Consistent evidence supports a link between exposure to wildfire smoke and increased pulmonary morbidity, with multiple studies showing associations between levels of particulate matter 2.5 (PM2.5) from wildfires and rates of hospitalization and emergency department (ED) visits for respiratory illnesses such as acute bronchitis, asthma, and chronic obstructive pulmonary disease.1-3 Additionally, some studies have demonstrated associations between exposure to wildfire smoke and an increased risk for cardiovascular disease (CVD).
“Emerging data suggests that wildfire smoke exposure increases cardiovascular events such as heart attacks and cardiovascular hospitalizations, and elderly patients and patients with underlying comorbidities such as cardiovascular disease and respiratory conditions seem to be more susceptible,” explained American Heart Association (AHA) volunteer Sanjay Rajagopalan, MD, FACC, FAHA, chief of cardiovascular medicine and chief academic and scientific officer at University Hospitals Harrington Heart and Vascular Institute in Cleveland, Ohio. “The chemical composition of wildfire smoke suggests that it may be even more toxic than traditional fossil fuel-based emissions.”4
Findings on Wildfire Smoke and CVD Risk
In a study published in 2022 in Geohealth, stratified analyses showed an increase in unscheduled hospital visits in California for all CVDs, ischemic heart disease, and heart failure among non‐Hispanic White patients and patients older than 65 years on days with the highest concentrations of PM2.5 from wildfires. The study authors also reported that higher temperatures may interact with wildfire-derived PM2.5 and further increase hospital visits for CVD among individuals with pre-existing heart disease.1
Another California-based study observed higher rates of ED visits for various CV events, including myocardial infarction (RR, 1.42; 95% CI, 1.09-1.84), ischemic heart disease (RR, 1.22; 95% CI, 1.01-1.47), and heart failure (RR, 1.22; 95% CI, 1.10-1.35) on days with dense smoke, with the highest rates found among adults aged 65 years and older.5
In other studies, the risk for out‐of‐hospital cardiac arrest increased on days with heavy smoke due to California wildfires, and elevated levels of PM2.5 from Colorado wildfires were associated with increased rates of CVD hospitalization and CV mortality (OR, 1.478; 95% CI, 1.12–1.94).6,2
In a study published in 2022, post-wildfire physician visits among older adults increased by 11% (95% CI, 3%-21%) for congestive heart failure and 19% (95% CI, 7%-33%) for ischemic heart disease, and patients with diabetes demonstrated a higher risk for CV morbidity (relative risk [RR], 1.22; 95% CI, 1.01-1.46) and respiratory morbidity (RR , 1.35; 95% CI, 1.09-1.67) following wildfires in Calgary, Canada.7
Other recent research suggests a slight increase in the risk of CV mortality associated with wildfire smoke, with 2 studies showing that 0.55 and 0.56 of CV deaths were attributable to wildfire-related PM2.5 exposure during each study period.8,9
Overall, however, findings regarding the connection between wildfire smoke and CV outcomes are mixed.2 “While some studies have indicated an uptick in emergency room admissions for CVD post-wildfire, others have not,” noted Julio Lamprea Montealegre, MD, PhD, MPH, clinical instructor in the division of cardiology at the University of California San Francisco. “The specific types of cardiovascular events that are most likely affected by wildfire exposure also remain unclear.”
Clinical Implications and Next Steps
Although further research is needed to elucidate the relationship between CVD and wildfire smoke exposure, wildfire-related CV events may become more prevalent with the potential intensification of wildfires in the coming years, according to Dr Rajagopalan and Dr Montealegre. This possibility highlights the need for increased awareness and preparation among patients, providers, and health systems.
“Awareness is the first prerequisite for appropriate intervention, and the association between cardiovascular events and wildfire smoke needs to be widely promulgated amongst health care personnel,” Dr Rajagopalan said. Patient awareness of neighborhood air pollution levels during wildfire episodes is also important. Higher-risk patients, such as the elderly and those with prior CV or respiratory conditions, should be educated about protective measures, he advised.
“The US Environmental Protection Agency (EPA) has set forth recommendations to mitigate exposure to particle pollution, particularly for vulnerable groups including those with pre-existing cardiovascular diseases,” Dr Montealegre stated. “Recommendations encompass both indoor and outdoor measures, such as employing portable air cleaners and limiting outdoor activities during times when the Air Quality Index (AQI) indicates unhealthy levels.”10 Patients and providers can check AirNow.gov to monitor daily AQI forecasts.
