations_112009.pdf

ABRIR AQUÍ para acceder al documento general WHO:
WHO | Rapid advice: antiretroviral therapy for HIV infection in adults and adolescents

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WHO | Rapid advice: use of antiretroviral drugs for treating pregnant women and preventing HIV Infection in infants

WHO | Pandemic (H1N1) 2009 - update 76

Pandemic (H1N1) 2009 - update 76
Weekly update
27 November 2009 -- As of 22 November 2009, worldwide more than 207 countries and overseas territories or communities have reported laboratory confirmed cases of pandemic influenza H1N1 2009, including over 7820 deaths.

As many countries have stopped counting individual cases, particularly of milder illness, the case count is likely to be significantly lower than the actual number of cases that have occurred. WHO is actively monitoring the progress of the pandemic through frequent consultations with the WHO Regional Offices and member states and through monitoring of multiple sources of data.

Situation update:
In temperate regions* of the northern hemisphere, the early arriving winter influenza season continues to be intense across parts of North America and much of Europe. In North America, the Caribbean islands and a limited number of European countries there are signs that disease activity peaked.

In the United States and Canada, influenza transmission remains very active and geographically widespread. In the United States, disease activity appears to have peaked in all areas of the country. In Canada, influenza activity remains similar but number of hospitalisations and deaths is increasing. Most countries in the Caribbean have ILI and SARI levels coming down.

In Europe, widespread and increasing transmission of pandemic influenza virus was observed across much of the continent and most countries that were not yet experiencing elevated ILI activity in the last few weeks, have seen a rapid increase in ILI. Very high activity is seen in Sweden, Norway, Moldova and Italy. Over 99% of subtyped influenza A viruses in Europe were pandemic H1N1 2009. Impact on health care services is severe in Albania and Moldova. Some countries seem to have peaked already: Belgium, Bulgaria, Belarus, Ireland, Luxemburg, Norway, Serbia, Ukraine and Iceland.

In East Asia, influenza transmission remains active. Intense influenza activity continues to be observed in Mongolia but has peaked already. In Japan, influenza activity remains stably elevated, but may be decreasing slightly in populated urban areas.

ILI activity in India and Nepal and Sri Lanka has increased.

In the tropical zone of the Americas and Asia, influenza transmission remains variable but low in many countries. In the tropical areas of Central and South America, most countries continue to report declining influenza activity, with the exception of Ecuador and Venezuela.

In the temperate region of the southern hemisphere, little pandemic influenza activity has been reported.

Weekly update (Virological surveillance data)
*Countries in temperate regions are defined as those north of the Tropic of Cancer or south of the Tropic of Capricorn, while countries in tropical regions are defined as those between these two latitudes.

**Abbreviations: influenza-like-illness (ILI), acute respiratory infection (ARI), and severe acute respiratory infection (SARI)

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WHO | Pandemic (H1N1) 2009 - update 76

DIRECTORIO DE DOCUMENTOS de NOVIEMBRE 2009

DIRECTORIO DE DOCUMENTOS de NOVIEMBRE 2009
Lunes 30 de NOVIEMBRE de 2009

CIENCIAS MÉDICAS NEWS©: Directorio de Documentos editados en NOVIEMBRE 2009
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un blog del conjunto salud equitativa®
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Consultas acumuladas por el grupo de blogs de salud equitativa®: 278.430
CIENCIAS MÉDICAS NEWS©: Directorio de documentos editados en noviembre de 2009

Desde su creación el 10 de enero de 2009, el blog ha recibido 103.000 consultas (30/11/2009 a las 14.50 horas de Argentina). Una vez más, cabe agradecer a todos los anónimos que buscan en estas páginas contenidos científicos fehacientes, lo cual se transfiere a la calidad de las fuentes que los proveen.
Este blog es usualmente consultado desde todo el mundo (quién lo hubiera dicho). Acceden a él, instituciones académicas, centros de investigación, instituciones de salud tanto públicas como privadas, entes oficiales de distintos gobiernos, así como también profesionales médicos, bioquímicos, farmacéuticos, enfermeros, psicólogos y muchos otros de aquellos que integran el “equipo de salud”.
Si bien la intención original era publicar todo en idioma español únicamente, las circunstancias nos fueron impulsando a incluir documentos en idioma inglés, los que hoy ocupan mayoritariamente las ediciones diarias. Pedimos disculpas por ello, pero bajo la evidencia del interés que los mismos documentos en idioma inglés despiertan, sustentamos la conducta prometiendo acrecentar las ediciones en español para aquellos que no son bilingües o no se sienten cómodos leyendo en inglés.
Agradezco profundamente a todas y cada una de las fuentes: Agencia Europea de Medicamentos, Food and Drug Administration-USA, National Institute of Health-USA; CDC-USA; AHRQ-USA; NGC-USA; NQMC-USA; Sociedad Internacional de Enfermedades Infecciosas [ISID], IntraMed, El Hospital (usa), El Médico Interactivo (España), Jano.es/Elsevier (España), Diario Médico (España), y a todas las demás instituciones del gobierno de los estados unidos de norteamérica y Europa, que nos aportan diariamente con información altamente calificada.
Este blog se nutre de información en red que se distribuye gratuitamente y no monetiza los contenidos por respeto a las necesidades de los profesionales del equipo de la salud. Por dicho motivo, tenemos la libertad de administrar la información que recibimos sin emitir opinión (salvo excepciones de ética y/o bioética explícitas) y sin calificar como así tampoco descalificar a las fuentes. En lo personal entiendo que la información científico-médica debe ser de acceso universal ya que ello habilita a la discusión y al crecimiento del conocimiento. Cerasale©. Noviembre 30, 2009.-

ranking de consultas hasta el 30 de Noviembre de 2009:
1. Argentina: 20.240 - 19,5 %
2. España: 16.035 - 15,4%
3. México: 15.570 – 15,0 %
4. Estados Unidos: 7.682 - 7,4 %
5. Venezuela: 6.829 - 6,6 %
6. Perú: 6.764 - 6,5 %
7. Colombia: 6.416 - 6,2 %
8. Chile: 4.230 - 4,1 %
9. Ecuador: 2.430 - 2,3 %
10. Bolivia: 2.152 - 2,1%
el resto: 15.471 - 14,9 %
total: 103.819 - 100,0 %

