Tips from Other Journals
Diuretics, NSAIDs and Steroids for Carpal Tunnel Syndrome
Oral medications are often used to treat patients with carpal tunnel syndrome to try to decrease the swelling that traps the median nerve against the flexor retinaculum. Chang and colleagues conducted a placebo-controlled, double-blind study to compare the effectiveness of oral steroids, nonsteroidal anti-inflammatory drugs (NSAIDs) and diuretics in the treatment of patients with mild to moderate carpal tunnel syndrome.
The study included 73 patients who were randomized to receive a four-week course of a diuretic (2 mg of trichlormethiazide daily), a long-acting NSAID (20 mg of a sustained-release form daily), a steroid (20 mg daily for two weeks, followed by 10 mg daily for two weeks) or placebo. All of the patients had evidence of mild to moderate carpal tunnel syndrome on electrodiagnostic testing. There were 16 patients each in the placebo and diuretic groups, 18 patients in the NSAID group and 23 patients in the steroid group. Patients rated their pain, numbness, paresthesias, weakness and clumsiness, and nocturnal awakening from zero (no symptoms) to 10 (severe symptoms).
At the completion of the study, only the patients in the steroid group were found to show significant symptomatic improvement. The benefit was significant after two weeks of treatment but became more pronounced after four weeks. In the steroid group, global symptom scores dropped from a mean score of 27.9 (+- 6.9) at the beginning of the study to a mean of 10.0 (+- 7.5) at the end of the study. Scores were virtually unchanged in the placebo group.
The authors conclude that the use of short-term steroids provides greater relief of symptoms of mild to moderate carpal tunnel syndrome than NSAIDs and diuretics. They note that further studies are needed to determine whether steroid therapy produces long-term relief of symptoms, whether symptoms recur after steroids are discontinued, whether two weeks or four weeks of therapy is optimal and whether low-dose short-term steroid therapy compares with conservative approaches such as splinting and local steroid injections.
CLARISSA C. KRIPKE, M.D.
Chang MH, et. al. Oral drug of choice in carpal tunnel syndrome. Neurology August 1998;51:390-3.
EDITOR'S NOTE: Although steroids were found to significantly reduce symptoms in this study, the confidence intervals were large. Therefore, a larger study is needed to determine the degree of improvement.
C.C.K.
Corticosteroids for Treatment of Varicella Pneumonia
Varicella pneumonia is an infrequent but severe complication of varicella infection and occurs most commonly in adults. Risk factors for varicella pneumonia include pregnancy, smoking and immunocompromised status. Standard therapy for this condition has been intravenous acyclovir, although even with treatment the mortality rate may be as high as 50 percent. Mer and Richards report data from a combined retrospective and prospective study of 15 patients admitted to the intensive care unit with varicella pneumonia.
The primary end points included length of intensive care and hospital stays, and rate of mortality. The diagnosis of varicella pneumonia was made clinically and was confirmed serologically by detection of IgM varicella antibody. Other data collected included patient demographics, clinical and laboratory features, need for mechanical ventilation, administration of intravenous acyclovir and corticosteroids, associated complications and death rates.
The study consisted of nine men and six women with a median age of 30 years (range: 23 to 63 years). Seven of the patients had documented contact with a child who had chickenpox, and one patient was infected by a spouse who had herpes zoster. All patients had bilateral pulmonary infiltrates documented on chest radiographs. Other noted complications included renal failure, myocarditis, pancreatitis and disseminated intravascular coagulation. All patients had markedly reduced partial pressure of arterial oxygen-percentage of inspired oxygen ratios.
Thirteen of the patients received intravenous acyclovir for at least seven days, and five patients also received 200 mg of hydrocortisone every six hours for 48 hours. The steroids were administered within 24 hours of admission to the intensive care unit.
The median hospital stay for all patients was 12 days. However, the steroid group had a median stay of only 10 days compared with 20 days in the group that did not receive steroids. In addition, the patients who did not receive steroids had a median intensive care stay of 12 days, compared with 5.5 days in the steroid group. No patients in the steroid group died, compared with four of the patients who did not receive steroids, although this difference was not statistically significant.
The authors conclude that the addition of corticosteroids to standard therapy with intravenous acyclovir appears to improve the outcome of patients with life-threatening varicella pneumonia. This response is similar to that seen with the use of steroids in patients with severe Pneumocystis carinii pneumonia. Steroids are beneficial because pneumonitis is a result of the host inflammatory response and not of virally mediated tissue injury. It is also hypothesized that steroids may improve pulmonary hemodynamics. With the administration of varicella vaccine, primary varicella may become a disease occurring most commonly in nonimmunized adults. Since this is the first published data on the use of steroids in the management of varicella pneumonia, the authors believe that their study should form the basis of a randomized controlled trial.