As roughly 67% of exposure to PM2.5 from outdoor origins occurs inside the home due to infiltration of outdoor pollutants, efforts to improve indoor air quality are essential in reducing wildfire smoke exposure and related health risks.11
In a review published in 2022 in Circulation, Hadley et al recommended various measures to reduce wildfire smoke exposure and the associated CV impact in affected areas.12 On the individual level, for example, they recommend the use of particle respirators such as N95 masks among vulnerable patients.12
In the health care setting, they recommend that clinicians ensure the aggressive management of traditional CVD risk factors and optimization of medical therapy among at-risk patients prior to the start of each fire season.12
More broadly, they recommend that health care facilities strive for cleaner indoor air and that health systems “make preparations for wildfire season to protect their susceptible patients and avoid shortfalls in beds, supplies, human resources, and key partnerships,” as described in the paper.12
Dr Montealegre emphasized the crucial need for a deeper dive into research aimed at elucidating the CV consequences of wildfire smoke. “Priorities include enhanced exposure science that offers a precise evaluation of individual exposure levels, rigorous mechanistic studies elucidating the connection between pollutants from wildfire smoke and cardiovascular repercussions, and clinical trials assessing the efficacy of mitigation techniques such as air filters in curtailing cardiovascular events,” he said.
Beyond efforts to mitigate the adverse health effects of wildfire smoke in high-risk individuals, the most important broader measures needed in this area are “steps to prevent climate change, which include ongoing efforts at decarbonizing our economy and uncoupling CO2 emissions from economic activity,” Dr Rajagopalan stated. “In this regard, movement to a fossil fuel-free future is not only eminently possible, but may also be associated with better health, better economies, and hopefully better climate in the not-too-distant future.”
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A 43-year-old soldier presents with a 10-year history of neck pain. The patient believes that carrying heavy objects and wearing helmets for 20 years while in service may have played a role in his worsening neck pain. He describes intermittent headaches and neck pain over the center of his cervical spine that is made worse with range of motion and prolonged positioning such as when driving. He has no pain radiating down the arms or weakness in the upper extremities. To help with pain, the patient has tried massage therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), and muscle relaxers for temporary relief. He rates his neck pain as 8 out of 10 on the numeric pain scale and notes that it affects his range of motion, which impacts activities of daily living. Imaging tests are performed (Figures 1-2) on the cervical spine that shows mild facet arthritis. Magnetic resonance imaging (Figure 3) of the neck shows mild facet inflammation but no evidence of nerve impingement.
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Autism spectrum disorder (ASD) is a developmental disorder characterized by ongoing problems with social communication, social interaction, and restricted, repetitive behaviors, interests, and activities.1,2 While an experienced clinician can reliably identify ASD in children as young as age 2 years, many children do not receive the diagnosis until they are much older, which delays effective treatment.3 Parents may be able to spot signs and symptoms of ASD very early in their child's life, which can lead to earlier evaluation and treatment. This article describes what you should do to prepare for the initial evaluation if you suspect your child may have ASD, or if you think you might have ASD.
Prevalence of Autism Spectrum Disorder
In the United States, approximately 1 in every 36 children aged 8 years is estimated to have ASD.4 Boys are approximately 4 times as likely to be diagnosed with ASD than girls.4 Because ASD is a lifelong condition, an estimated 2.2% of U.S. adults (approximately 5.4 million people aged 18 years and older) are living with ASD.5
Early Signs of Autism Spectrum Disorder
Autism spectrum disorder can be diagnosed at any age.6 Symptoms of ASD are generally identified when a child is aged 12 to 24 months, though they may appear earlier than 12 months if severe, or later than 24 months if subtle.1 Parents or caregivers may be able to notice early signs of ASD before their child is 1 year old.2
Typical early symptoms of ASD include1:
A delay in language development;
A lack of social interest or unusual social interactions (such as pulling someone by the hand without trying to look at them);
Abnormal patterns of play (such as carrying toys around but not actually playing with them); and
Atypical communication (such as knowing the alphabet but not responding to their own name).