ARCHIVO DEL BLOG
• ▼ 2009 (3918)
o ▼ noviembre (550)
 3905. ▲ Indoor Tanning: The Risks of Ultraviolet Rays
 3904. ► Infecciones de transmisión sanguínea o sexual [WHO...
 3903. H1N1 - gripe porcina - ISID / Arabia Saudita (2)
 3902. ♠ NEJM -- Use of Diuretics in Patients with Hyperten...
 3901. H1N1 - gripe porcina - FRANCIA: grave mutación ide...
 3900. VARICELA en VENEZUELA [ISID]
 3899. ♠ NEJM -- Rituximab, B-Lymphocyte Depletion, and Pre...
 3898. Preventing Chronic Disease: January 2009: 07_0227_...
 3897. Preventing Chronic Disease: January 2009: 08_0009_...
 3896. International Diabetes Federation releases importa...
 3895. New International Diabetes Federation study reveal...
 3894. ♣♣ January 2010 expedited articles now online / CDC
 3893. ♣ Trichinosis and Soft-Shelled Turtles | CDC EID
 3892. ♣ E. vogeli Infection, French Guiana | CDC EID
 3891. H1N1 - gripe porcina - ISID / FRANCIA: nuevas muta...
 3890. Reportan más de 1.000 muertes por H1N1 en la últim...
 3889. ♣ Outbreak of Antiviral Drug–Resistant Influenza A |...
 3888. ♣ Susceptibility of Poultry to Pandemic (H1N1) 2009 ...
 3887. ♣ Tick-borne Agents in Rodents, China | CDC EID
 3886. ♣ Rickettsia slovaca in Dermacentor marginatus Ticks...
 3885. ♣ Identical Strains of Borrelia hermsii in Mammal an...
 3884. ♣ Francisella tularensis Cluster in Europe | CDC EID...
 3883. ♣ Wild Felids as Hosts for Human Plague | CDC EID
 3882. ♣ Diagnostic Assay for Rickettsia japonica | CDC EID...
 3881. ♣ B. rochalimae in Raccoons, Coyotes, and Red Foxes ...
 3880. ♣ Delineating A. phagocytophilum Ecotypes | CDC EID
 3879. ♣ Tularemia Outbreaks in Sweden | CDC EID
 3878. Agriflu // Influenza Virus Vaccine
 3877. ► CDC H1N1 Flu |Q&A about CDC’s Guidance for Emergen...
 3876. ► Hospital Planning for 2009 H1N1 Influenza AND H5N...
 3875. ► CDC Guidance for Emergency Shelters for the 2009-2...
 3874. ♠ NEJM -- A Difficult Balance -- Pain Management, Dr...
 3873. ♠ NEJM -- Identification of a Novel Antibody Associa...
 3872. ♣ Campylobacteriosis, England and Wales, 1990–2007 |...
 3871. ♣ A Groundhog, a Novel Bartonella Sequence, and My F...
 3870. ♣ Parachlamydia and Rhabdochlamydia in Premature Neo...
 3869. ♣ Ehrlichia chaffeensis Infection, Sika Deer, Japan ...
 3868. H1N1 - gripe porcina - ISID/MÉXICO: mutación viral...
 3867. H1N1 - gripe porcina - ISID: embolismo pulmonar
 3866. ♣ Control of S. iniae | CDC EID
 3865. ♣ Molecular Epidemiology of Glanders, Pakistan | CDC...
 3864. ♣ Methicillin-Resistant Staphylococcus aureus in Mar...
 3863. ♣ Streptococcus suis Meningitis, Hawaii | CDC EID
 3862. ♣ Chorioamnionitis and Neonatal Sepsis from Communit...
 3861. H1N1 - gripe porcina - ISID/U.S.A.: re-infecciones...
 3860. ▲ Deaths in Acute Hospitals: Caring to the End? - AH...
 3859. Virus del Nilo Occidental en Costa Rica - ISID
 3858. H1N1 - gripe porcina - ISID/CANADÁ: reactogenicida...
 3857. Experto chino advierte por mutación de gripe pandé...
 3856. INVESTIGACIÓN CARDIOVASCULAR - ESPAÑA
 3855. ♣ CA-MRSA in Outpatients, United States, 1999–2006, ...
 3854. ♣ Respiratory Infection and Pandemic (H1N1) 2009 | C...
 3853. ♣ Possible Interruption of Malaria Transmission | CD...
 3852. ♣ Mycobacterium bovis and M. tuberculosis in Goats, ...
 3851. ♣ Oropouche Fever Outbreak, Manaus, Brazil, 2007–200...
 3850. ♣ Delineating A. phagocytophilum Ecotypes | CDC EID
 3849. ♣ New Adenovirus in Bats, Germany | CDC EID
 3848. ♣ Extracorporeal Membrane Oxygenation for Pandemic (...
 3847. ♣ Respiratory Disease in Adults during Pandemic (H1N...
 3846. ♣ Susceptibility of Poultry to Pandemic (H1N1) 2009 ...
 3845. ♣ Porcine Kobuvirus in Piglets, Thailand | CDC EID
 3844. ♣ Filoviruses: A Compendium of 40 Years of Epidemiol...
 3843. ► Pseudo-Outbreak of Antimony Toxicity in Firefighte...
 3842. ► Acute HIV Infection --- New York City, 2008
 3841. HIV Infection Among Injection-Drug Users --- 34 St...
 3840. → filgrastim - EPARs for human use - Ratiograstim
 3839. → Telmisartan and hydrochlorothiazide - EPARs for h...
 3838. → telmisartan / hydrochlorothiazide - EPARs for huma...
 3837. → Recombinant coagulation Factor IX - EPARs for huma...
 3836. → European Medicines Agency - Withdrawals of Applica...
 3835. → Vitespen - European Medicines Agency - Withdrawals...
 3834. HIV/AIDS Update -Intelence (etravirine) label upda...
 3833. Arepanrix® ha causado 6 reacciones alérgicas grave...
 3832. ♀ Abortion Surveillance --- United States, 2006
 3831. Posible caso de transmisión entre humanos de virus...
 3830. ♣ Hemorrhagic Fever with Renal Syndrome | CDC EID
 3829. ♣ Aleutian Mink Disease Virus and Humans | CDC EID
 3828. ♣ Recombination in Strains of PRRSV | CDC EID
 3827. ♣ Transplacental Transmission of BTV-8 in Cattle | C...
 3826. ♣ Dobrava-Belgrade Virus, Germany | CDC EID
 3825. ♣ Mopeia Virus–related Arenavirus, Morogoro, Tanzani...
 3824. ♣ Prevalence of Pandemic (H1N1) 2009, United States ...
 3823. ♣ Respiratory Infection and Pandemic (H1N1) 2009 | C...
 3822. ♣ Hantavirus Infection, Brazil | CDC EID
 3821. FDA news
 3820. OMS investiga expansión de gripe H1N1 resistente a...
 3819. ♣ Sympatry of 2 Hantavirus Strains, Paraguay | CDC E...
 3818. ♣ Outbreak of Antiviral Drug–Resistant Influenza A |...
 3817. ♣ Oseltamivir-Resistant Pandemic (H1N1) 2009 Virus |...
 3816. ♣ Pandemic Influenza as Urban Health Crisis | CDC EI...
 3815. ♣ Calicivirus in Rabbits, Michigan | CDC EID
 3814. ♣ HPAI in Backyard Chickens, Bangladesh | CDC EID
 3813. ♣ Infection Control and Epidemic Respiratory Virus |...
 3812. ♣ Genomic Signatures of Pandemic (H1N1) 2009 Virus |...
 3811. ▲ Selzenttry (maraviroc) by FDA [MUY IMPORTANTE MODI...
 3810. H1N1- gripe porcina - ISID / reacciones adversas g...
 3809. ♣ Chorioamnionitis and Neonatal Sepsis from Communit...
 3808. ♣ Novel MRSA, Hong Kong | CDC EID
 3807. ♣ CTX-M β-Lactamase and Virulence of E. coli K1 | CD...
 3806. Vol. 15, No. 12 Cover: "I think I could turn and l...
 3805. → infliximab - EPARs for human use - Remicade
 3804. → Cetrorelix (as acetate) - EPARs for human use - Ce...
 3803. SARM - ISID/USA [2]
 3802. WHO | Clinical management of human infection with ...
 3801. RITONAVIR by FDA