JEFFREY T. KIRCHNER, D.O.
Mer M, Richards GA. Corticosteroids in life-threatening varicella pneumonia. Chest August 1998;114:426-31.
Is a Speculum Necessary for Detecting Vaginal Infections?
One fourth of sexually active adolescents will be infected each year with a sexually transmitted disease (STD). Early detection of STDs in female patients is critical in preventing sequelae such as pelvic inflammatory disease and infertility. Traditionally, evaluation for STDs required the patient to undergo a pelvic examination using a speculum, which may have been a deterrent for some patients. Urine-based nucleic acid amplification tests are able to diagnose chlamydial and gonorrheal infections without a speculum examination, leaving the question of whether such an examination is necessary for diagnosing other infections. Blake and colleagues studied this population to determine if various vaginal infections could be detected without the use of a speculum.
Female patients between 12 and 22 years of age who presented to a primary care clinic were included in the study if they required a pelvic examination during their visit. Information about the history of present illness was recorded, and the clinician performing the examination listed any positive vaginal or cervical findings. Before each speculum examination, a cotton swab was blindly inserted into the vaginal pool to collect vaginal secretions. Another swab was used to collect secretions along the anterior lateral vaginal wall and was then applied to phenaphthazine pH paper. During the speculum examination, standard specimens were collected for detection of trichomoniasis, bacterial vaginosis and vulvovaginal candidiasis. Another swab was used to collect vaginal pool secretions; this specimen was cultured for trichomoniasis. A final swab was used to collect a specimen from the anterior lateral vaginal wall and was evaluated for evidence of bacterial vaginosis by the Gram stain method.
For detection of trichomoniasis, the specimen collected by the speculum method was 75 percent sensitive and the specimen collected by the swab method was 77 percent sensitive. Of the 74 infections diagnosed by traditional speculum collection, 91 percent were also detected by the swab method. Sixty-seven of 99 patients had positive results by both methods. Similarly, sensitivity of detection of bacterial vaginosis was not significantly different for speculum and nonspeculum methods of collection. Again, the confidence interval was small enough to indicate that the speculum examination was unlikely to detect more infections than the swab method. For diagnosing vulvovaginal candidiasis, however, the authors found that although the difference between the speculum method and the swab method was not statistically significant, the speculum method may be more sensitive.
Previously undiagnosed cases of herpes or genital warts were not more likely to be detected using a speculum examination alone, since lesions characteristic of these conditions were found during external examination of the genitals. Also of note, the findings of cervical mucopus and cervical friability on speculum examination were not particularly sensitive or highly predictive in the diagnosis of cervicitis.
The authors conclude that evaluations for trichomoniasis, bacterial vaginosis and vulvovaginal candidiasis can be done reliably without a speculum examination. Once urine-based tests for gonorrheal and chlamydial infections are more widely available, it may be possible to perform routine STD evaluations without a speculum. Removal of obstacles to care (such as a pelvic examination) may be quite important in the early diagnosis and treatment of female patients with STDs.
GRACE BROOKE HUFFMAN, M.D.
Blake DR, et al. Evaluation of vaginal infections in adolescent women: can it be done without a speculum? Pediatrics October 1998;102:939-44.
Treatment of Croup with Parenteral or Inhaled Steroids
Croup is a common pediatric respiratory condition that occurs most often in children younger than six years. Many children with croup present to the emergency department and ultimately require hospital admission. Several studies have found that the use of glucocorticoids may result in significant clinical improvement in children with this viral illness. Johnson and colleagues performed a randomized, double-blind, placebo-controlled trial to determine whether the administration of steroids to children with moderately severe croup would decrease their need for hospitalization.
Children enrolled in the study were between the ages of three months and nine years and were seen at one of two hospital emergency departments. All of the study subjects presented with acute onset of respiratory stridor associated with a barking cough and had persistent respiratory distress after treatment with humidified oxygen for 30 minutes. A croup scoring system was used that assessed degree of stridor, retractions, air entry, cyanosis and level of consciousness. Children with symptoms or signs suggestive of epiglottitis, bacterial tracheitis or supraglottic foreign body were excluded from the study. A history of recent steroid use, chronic pulmonary disease or immune dysfunction were also exclusion criteria.