The 2 types of symptoms of ASD are difficulties with social communication/interactions and restricted, repetitive behavior, interests, or activities.1
Specific social communication/interactions problems include avoiding eye contact, having difficulty using nonverbal gestures, using stilted or scripted speech, interpreting abstract ideas literally, having trouble recognizing one's own emotions as well as the emotions of other people, and having difficulty making or keeping friends.2
A child who shows restricted interests is extremely focused on a specific subject to the exclusion of other subjects and expects others to be just as interested in that subject.2 A child with ASD has inflexible behavior and extreme difficulty dealing with change, particularly changes in routine or participating in new experiences.2 Repetitive behaviors might include movements such as hand flapping, rocking, or spinning, being hypersensitive to stimuli such as loud noises, and arranging toys or other items in a very particular pattern.1,2
Studies have shown that, with rare exceptions, a child with ASD will experience deterioration in their social and communication behaviors over the first 2 years of life. During the second year of life (aged 12 to 24 months) repetitive behaviors and abnormal play typically become more obvious. A small number of patients with ASD experience these behavioral declines in adolescence. Some people with ASD may not seek an evaluation for ASD until they are an adult, possibly prompted by an ASD diagnosis in a child in their family.1,2
Autism Spectrum Disorder Screening: Resources and Tools
While parents can informally assess their child for signs and symptoms of ASD, they also can use tools designed for that purpose. While these tools generally are intended to be used by clinicians, they rely at least in part on input from parents, so parents may find it helpful to explore them before their child is evaluated by a specialist.
The Modified Checklist for Autism in Toddlers (M-CHAT-R; available at www.mchatscreen.com) is a screening tool intended to be used by primary care providers, specialists, or other professionals to determine a child’s risk for ASD.7 It consists of 2 parts: the M-CHAT-R and the M-CHAT-R Follow-up (M-CHAT-R/F).
The M-CHAT-R consists of 20 yes/no questions about how a child usually behaves. Scoring of the M-CHAT-R is interpreted as follows7:
Total score 0 to 2: Low risk. Repeat screen after second birthday for children under 24 months of age.
Total score 3 to 7: Medium risk. A clinician should administer the M-CHAT-R/F to obtain further details about at-risk responses. If the score is still 2 or higher, the child has screened positive.
Total score 8 to 20: High risk. The child should receive immediate diagnostic assessment and early intervention evaluation from a clinician.
If a child screens positive on the M-CHAT-R, a clinician should administer the M-CHAT-R/F, which consists of 20 pass/fail questions and detailed instructions for how to interpret the results.7 Because the goal of the M-CHAT-R is to detect as many cases of ASD as possible, it has a high rate of false positives, which means that not every child whose M-CHAT-R results suggest they are at risk for ASD will be diagnosed with the disorder.7 However, children who screen positive on the M-CHAT-R are at risk for other developmental disorders and should be evaluated by an experienced clinician.7
In addition to M-CHAT, several other tools that include input from parents can be used to screen children for development delays that might suggest a diagnosis of ASD3:
Ages and Stages Questionnaires (https://agesandstages.com) is a general developmental screening tool to be completed by a parent or caregiver. It features 19 age-specific questionnaires that address communication, gross motor, fine motor, problem-solving, and individual adaptive skills.
Parents’ Evaluation of Developmental Status (https://pedstest.com) is a general developmental screening tool. It is a parent-interview form used to screen for developmental or behavioral problems that warrant further evaluation.
Communication and Symbolic Behavior Scales (https://brookespublishing.com/product/csbs) is a standardized tool to screen for communication and symbolic abilities in children up to age 24 months.
Screening Tool for Autism in Toddlers and Young Children (https://vkc.vumc.org/vkc/triad/stat) is an interactive screening tool for children with suspected developmental delays. It features 12 activities that evaluate play, communication, and imitation skills.
Screening tools such as these are used to help identify a child who might have a neurodevelopmental delay such as ASD, but they do not provide conclusive evidence of a delay and they do not establish a diagnosis.3 Parents who thinks their child might have ASD should express their concerns to their child's pediatrician. The American Academy of Pediatrics recommends that pediatricians conduct general developmental screening of all children at 9, 18, and 30 months of age, and screening specifically for symptoms of ASD at 18 and 24 months.8 If necessary, the pediatrician will refer parents to a specialist who will conduct a thorough evaluation using the appropriate diagnostic criteria.