 3800. → olanzapine - EPARs for human use - Olanzapine Tev...
 3799. → olanzapine - EPARs for human use - Olanzapine Neop...
 3798. → olanzapine - EPARs for human use - Olanzapine Myl...
 3797. → rufinamide - EPARs for human use - Inovelon
 3796. → European Medicines Agency - Human Medicines - Medi...
 3795. Infección entérica desconocida - ISID / COLOMBIA
 3794. Canadá retira un lote de 172.000 vacunas de la gri...
 3793. Vaccines: NIS/2008 NIS Data Released
 3792. - Best evidence statement (BESt). Waste blood volume...
 3791. - Best evidence statement (BESt). Cystic fibrosis - ...
 3790. - Best evidence statement (BESt). Confirmation of na...
 3789. ► United Kingdom national guideline for the manageme...
 3788. ► UK national guidelines on the management of syphil...
 3787. ► UK national guidelines for HIV testing 2008.
 3786. 2007 UK national guideline on the management of vu...
 3785. CDC - Seasonal Influenza (Flu) - Weekly Report: In...
 3784. La Asociación Médica Mundial considera obligatorio...
 3783. WHO | Pandemic (H1N1) 2009 - update 75
 3782. OMS | Importancia para la salud pública de la muta...
 3781. → Nitric oxide - EPARs for human use - INOmax
 3780. → Anagrelide hydrochloride - EPARs for human use - X...
 3779. Nursing management of adults with severe traumatic...
 3778. Neurologic assessment of the older adult. A guide ...
 3777. Guide to the care of the hospitalized patient with...
 3776. Care of the patient with seizures. 2nd edition.
 3775. Care of the patient with aneurysmal subarachnoid h...
 3774. ▲ DIAGNOSIS AND MANAGEMENT OF UNCOMPLICATED LOWER UR...
 3773. ▲Peramivir IV Renal Dosing Recommendations - Inform...
 3772. ▲ Opioid Drugs and Risk Evaluation and Mitigation St...
 3771. * IntraMed - Artículos - Sarcoidosis
 3770. 33 muertos por gripe A(H1N1) en México en tan sólo...
 3769. Documento de Consenso sobre el Manejo de la gripe ...
 3768. H1N1 - gripe porcina - ISID / Arabia Saudita
 3767. How long does it take to train a surgeon? - AHRQ ...
 3766. Health Literacy and Quality: Focus on Chronic Illn...
 3765. "What Did the Doctor Say?:" Improving Health Liter...
 3764. Disclosure of hospital adverse events and its asso...
 3763. Diagnostic Error in Medicine - AHRQ Patient Safety...
 3762. To Err Is Human: Building a Safer Health System - ...
 3761. OMS | El uso de antivíricos y el riesgo de farmaco...
 3760. H1N1 - gripe porcina - ISID / NORUEGA: mutación vi...
 3759. Gripe H1N1 avanza hacia este,llega a máximo en alg...
 3758. Noruega dice halla una mutación del H1N1 en víctim...
 3757. OMS | Gripe pandémica por A (H1N1) 2009: Ucrania —...
 3756. * IntraMed - Noticias médicas - Los opiáceos podrían...
 3755. → Cetuximab - European Medicines Agency - Refusals -...
 3754. → Bevacizumab - European Medicines Agency - Refusals...
 3753. → European Medicines Agency - Human Medicines - CHMP...
 3752. → European Medicines Agency - Human Medicines - Refu...
 3751. → Aripiprazole - European Medicines Agency - Withdra...
 3750. → European Medicines Agency - Human Medicines - Refe...
 3749. →tocilizumab - EPARs for human use - RoActemra
 3748. → European Medicines Agency - Withdrawals of Applica...
 3747. ▲ Medication Guides by FDA
 3746. H1N1 - gripe porcina - ISID / USA: resistencias
 3745. → Milnacipran - European Medicines Agency - Refusals...
 3744. → Milnacipran - European Medicines Agency - Refusals...
 3743. → Becaplermin - European Medicines Agency - Refusals...
 3742. → Interferon beta-1b / EPARs for human use - Betafe...
 3741. → Iclaprim - European Medicines Agency - Withdrawals...
 3740. → Gemifloxacin - European Medicines Agency - Withdra...
 3739. → European Medicines Agency - Human Medicines - Orph...
 3738. → European Medicines Agency - Human Medicines - Orph...
 3737. → Efavirenz / EPARs for human use - Sustiva
 3736. → Pramipexole / EPARs for human use - Mirapexin
 3735. →Pramipexole - EPARs for human use - Sifrol
 3734. Vicks Sinex Nasal Spray - Recall
 3733. Cardiac Science Corp. Powerheart and CardioVive Au...
 3732. Early Communication about an Ongoing Safety Review...
 3731. Células madre embrionarias humanas podrían produci...
 3730. H1N1 - gripe porcina - ISID / VENEZUELA
 3729. LEPRA - ISID / PERÚ
 3728. H1N1 - gripe porcina - ISID / UCRANIA
 3727. H1N1 - gripe porcina - ISID / UK
 3726. Ending Health Care-Associated Infections
 3725. Muertes no se vinculan con vacuna H1N1: OMS
 3724. Peramivir IV Renal Dosing Recommendations / Drug I...
 3723. WHO | Safety of pandemic vaccines
 3722. Drug Information Update- FDA Issues 22 Warning Let...
 3721. Prevention Of Pneumococcal Infections Secondary To...
 3720. 2009 H1N1 and Pneumococcal Disease in the News
 3719. Mumps Outbreak --- New York, New Jersey, Quebec, 2...
 3718. Outbreak of Rickettsia typhi Infection --- Austin,...
 3717. ► West Nile Virus Transmission via Organ Transplanta...
 3716. Estimated County-Level Prevalence of Diabetes and ...
 3715. Call for Public Review : Diagnosis and Treatment o...
 3714. ▬ Renal cell carcinoma.
 3713. Clinical practice guideline for the management of ...
 3712. Adalimumab, etanercept and infliximab for ankylosi...
 3711. rosuvastatina (Crestor) reduce en casi la mitad el...
 3710. CDC Guidance on Helping Child Care and Early Child...
 3709. Type 1 diabetes in adults. National clinical guide...
 3708. Prevención de las infecciones asociadas al cuidado...
 3707. Los diabéticos se benefician de nuevas pautas anti...
 3706. FDA Approves Additional Vaccine for 2009 H1N1 Infl...
 3705. ▬ Human Papillomavirus Quadrivalent (Types 6, 11, 16...
 3704. FDA MedWatch - IDS Sports Dietary Supplements - Fi...
 3703. Immune System of Healthy Adults May Be Better Prep...
 3702. Susceptibility of Poultry to Pandemic (H1N1) 2009 ...
 3701. FDA MedWatch - Clopidogrel (marketed as Plavix) an...
 3700. FDA MedWatch - Cardiovascular Systems ViperSheath ...
 3699. Drug Information Update- FDA Approves Qutenza (cap...
 3698. TIP 48: Managing Depressive Symptoms in Substance ...
 3697. TIP 49: Incorporating Alcohol Pharmacotherapies In...
 3696. TIP 50: Addressing Suicidal Thoughts and Behaviors...
 3695. New Publication on Clinical Supervision for Substa...
 3694. ► Breast Cancer: Screening