Eligible children were randomized to receive intramuscular dexamethasone (0.6 mg per kg), a single dose of nebulized budesonide (4.0 mg) or placebo. All patients received racepinephrine plus saline combined with budesonide or placebo via nebulizer. The nebulized study drugs were identical in appearance. A placebo injection was not used, but all children were briefly separated from their parents and had a bandage placed on the thigh to maintain the masking component of the study. Racepinephrine was given as needed. The children were assessed hourly for five hours after treatment and then were discharged or admitted to the hospital. The parents of children who were sent home from the emergency department were followed by telephone 72 hours after discharge to assess the need for reevaluation.
A total of 4,075 children with a diagnosis of croup were seen during the enrollment period. After exclusion criteria were applied and parental consent was obtained, 145 children were randomized into the three groups. The baseline characteristics, including duration of symptoms, oxygen saturation and croup scores, did not differ significantly between groups. In the placebo group, 67 percent of children were hospitalized, compared with 35 percent in the budesonide group and 17 percent in the dexamethasone group. The study was terminated early because of the significant differences in rates of hospitalization among the groups. Patients were reassessed by study nurses and physicians, who found the mean changes in croup scores to be significantly greater in the two treatment groups. Sixteen children in the placebo group received additional racepinephrine treatments, compared with nine in the budesonide group and four in the dexamethasone group. No gastrointestinal bleeding or bacterial tracheitis was noted.
The authors conclude that the treatment of croup with glucocorticoids produces rapid clinical improvement and significantly reduces the rate of hospitalization. Treatment with intramuscular dexamethasone appears to offer the most benefit.
JEFFREY T. KIRCHNER, D.O.
Johnson DW, et al. A comparison of nebulized budesonide, intramuscular dexamethasone, and placebo for moderately severe croup. N Engl J Med August 20, 1998;339:498-503.
EDITOR'S NOTE: This study contributes to a growing body of literature showing corticosteroids to be very effective in treating croup. This effect is apparent in children with mild, moderate or severe symptoms. Nebulized budesonide is not currently available in this country, but many emergency department settings have adopted a protocol of using intramuscular dexamethasone at a standard dosage of 0.6 mg per kg. In children with mild croup, data support the use of oral dexamethasone (0.6 mg per kg), which can easily be given at a physician's office without nebulized epinephrine.
J.T.K.
Algorithm for Subcutaneous Heparin Treatment of DVT
Patients with deep venous thrombosis (DVT) of the lower extremities are usually treated with unfractionated or low-molecular-weight heparin followed by long-term oral anticoagulation. Nomograms may help to determine the rate of intravenous administration of unfractionated heparin that ensures prompt, adequate anticoagulation. Subcutaneous heparin has been shown to be as effective and safe as intravenous heparin. Prandoni and associates devised a weight-based algorithm for subcutaneous administration of unfractionated heparin following administration of an intravenous loading dose.
Algorithm
The rightsholder did not grant rights to reproduce this item in electronic media. For the missing item, see the original print version of this publication. Seventy symptomatic outpatients with a first episode of proximal venous thrombosis were given an intravenous bolus of sodium heparin and a subcutaneous injection of calcium heparin in dosages adjusted according to body weight (see the accompanying algorithm). The activated partial thromboplastin time (aPTT) was first measured after six hours, and subsequent dosage adjustments during the first 48 hours were scheduled according to the algorithm. The aPTT was performed in the mid-interval. After the first 48 hours, heparin administration was managed on the basis of daily aPTT determinations. Therapy was discontinued if the International Normalized Ratio (INR) was greater than 2 for two consecutive days in patients who had received heparin for at least five days and who started sodium warfarin therapy on the first or second day. Therapy with sodium warfarin was continued for 12 weeks, and patients were followed after one and three months.
Proper anticoagulation was achieved in 87 percent of patients within 24 hours and in 99 percent of patients within 48 hours. None of the patients had major bleeding or heparin-induced thrombocytopenia, and thromboembolism recurred in only three patients. The mean daily amount of heparin required to prolong the aPTT during the first 24 hours was greater than the dosage usually required with intravenous heparin administration.
The authors conclude that the use of a weight-based algorithm for the subcutaneous administration of unfractionated heparin may simplify the initial treatment of venous thromboembolic disorders. This regimen allows early patient mobilization and early discharge of appropriate patients. This approach is significantly less expensive than similar treatment with low-molecular-weight heparins.
RICHARD SADOVSKY, M.D.