Autism Spectrum Disorder Diagnostic Criteria
In order to receive a diagnosis of ASD, a child needs to meet the criteria established by the American Psychiatric Association and published in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision.1 Those criteria can be summarized as follows1:
A. Persistent deficits in social communication and social interaction as manifested by all of the following:
Deficiencies in social-emotional reciprocity (such as an inability to engage in normal back-and-forth conversation);
Deficiencies in nonverbal gestures used in social interaction (such as problems with eye contact, body language, or understanding or using gestures); and
Deficiencies in developing, maintaining, and understanding relationships (such as a lack of interest in peers).
B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least 2 of the following:
Repetitive motor movements, use of objects, or speech (such as body rocking, arm or hand flapping, lining up toys, repeating words just spoken by another person);
Insistence on sameness, inflexible adherence to routine, or ritualized patterns of behavior (such as difficulty with transitions, rigid thinking patterns, need to eat the same food each day);
Highly restricted, fixated interests that are abnormal in intensity or focus (such as a strong attachment to peculiar objects); and
Hypersensitivity or hyporeactivity to sensory input or abnormal interest in sensory aspects of the environment (such as indifference to pain or temperature, adverse response to specific sounds or textures).
To meet these criteria, a child must not only have the required number of symptoms but the symptoms must have been apparent early in the child's developmental period and must cause significant impairment in functioning.1 These symptoms must not be better explained by an intellectual disability or global developmental delay.1
Autism Spectrum Disorder Checklist for Parents
To best help a child who they suspect might have ASD, parents can be better informed about the condition and diagnosis. Some checklist items for parents to address include:
Keep track of your child’s developmental milestones through the Centers for Disease Control and Prevention (CDC) milestone tracker app (https://www.cdc.gov/ncbddd/actearly/milestones-app.html), which outlines incremental milestones for children from age 2 months to 5 years.9
Research the initial signs/symptoms and diagnostic criteria of ASD.1
Use a developmental screening tool, such as the M-CHAT-R or Ages and Stages Questionnaire, to prepare for your child's initial diagnostic evaluation with their pediatrician.3
Seek out an evaluation from a specialist such as a psychiatrist or psychologist.2
Autism Spectrum Disorder Checklist for Patients
An adolescent or adult who suspects they may have ASD can follow a similar checklist:
Research the symptoms and diagnostic criteria of ASD.
Express your concerns to your primary care provider.
Seek out a specialized evaluation from a specialist.
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The Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP) addressed new initiatives and voted on several vaccine recommendations in their first 2024 meeting, held from February 28 to 29.
The ACIP discussed several vaccines during the 2-day meeting, including those for protection against COVID-19, Chikungunya, diphtheria and tetanus (DT), Hemophilus influenzae type b (Hib), polio, respiratory syncytial virus (RSV), meningococcal disease, and pneumococcal disease. The updated recommendations for vaccination against COVID-19, RSV, and pneumococcal disease are available here.
DT Vaccine
The DT vaccine, which was previously recommended for children younger than 7 years with a contraindication to pertussis-containing vaccines, has been discontinued in the United States. The ACIP now recommends the tetanus and diphtheria (Td) vaccine for this group, particularly in those who develop encephalopathy within 7 days of DT vaccination.1 Current guidelines indicate the diphtheria, tetanus, and pertussis (DTaP) vaccine as the first dose in the vaccination series. Children aged 7 years and older with contraindications may now receive Td for all remaining doses. Although it remains a viable option, the Td vaccine contains a lower dose of diphtheria toxoid, suggesting a decrease in its efficacy.
The ACIP approved the vaccines for children resolution for coverage of the Td vaccine in children younger than 7 years who have contraindications to pertussis-containing vaccines.2 This update is anticipated to be included in the recommended immunization schedule. Guidelines regarding the administration of a single booster dose of the Tdap vaccine among children aged between 11 and 12 years remain unchanged.
"
Revisions to the schedule should optimize protection against meningitis.
Meningococcal Vaccination
The meningococcal conjugate vaccine (MenABCWY), a pentavalent formulation from Pfizer®, was approved by the Food and Drug Administration (FDA) in October 2023. The ACIP now recommends the MenABCWY vaccine among children and adolescents for whom both the MenACWY and MenB vaccines are indicated at a single visit. The approval of the MenABCWY vaccine provides multiple options for revising the meningococcal vaccine schedule, including the elimination of a MenACWY vaccine dose in children aged 11 to 12 years and a change in the recommended age group for MenB vaccination to increase protection at the time of college entry.