 3693. Search for Guides, Reviews, and Reports - AHRQ Eff...
 3692. PREVENTION OF FALLS IN THE ELDERLY - NGC - Compare...
 3691. Stereotactic radiosurgery for patients with intrac...
 3690. Venous thromboembolism diagnosis and treatment.
 3689. Diagnosis and treatment of headache.
 3688. Diagnosis and management of chronic obstructive pu...
 3687. Adapting your practice. Treatment and recommendati...
 3686. Early acute management in adults with spinal cord ...
 3685. ► Guideline implementation for breast healthcare in ...
 3684. Bariatric surgery and pregnancy.
 3683. ► Antibiotic prophylaxis for gynecologic procedures....
 3682. ► Age-related macular degeneration.
 3681. FDA MedWatch - Negative Pressure Wound Therapy (NP...
 3680. FDA MedWatch - October 2009 Drug Safety Labeling C...
 3679. ∑ Osteoporosis y enfermedades gastrointestinales
 3678. ∑ Dysphagia
 3677. ∑ Diverticular Disease
 3676. ∑ Asymptomatic Gallstone Disease / Litiasis vesicula...
 3675. ∑ Acute diarrhea
 3674. ∑ Obesity
 3673. ∑ Hepatitis B
 3672. ∑ Management of acute viral hepatitis
 3671. ∑ Esophageal Varices
 3670. ∑ Probiotics and Prebiotics
 3669. ∑ Malabsorption
 3668. ∑ Helicobacter Pylori in developing countries
 3667. ∑ Celiac Disease
 3666. ∑ Irritable bowel syndrome: a global perspective - A...
 3665. ∑ Inflammatory bowel disease: a global perspective -...
 3664. ► Practice Guideline Update on the Use of Pharmacolo...
 3663. → ribavirin - Authorised Medicines for Human Use - R...
 3662. → Influenza virus surface antigens, inactivated: A/C...
 3661. → Efavirenz - EPARs for human use - Sustiva
 3660. → Split influenza virus, inactivated, containing ant...
 3659. → pandemic influenza vaccine (whole virion, vero cel...
 3658. → Ritonavir - EPARs for human use - Norvir
 3657. → Peginterferon alfa-2a / EPARs for human use - Pega...
 3656. → capsaicin - EPARs for human use - Qutenza
 3655. → Telithromycin - EPARs for human use - Ketek
 3654. → ulipristal - EPARs for human use - Ellaone
 3653. → adalimumab - EPARs for human use - Humira
 3652. → Stavudine - EPARs for human use - Zerit
 3651. → Leflunomide - EPARs for human use - Arava
 3650. → Human Medicines - Herbal Medicinal Products - Adop...
 3649. Influenza A (H1N1) 2009 Monovalent Vaccines Descri...
 3648. Search for Guides, Reviews, and Reports - AHRQ Eff...
 3647. FDA to Examine the Safety of Caffeinated Alcoholic...
 3646. H1N1 - gripe porcina - ISID / CHINA: muertes por E...
 3645. CHAGAS en ESPAÑA: ISID - importada e instalada
 3644. Guidelines on the diagnosis and management of chro...
 3643. Guidelines on the diagnosis and management of mult...
 3642. ♥ Guidelines for the use of fresh-frozen plasma, cry...
 3641. ♠ Guideline for laboratory diagnosis of malaria.
 3640. ♥ (1) Transfusion guidelines for neonates and older ...
 3639. tranexamic acid - FDA Approves Lysteda to Treat He...
 3638. Monovalent Influenza Vaccine Dosage, Administratio...
 3637. Toxocara - ISID / Argentina
 3636. Safety indicators for inpatient and outpatient ora...
 3635. ▲ Basic guidelines for diabetes care.
 3634. Gripe muestra señales de incremento en algunas áre...
 3633. Research Activities, November 2009: Agency News an...
 3632. Research Activities, November 2009: Agency News an...
 3631. Research Activities, November 2009: Mental Health:...
 3630. Research Activities, December 2008: Outcomes/Effec...
 3629. WHO | Pandemic (H1N1) 2009 - update 74
 3628. WHO: Interim Planning Considerations for Mass Gath...
 3627.  CDC H1N1 Flu | Questions and Answers Regarding Res...
 3626.  Quick Facts for Clinicians on Antiviral Treatments...
 3625.  Interim Guidance on Infection Control Measures for...
 3624. H1N1 - gripe porcina - ISID / U.S.A.: expansión
 3623. Information for Healthcare Professionals - Chondro...
 3622. Clinical Utility of Cancer Family History Collecti...
 3620. ♀ Screening for Syphilis Infection in Pregnancy
 3619. ♀ Screening: Hepatitis B Virus Infection in Pregnanc...
 3618. ◙ Idiopathic macular hole.
 3617. ◙ Conjunctivitis.
 3616. ◙ Cataract in the adult eye.
 3615. ◙ Diabetic retinopathy.
 3614. ◙ Bacterial keratitis.
 3613. ◙ Amblyopia.
 3612. ◙ Age-related macular degeneration.
 3611. El número de pacientes infectados por bacterias re...
 3610. → clopidogrel / EPARs for human use - Clopidogrel BM...
 3609. → octocog alfa / EPARs for human use - Kogenatebayer...
 3608. → doxorubicin hydrochloride / EPARs for human use - ...
 3607. → octocog alfa / EPARs for human use - Helixate NexG...
 3606. →Cidofovir anhydrous / EPARs for human use - Vistid...
 3605. ♥ Recommendations for the Assessment of Blood Donor ...
 3604. Mumps Outbreak --- New York, New Jersey, Quebec, 2...
 3603. FDA Expands Approved Use of H1N1 Vaccines to Inclu...
 3602. Update: Influenza Activity --- United States, Augu...
 3601. Effectiveness of 2008--09 Trivalent Influenza Vacc...
 3600. Synthes USA, Ti Synex II Vertebral Body Replacemen...
 3599. CDC Novel H1N1 Flu | CDC Estimates of 2009 H1N1 In...
 3598. Extirpan las glándulas suprarrenales por vía anter...
 3597. Reviews of Selected Pharmacogenetic Tests for Non-...
 3596. IABS: Upcoming Conferences
 3595. Comida contaminada, sorpresivamente letal
 3594. * IntraMed - Artículos - Material de las Jornadas In...
 3593. Error tracking in a clinical biochemistry laborato...
 3592. Errors in laboratory medicine: practical lessons t...
 3591. Preventing catheter-associated bloodstream infecti...
 3590. ♣ AHRQ Patient Safety Network - Glossary
 3589. An intervention to decrease catheter-related blood...
 3588. Managing Patients' Medicines after Discharge from ...
 3587. November 16-17, 2009: Blood Products Advisory Comm...
 3586. Las prótesis invertidas logran una mejor función d...
 3585. H1N1 - gripe porcina - CHINA: máscaras defectuosas...
 3584. malaria / ISID
 3583. What is Substance Abuse Treatment? A Booklet for F...
 3582. Alcohol and Drug Treatment- How It Works, And How ...
 3581. TIP 42: Substance Abuse Treatment for Persons With...
 3580. TIP 50: Addressing Suicidal Thoughts and Behaviors...
 3579. → Nitisinone - EPARs for human use - Orfadin
 3578. Research Activities, October 2009: Elderly/Long-Te...
 3577. Research Activities, November 2009: Elderly/Long-T...