Prandoni P, et al. Use of an algorithm for administering subcutaneous heparin in the treatment of deep venous thrombosis. Ann Intern Med August 15, 1998;129:299-302.
Low-Dose Tamoxifen and Reduced Risk of Fractures
Tamoxifen is currently used as adjuvant therapy for breast cancer, but it is also known to stabilize bone mineral density at various sites. Breuer and associates conducted a cross-sectional study to determine the effect of tamoxifen on the incidence of bone fracture in older residents of long-term care facilities.
Study subjects were women older than 65 years who were undergoing treatment with tamoxifen. An attempt was made to match each study subject with four women who had not been treated with this medication. The control subjects and study subjects were similar in ethnicity and age and, when possible, resided in the same nursing home. Researchers obtained minimum data set information about participants' demographics, dosage of tamoxifen and occurrence of bone fracture.
Dosage information was available for 1,373 patients who had taken tamoxifen. These women were further divided according to dosage: those taking 20 mg or more a day (91 percent) and those taking 10 mg a day (9 percent). The study subjects were then matched with 5,196 control subjects.
Of the control patients, 7.62 percent had had a fracture, compared with 6.73 percent of the women who received 20 mg of tamoxifen daily and 3.2 percent of women who received 10 mg of tamoxifen daily. When hip fracture alone was reviewed, the risk was 4.98 percent in the control group, 4.57 percent in the group that received 20 mg of tamoxifen per day and 2.4 percent in the group that received 10 mg per day. The difference between the control group and the group taking 10 mg per day nearly reached statistical significance. Adjusting for use of hormone replacement therapy did not appreciably alter the results.
The authors acknowledge some of the problems accompanying a cross-sectional study based on minimum data set information. Chronologic relationships are not always clear, and there may be inaccuracies and inconsistencies. However, they conclude that this study provides some preliminary evidence that a 10-mg daily dosage of tamoxifen is associated with a reduced risk of bone fractures in older nursing home residents.
GRACE BROOKE HUFFMAN, M.D.
Breuer B, et al. Effect of tamoxifen on bone fractures in older nursing home residents. J Am Geriatr Soc August 1998;46:968-72.
Ipratropium Bromide in the Treatment of Acute Asthma
Beta2 agonists have been the mainstay of therapy in patients with acute asthma, mainly because of efficacy and rapid onset of action. Ipratropium bromide is an anticholinergic bronchodilator that acts more slowly than the beta agonists but has a longer duration of effect. It has been used most commonly in patients with chronic obstructive pulmonary disease, but results of several studies have suggested a synergistic benefit when ipratropium is used in combination with a beta agonist. Lanes and colleagues conducted a pooled analysis of three randomized double-blinded trials that evaluated the effectiveness of a combination of albuterol and ipratropium in the treatment of acute asthma.
The trials were conducted in the United States, Canada and New Zealand. Study subjects were between 18 and 55 years of age and were diagnosed with acute asthma using American Thoracic Society criteria. In addition, study subjects were required to have a smoking history of less than 10 pack-years and a baseline forced expiratory volume in one second (FEV1) of less than 70 percent of normal predicted value.
The patients were randomized to receive 3.0 mg of nebulized albuterol sulfate solution (2.5 mg of albuterol base plus 0.5 mg of saline solution) or 2.5 mg of albuterol plus 0.5 mg of ipratropium bromide. The treatments were administered at baseline and repeated after 90 minutes. The patients in the Canadian and New Zealand studies also received one dose of parenteral corticosteroid. Spirometry was performed at baseline and at 45 minutes and 90 minutes after treatment. The primary outcome was a change in FEV1 from baseline. After 90 minutes, the patients were admitted to the hospital or discharged with arrangement for 24-hour follow-up.
A total of 1,064 patients were enrolled in the three trials, with essentially an equal number randomized to treatment with albuterol alone or to treatment with albuterol with ipratropium bromide. The groups did not differ significantly in regard to baseline FEV1, recent asthma therapies or demographics.
The patients who received combination therapy had a mean improvement in FEV1 of 572 mL at 45 minutes compared with those receiving only albuterol, who had a mean improvement of 528 mL. At 90 minutes the combination group had a mean improvement of 677 mL in FEV1 compared with the albuterol group, which had a mean improvement of 630 mL in FEV1. The presence of an upper respiratory tract infection was the best predictor of response to combination therapy; these patients had greater overall improvements in FEV1 (83 mL at 45 minutes and 105 mL at 90 minutes) than those receiving only albuterol. In addition, patients who received combination therapy had an 8 percent lower risk of requiring additional asthma treatment, a 16 percent lower risk of asthma exacerbation and a 20 percent lower risk of needing hospitalization.