Evidence suggests that college-aged students have a 3.5-fold higher risk for serogroup B disease than noncollege-aged students, with disease incidence peaking at 19 years of age and declining after 20 years of age.3 According to the ACIP, "Revisions to the schedule should optimize protection against meningitis." They also noted that the approval of a pentavalent formulation will serve to lower the number of injections needed for protection against meningococcal disease.
The ACIP proposed several options to consider for revising the recommended meningococcal vaccine schedule, as shown in the table:3
Option
ACWY Dose #1
ACWY Dose #2
B Dose #1
B Dose #2
Current Recommendation
11-12 years
16 years
16-23 years (preferred 16-18 years) *SCDM
16-23 years (preferred 16-18 years) *SCDM
1
11-12 years
16 years
16 years
17-18 years
2
11-12 years
16 years
16 years risk-based
17-18 years risk-based
3
No dose
16 years
16 years risk-based
17-18 years risk-based
4
15 years
17-18 years
17-18 years
17-18 years
*SCDM = shared clinical decision making
There is ongoing discussion regarding these 4 options as the ACIP noted that the existing vaccination platform took years to implement and any revisions to the schedule may affect school requirements.
Chikungunya Vaccination
Chikungunya is a viral disease transmitted to humans by infected mosquitoes. The Chikungunya vaccine (IXCHIQ) was licensed in the US by the FDA in November 2023 for use among individuals at risk for exposure to the virus, including travelers, laboratory workers, and those residing in areas with increased transmission risk. The vaccine is available as a single-dose primary schedule for individuals aged 18 years and older.4
The ACIP recommends the vaccine for adults traveling to a country or territory where there has been an outbreak of Chikungunya.2
However, the vaccine may be considered for the following individuals in the event of planned travel to a country or territory where there is no outbreak but where substantial evidence of transmission has occurred within the past 5 years:2
Individuals aged 65 years and older with underlying health conditions likely to have mosquito exposure
Individuals scheduled to remain abroad an extended period (≥6 months)
In regard to laboratory workers, the ACIP recommends Chikungunya vaccination for those whose research or diagnostic work involves the use of live viruses. The ACIP noted that the virus is primarily transmitted through aerosol, as well as percutaneous and possibly mucosal routes.2
Individuals who are pregnant should avoid exposure to Chikungunya.6 The ACIP noted that Chikungunya vaccination should be deferred until after delivery but may be considered for individuals at increased risk for exposure. However, they recommend against vaccination during the first trimester as well as after 36 weeks’ gestation.
Polio Vaccination
The ACIP considered modifying the polio vaccine schedule for US children who have been vaccinated against polio in other countries. Six countries (Bangladesh, Cuba, Ecuador, India, Nepal, and Sri Lanka) include fractional inactivated polio virus (fIPV) vaccination in recommended routine childhood immunization schedules.8
According to the ACIP, 2 fIPV doses are considered valid and counted as one full intramuscular dose of IPV with respect to the US schedule. However, 1 fIPV dose is not considered a viable alternative to 1 IPV dose.8
Guidelines regarding children who have been vaccinated against polio in the US remain unchanged.
Hib Vaccination
There are ongoing discussions regarding the expansion of Hib vaccine recommendations for American Indian and Alaska Native (AI/AN) infants. Guidelines suggest the use of PedvaxHIB® (Hemophilus b conjugate vaccine) for AI/AN infants. However, the emergence of combination vaccines, such as Vaxelis®, may expand options for this population.
Vaxelis, initially licensed by the FDA in December 2018, is a hexavalent vaccine comprising DTaP, inactivated polio, Hemophilus influenzae type B conjugate, and hepatitis B virus vaccine formulations. Similar to PedvaxHIB, Vaxelis contains Hib conjugate at a lower dose.7 Combination vaccines provide an opportunity for fewer shots, reduce the risk for missed doses, and lower the burden of vaccine administration. Results of a phase 4 trial conducted among AI/AN infants (N=333) showed that Vaxelis was noninferior to PedvaxHIB with respect to Hib antibody levels 30 days following receipt of the first vaccine dose.8
Members of the ACIP will vote on additional vaccine recommendations at their next scheduled meeting in June of 2024.
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