 3576. Pregnancy in women who had cancer in childhood. [E...
 3575. Ovarian failure and reproductive outcomes after ch...
 3574. Female survivors of childhood cancer: preterm birt...
 3573. Call for Public Review: Report on the Evidence Reg...
 3572. CDC H1N1 Flu | CDC Health Alert Network (HAN) Info...
 3571. AFLURIA - Influenza Virus Vaccine
 3570. Influenza A (H1N1) 2009 Monovalent Vaccine (CSL Li...
 3569. Influenza A (H1N1) 2009 Monovalent Vaccine (ID Bio...
 3568. Comparative Effectiveness of Treatments To Prevent...
 3567. Incorporating Alcohol Pharmacotherapies Into Medic...
 3566. ♦ Screening for skin cancer: U.S. Preventive Service...
 3565. ♦ Screening for skin cancer: a clinical practice gui...
 3564. ♦ Identification and management of high-risk individ...
 3563. ♦ Population-based whole-body skin screening for mel...
 3562. ♦ Prevention. In: Clinical practice guidelines for t...
 3561. ♦ Skin melanoma.
 3560. NGC - Compare - Comparison
 3559. Más de 6.000 muertos y medio millón de infectados ...
 3558. External Biphasic Defibrillators MedWatch
 3557. H1N1 influenza vaccine [MedWatch]
 3556. Influenza Virus Vaccine for the 2009-2010 Season
 3555. Influenza A (H1N1) 2009 Monovalent Vaccines Compos...
 3554. ♠ Recommended Pediatric Dosage of RETROVIR
 3553. FDA Commissioner Addresses Nation’s Doctors on H1N...
 3552. vacuna para la leishmaniasis [Red de Investigación...
 3551. ☼ MELANOMA (all about) from Clinical practice guidel...
 3550. ☼ Treatment of primary melanoma. In: Clinical practi...
 3549. ☼ Treatment of disseminated melanoma. In: Clinical p...
 3548. ☼ Treatment of desmoplastic melanoma. In: Clinical p...
 3547. ☼ Psychosocial issues in melanoma. In: Clinical prac...
 3546. ☼ Prognostic factors and survival outcomes in cutane...
 3545. ☼ Prevention. In: Clinical practice guidelines for t...
 3544. ☼ Pregnancy and melanoma (including hormone replacem...
 3543. ☼ Population-based whole-body skin screening for mel...
 3542. ☼ Palliative care in melanoma. In: Clinical practice...
 3541. ☼ Ocular melanoma. In: Clinical practice guidelines ...
 3540. ☼ Occult melanoma. In: Clinical practice guidelines ...
 3539. ☼ Multidisciplinary care of melanoma. In: Clinical p...
 3538. ☼ Mucosal melanoma. In: Clinical practice guidelines...
 3537. ☼ Melanoma in specific populations in Australia. In:...
 3536. ☼Melanoma in Maori and melanoma in Pacific peoples ...
 3535. ☼ Melanoma in children. In: Clinical practice guidel...
 3534. ☼ Management of regional lymph nodes in melanoma. In...
 3533. ☼ Management of locoregionally recurrent melanoma. I...
 3532. ☼ Lentigo maligna. In: Clinical practice guidelines ...
 3531. ☼ Identification and management of high-risk individ...
 3530. ☼ Histopathological reporting of cutaneous melanoma....
 3529. ☼ Follow-up. In: Clinical practice guidelines for th...
 3528. ☼ Congenital melanocytic naevi. In: Clinical practic...
 3527. ☼ Criteria for Determining Disability in Infants and...
 3526. ☼ Complementary and alternative medicine. In: Clinic...
 3525. ☼ Clinical trials. In: Clinical practice guidelines ...
 3524. ☼ Clinical diagnosis. In: Clinical practice guidelin...
 3523. ☼ Classification and staging of melanoma. In: Clinic...
 3522. ☼ Biopsy. In: Clinical practice guidelines for the m...
 3521. ☼ Appropriate investigations. In: Clinical practice ...
 3520. ☼ Adjuvant systemic therapy of melanoma. In: Clinica...
 3519. Hispanic Diabetes Disparities Learning Network in ...
 3518. Hospira Brand Propofol and Liposyn Products - Reca...
 3517. Edwards Lifesciences CardioVations EndoClamp Aorti...
 3516. Cutaneous T-cell lymphoma / FDA Approves Drug Trea...
 3515. November 16-17, 2009: Blood Products Advisory Comm...
 3514. → clopidogrel besilate - EPARs for human use - Clopi...
 3513. → Clopidogrel hydrogen sulphate - EPARs for human u...
 3512. → Pegfilgrastim - EPARs for human use - Neulasta
 3511. → Sodium phenylbutyrate - EPARs for human use - Ammo...
 3510. → sevelamer carbonate - EPARs for human use - Renvel...
 3509. → filgrastim - EPARs for human use - Zarzio
 3508. → Celecoxib - EPARs for human use - Onsenal
 3507. → filgrastim - EPARs for human use - Filgrastim Hexa...
 3506. Ω Human Fluid and Caloric Requirements by FDA
 3505. Ω Dose Calculator by FDA
 3504. H1N1 - gripe porcina - MÉXICO: incremento de decso...
 3503. ISID / BRASIL: botulismo
 3502. H1N1 today: Vaccination
 3501. CDC H1N1 Flu | Interim guidance for use of 23-vale...
 3500. ISID / CHILE: leptospirosis
 3499. ISID / U.S.A.: infecciones
 3498. ISID / PERÚ: rabia por murciélagos
 3497. WHO recommendations for the prevention of postpart...
 3496. Global strategy for the diagnosis, management, and...
 3495. en España se diagnostican unos 20.000 casos de cán...
 3494. El diagnóstico diferencial y la profilaxis, retos ...
 3493. Los niños representan ya uno de cada tres casos re...
 3492. H1N1 - gripe porcina - ISID / VENEZUELA
 3491. H1N1 - gripe porcina - OMS: China Y Japón
 3490. H1N1 - gripe porcina - ARGENTINA: 10% de los deces...
 3489. Research Activities, November 2009: Research Brief...
 3488. Research Activities, November 2009: Agency News an...
 3487. Research Activities, November 2009: Agency News an...
 3486. Research Activities, November 2009: Agency News an...
 3485. Research Activities, November 2009: Agency News an...
 3484. romidepsin: to Treat Cutaneous T-cell Lymphoma
 3483. WHO | Pandemic (H1N1) 2009 - update 73
 3482. Evolution of pandemic H1N1 2009 in animals
 3481. WHO | Infection of farmed animals with the pandemi...
 3480. ► Blood Guidances Update
 3479. What's New from the Office of Oncology Drug Produc...
 3478. Handwashing Video HAI Heathcare Associated Infecti...
 3477. 2nd World HAI Forum: Experts Discuss Looming Threa...
 3476. Berinert [C1 Esterase Inhibitor (Human)]
 3475. Approval History, Letters, Reviews and Related Doc...
 3474. Gripe H1N1 tiende "emboscada" a algunos países: ex...
 3473. → Human Medicines - Herbal Medicinal Products - Adop...
 3472. ▲ Allergic rhinitis and its impact on asthma.
 3471. ▲ Clinical practice guideline for the management of ...
 3470. Medical, Statistical, and Clinical Pharmacology Re...
 3469. Announcement: First Global Ministerial Conference ...
 3468. Announcement: Application Deadline for The CDC Exp...
 3467. Human Rabies --- Missouri, 2008
 3466. Human Vaccinia Infection After Contact with a Racc...
 3465. State Medicaid Coverage for Tobacco-Dependence Tre...
 3464. Developmental trajectories of self-management skil...
 3463. Paul Coverdell National Acute Stroke Registry Surv...
 3462. Stiff Nights - product contains undeclared drug in...
 3461. FDA Warns Consumers on Sexual Enhancement Products...
 3460. Association between antidepressant drug use during...
 3459. →darunavir - EPARs for authorised medicinal produc...
 3458. → aztreonam - EPARs for authorised medicinal product...
 3457. CDC H1N1 Flu | Interim Guidance for People who hav...
 3456. IDPH News: H1N1 Flu Confirmed in Iowa Cat
 3455. AASLD position paper: the management of acute live...
 3454. ▲ (1) Chronic hepatitis B. (2) Corrections to AASLD ...
 3453. Radioterapia y trastuzumab en tratamiento adyuvant...
 3452. Irradiar la mama completa de forma hipofraccionada...
 3451. Logran reducir la RT a cuatro semanas tras lumpect...
 3450. El tiempo entre terapia y PSA recurrente predice l...
 3449. ▲ Allergy diagnostic testing: an updated practice pa...
 3448. ▲ Allergy diagnostic testing: an updated practice pa...
 3447. ♦ Allergen immunotherapy: a practice parameter secon...
 3446. La AEV defiende la seguridad de la vacuna y rechaz...
 3445. * Humanidades medicas - Azucena Couceiro Vidal - Lai...
 3444. → European Medicines Agency - Human Medicines - Orph...
 3443. Vacuna eficaz contra el tumor vulvar intraepitelia...
 3442. Assessing Patient Safety Practices and Outcomes in...
 3441. Enhancing Patient Care: A Practical Guide to Impro...
 3440. Dosage Delivery Devices for OTC Liquid Drug Produc...
 3439. Genomic Signatures of Influenza A Pandemic (H1N1) ...
 3438. Respiratory Infection in Institutions during Early...
 3437. Cost-effectiveness Analysis of Hospital Infection ...
 3436. Pandemic influenza as 21st century urban public he...
 3435. Mobility, Globalization, and Drug Resistance | CDC...
 3434. Diagnosis and management of chronic kidney disease...
 3433. Sífilis - ISID / CHINA
 3432. CDC H1N1 Flu | Monovalent Influenza Vaccine Dosage...
 3431. USDA National Veterinary Services Laboratories Pre...
 3430. Guidance to Pharmacies on Advance Compounding of T...
 3429. WHO | Experts advise WHO on pandemic vaccine polic...
 3428. Massachusetts Department of Mental Retardation hea...
 3427. ► Cutaneous melanoma. A national clinical guideline....
 3426. Screening for skin cancer: a clinical practice gui...
 3425. FDA Unveils Safe Use Initiative that Targets Preve...
 3424. → European Medicines Agency - Withdrawals of Applica...
 3423. → Ibritumomab tiuxetan - EPARs for authorised medic...
 3422. → Human Medicines - Herbal Medicinal Products - Publ...
 3421. → European Medicines Agency - Human Medicines - Medi...
 3420. → Human Medicines - Herbal Medicinal Products - Adop...
 3419. → European Medicines Agency - EMEA monthly medicines...
 3418. → European Medicines Agency - Refusals - Medicinal P...
 3417. La prehipertensión incrementa significativamente e...
 3416. FDA MedWatch - November 2009 FDA Patient Safety Ne...
 3415. Dietary Supplements-Sold on Internet: undeclared s...
 3414. Leptospirosis - ISID / República Dominicana
 3413. FDA's MedWatch Safety Alerts: October 2009
 3412. H1N1 - gripe porcina - ARGENTINA: dos nuevas muert...
 3411. Influenza (Flu) Antiviral Drugs and Related Inform...
 3410. Influenza Drugs Information: by FDA
 3409. parálisis supranuclear progresiva
 3408. NCTR Research Highlights
 3407. ♣ ArrayTrack™ News
 3406. ARGENTINA: Una novedosa técnica para realizar angi...
 3405. La penicilina no provoca defectos congénitos
 3404. ▲ MANAGEMENT OF HIP FRACTURE IN OLDER PEOPLE
 3403. ► "pancreatic cancer" // NGC - Search Results
 3402. ◊ ACR Appropriateness Criteria® postmastectomy radio...
 3401. ◊ ACR Appropriateness Criteria® locally advanced bre...
 3400. ◊ ACR Appropriateness Criteria® conservative surgery...
 3399. ◊ ACR Appropriateness Criteria® acute chest pain - l...
 3398. Initial Results Show Pregnant Women Mount Strong I...
 3397. exenatide - Altered kidney function, including acu...
 3396. ■ ICSI - Prenatal Care, Routine (Guideline)
 3395. Smoking and the progression of diabetic nephropath...
 3394. Specific effects of calcium channel blockers in di...
 3393. Protein restriction to prevent the progression of ...
 3392. Multifactorial therapy and the progression of diab...
 3391. Glucose control and progression of diabetic nephro...
 3390. Control of hypercholesterolaemia and progression o...
 3389. Analgesic-associated kidney disease.
 3388. "La alarma sobre las eritropoyetinas para la anemi...
 3387. efectos secundarios
 3386. telangiectasia hemorrágica hereditaria [HHT] inves...
 3385. Síndrome metabólico: mortalidad global y de causa ...
 3384. * IntraMed - Entrevistas - Los significados inconsci...
 3383. Research Activities, October 2009: Outcomes/Effect...
 3382. ESPAÑA: Vacunas, antivirales y cautela: herramient...
 3381. Research Activities, November 2009: Women's Health...
 3380. Research Activities, November 2009: Women's Health...
 3379. Research Activities, November 2009: Women's Health...
 3378. Research Activities, November 2009: Women's Health...
 3377. Research Activities, November 2009: Feature Story:...
 3376. Use of failure mode and effects analysis for proac...
 3375. Conducting Filial Therapy With Homeless Parents
 3374. Effects of Social Support and Conflict on Parentin...
 3373. Commentary: A Provider Perspective on Supporting P...
 3372. Acknowledgements: Special Section on Parenting and...
 3371. Commentary: A Consumer Perspective on Parenting Wh...
 3370. Examining the Impact of Parental Risk on Family Fu...
 3369. Parenting, Parental Mental Health, and Child Funct...
 3368. What Research Tells Us About the Intersecting Stre...
 3367. Parenting and Homelessness: Overview and Introduct...
 3366. Parent-Adolescent Violence and Later Behavioral He...
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Indoor Tanning: The Risks of Ultraviolet Rays

Indoor Tanning: The Risks of Ultraviolet Rays

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On this page:
Cancer Risk
Other Risks
Tanning in Children and Teens
FDA Regulation
The Riskiest Practices
Melanoma: One Woman's Story

Sunlamps and tanning beds promise consumers a bronzed body year-round, but the ultraviolet (UV) radiation from these devices poses serious health risks.

“Although some people think that a tan gives them a ‘healthy’ glow, any tan is a sign of skin damage,” says Sharon Miller, M.S.E.E., a Food and Drug Administration (FDA) scientist and international expert on UV radiation and tanning.

“A tan is the skin’s reaction to exposure to UV rays,” says Miller. “Recognizing exposure to the rays as an ‘insult,’ the skin acts in self-defense by producing more melanin, a pigment that darkens the skin. Over time, this damage will lead to prematurely aged skin and, in some cases, skin cancer.”

Two types of UV radiation that penetrate the skin are UV-B and UV-A rays.

UV-B rays penetrate the top layers of skin and are most responsible for sunburns.
UV-A rays penetrate to the deeper layers of the skin and are often associated with allergic reactions, such as a rash.
Both UV-B and UV-A rays damage the skin and can lead to skin cancer. Tanning salons use lamps that emit both UV-A and UV-B radiation.

Cancer Risk
Exposure to UV radiation—whether from the sun or from artificial sources such as sunlamps used in tanning beds—increases the risk of developing skin cancer, according to the National Cancer Institute (NCI). Melanoma, the deadliest form of skin cancer, is linked to getting severe sunburns, especially at a young age.

In July 2009, the International Agency for Research on Cancer (IARC), part of the World Health Organization, concluded that tanning devices that emit UV radiation are more dangerous than previously thought. IARC moved these devices into the highest cancer risk category: “carcinogenic to humans.” Previously, it had categorized the devices as “probably carcinogenic to humans.”

Development of cancer is a long process that may take decades. Therefore, IARC also recommended banning commercial indoor tanning for those younger than 18 years to protect them from the increased risk for melanoma and other skin cancers.

IARC’s conclusions and recommendations were based on its 2006 review of 19 studies conducted over 25 years on the use of indoor tanning equipment. The review found evidence of

. an association between indoor tanning and two types of skin cancer: squamous cell carcinoma and melanoma
.. an association between UV-emitting tanning devices and cancer of the eye (ocular melanoma)
... both UV-A and UV-B rays causing DNA damage, which can lead to skin cancer in laboratory animals and humans
... the risk of melanoma of the skin increasing by 75 percent when tanning bed use started before age 35

IARC’s review had some limitations, says Ron Kaczmarek, M.D., M.P.H., an FDA epidemiologist who analyzed the review. Limitations include possible inaccuracy of people’s memories of their tanning experiences, not knowing the amount of UV radiation emitted by each tanning device, and the inability to separate the effects of individuals’ indoor and outdoor exposure. Nevertheless, IARC concluded that there is convincing evidence of an association between the use of indoor tanning equipment and melanoma risk, and that the use of tanning beds should be discouraged.

“It’s well established that UV radiation from the sun causes skin cancer,” says Miller. “Since lamps used in tanning beds emit UV radiation, the use of indoor tanning devices also increases your risk of skin cancer.”


Other Risks
In addition to the serious risk of skin cancer, tanning can cause:

* Premature aging. Tanning causes the skin to lose elasticity and wrinkle prematurely. This leathery look may not show up until many years after you’ve had a tan or sunburn.
* Immune suppression. UV-B radiation may suppress proper functioning of the body’s immune system and the skin’s natural defenses, leaving you more vulnerable to diseases, including skin cancer.
* Eye damage. Exposure to UV radiation can cause irreversible damage to the eyes.
* Allergic reaction. Some people who are especially sensitive to UV radiation may develop an itchy red rash and other adverse effects.

Advocates of tanning devices sometimes argue that using these devices is less dangerous than sun tanning because the intensity of UV radiation and the time spent tanning can be controlled. But there is no evidence to support these claims. In fact, sunlamps may be more dangerous than the sun because they can be used at the same high intensity every day of the year—unlike the sun whose intensity varies with the time of day, the season, and cloud cover.


Tanning in Children and Teens
FDA is particularly concerned about children and teens being exposed to UV rays. Intermittent exposures to intense UV radiation leading to sunburns, especially in childhood and teen years, increase the risk of melanoma, according to NCI.

FDA believes that limiting sun exposure and using sunscreen or sunblock are particularly important for children since these measures can prevent sunburn at a young age.

NCI reports that women who use tanning beds more than once a month are 55 percent more likely to develop melanoma. Teenage girls and young women make up a growing number of tanning bed customers.

“Young people may not think they are vulnerable to skin cancer,” says Kaczmarek. “They have difficulty thinking about their own mortality.” Yet of the more than 68,000 people in the United States who will learn they have melanoma this year, one out of eight will die from it, according to NCI estimates. In addition, the American Academy of Dermatology reports that melanoma is the second most common cancer in women 20 to 29 years old.

Some states are considering laws to ban those under age 18 from using tanning beds. And many states now have laws that require minors to have a parent’s consent or be accompanied by a parent to the tanning facility.

FDA’s current performance standard requires that a sunlamp product’s label include a recommended exposure schedule. FDA has advised manufacturers that this schedule should provide for exposures of no more than three sessions in the first week.

In an NCI-sponsored study published in September 2009 in the Archives of Dermatology, the study researchers hired and trained college students to pose as 15-year-old, fair-skinned girls who had never tanned before. By telephone, the students asked more than 3,600 tanning facilities in all 50 states about their practices.

Less than 11 percent of the facilities followed FDA’s recommended exposure schedule of three or fewer sessions the first week. About 71 percent said they would allow a teen to tan all seven days the first week, and many promoted frequent tanning with “unlimited tanning” discount price packages.

About 87 percent of the facilities required parental consent, leading the researchers to conclude that “many parents are allowing their teens to tan and are providing written consent or accompaniment.”

“Parents should carefully consider the risks before allowing their children under 18 to tan,” says Miller.


FDA Regulation
FDA regulates radiation-emitting products, including sunlamps and products that contain them, such as tanning beds and booths and portable home units. Manufacturers of sunlamps must comply with FDA regulations, including the performance standard for sunlamp products.

FDA requires sunlamp products to carry a warning label with specific information. Based on the results of consumer testing, FDA is considering amending the warning label requirements to
- strengthen the warnings about skin cancer and irreversible eye damage
- make the warning easier for consumers to read and understand
In a December 2008 Report to Congress, FDA noted that FDA/NCI studies found that the UV exposures typically provided by sunlamp products are excessive, and that comparable cosmetic effects can be produced with exposures that are only one-third or even one-fourth the levels currently used. FDA is evaluating the results of this research and considering whether those results warrant changes to its performance standard for sunlamp products.

The Riskiest Practices
FDA, NCI, the American Academy of Dermatology, and other health organizations advise limiting exposure to natural UV radiation from the sun and avoiding artificial UV sources such as tanning beds entirely.

All use of tanning beds increases the risk of skin cancer. Certain practices are especially dangerous. These include:

.Failing to wear the goggles provided, which can lead to short- and long-term eye injury.
..Starting with long exposures (close to the maximum time for the particular tanning bed), which can lead to burning. Because sunburn takes 6 to 48 hours to develop, you may not realize your skin is burned until it’s too late.
...Failing to follow manufacturer-recommended exposure times on the label for your skin type.
....Tanning while using certain medications or cosmetics that may make you more sensitive to UV rays. Talk to your doctor or pharmacist first.


Melanoma: One Woman's Story
Brittany Lietz Cicala of Chesapeake Beach, Md., began tanning indoors at age 17. She stopped at age 20 when she was diagnosed with melanoma, the deadliest form of skin cancer. The former Miss Maryland says she used tanning beds at least four times a week, and sometimes every day.

"Growing up, until I started using tanning beds, my parents were very strict about me wearing sunscreen," says Cicala. Although she also tanned in the summer sun during her 3 years of tanning bed use, Cicala estimates that 90 percent of her UV exposure was in tanning beds during this period.

In the 4 years since she was diagnosed with melanoma, Cicala’s surgeries have left her with about 25 scars. Cicala gets a head-to-toe skin exam every 3 months, which usually results in removal of a suspicious growth.

This article appears on FDA's Consumer Updates page, which features the latest on all FDA-regulated products.

Date Posted: November 30, 2009

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Indoor Tanning: The Risks of Ultraviolet Rays