The authors conclude that adding ipratropium bromide to albuterol in the treatment of acute asthma appears to improve lung function and lowers the risk of further asthma exacerbation and subsequent hospitalization. However, the mean improvements in the FEV1 were relatively small, and further trials to determine additional clinical outcomes are needed.
JEFFREY T. KIRCHNER, D.O.
Lanes SF, et al. The effect of adding ipratropium bromide to salbutamol in the treatment of acute asthma. A pooled analysis of three trials. Chest August 1998;114:365-72.
Colonoscopy for Small Adenomatous Polyps
Screening for colorectal cancer with fecal occult blood testing and lower endoscopy with removal of polyps reduce the mortality rate from colorectal cancer. Screening with flexible sigmoidoscopy is becoming standard for asymptomatic persons older than 50 years. Because adenomatous polyps found in the distal colon have been associated with adenomatous polyps in the proximal colon, full colonoscopy is generally recommended for patients with distal adenomas. Small polyps (less than 1 cm) seem to have a lower risk of malignant transformation than do larger polyps and are less likely to be malignant or to have high-grade histologic features. With increasing data, it appears that there is a low prevalence of histologically advanced polyps in the proximal colon among patients with small distal tubular adenomas. Wallace and associates conducted a study to determine the prevalence of advanced adenomatous polyps in the proximal colon among patients with small tubular adenomas found on flexible sigmoidoscopy.
Data were prospectively collected from flexible sigmoidoscopy examinations performed on a cohort of 4,490 average-risk patients. All polyps smaller than 10 mm identified by flexible sigmoidoscopy were biopsied and examined histologically. Polyps were characterized as nonneoplastic or neoplastic by a gastrointestinal pathologist. Patients with single small adenomas (1 to 5 mm) were informed of the implications of a single small distal adenoma found on flexible sigmoidoscopy, and colonoscopy was performed within six months.
Among the 90 patients with a single tubular adenoma 1 to 5 mm in diameter noted on flexible sigmoidoscopy, none was found to have advanced proximal polyps on colonoscopy. Among the 148 patients with multiple tubular adenomas 1 to 5 mm in diameter or any adenoma 6 to 10 mm in diameter, eight patients (5.4 percent) were found to have advanced proximal polyps on colonoscopy. Villous adenomas of any size found on flexible sigmoidoscopy were considered advanced and, therefore, were not grouped with tubular adenomas.
The authors conclude that the prevalence of tubular adenomas larger than 10 mm, villous adenomas and cancer in the proximal colon is very low in asymptomatic patients with a single small adenoma (1 to 5 mm) and who have no other risk factors for colon cancer. These patients may not require follow-up colonoscopy. Patients with multiple adenomatous polyps of any size, tubular adenomas larger than 5 mm or advanced polyps in the distal colon should undergo a colonoscopy.
RICHARD SADOVSKY, M.D.
Wallace MB, et al. Is colonoscopy indicated for small adenomas found by screening flexible sigmoidoscopy? Ann Intern Med August 15,1998;129:273-8.
Predictors of Vision Loss and Stroke in Giant Cell Arteritis
Temporal, or giant cell, arteritis is associated with significant morbidity, including permanent vision loss and stroke, if it is not promptly treated. González-Gay and colleagues performed a retrospective study of patients with giant cell arteritis to identify clinical features that would serve as predictors of vision loss and stroke.
A total of 239 patients were included in the study. Giant cell arteritis was confirmed by biopsy in each patient. Clinical features of the disease included thickening, swelling or tenderness of at least one temporal artery, recent onset of headache that was atypical for the patient, jaw claudication, vision changes, fever and weight loss. Cerebrovascular involvement was characterized by a transient ischemic attack or stroke. All of the patients received treatment with oral corticosteroids (prednisone at dosages ranging from 45 to 80 mg daily or the equivalent [60 mg in the majority of patients]) after the diagnosis was established.
Ocular symptoms occurred in 69 (28.9 percent) of the 239 patients. As a group, these patients had a higher frequency of cerebrovascular involvement than the 170 patients without ocular involvement. Ocular involvement did not relate to a delay in diagnosis; the time to diagnosis was somewhat shorter in patients with ocular manifestations. Permanent vision loss occurred in 34 (14.2 percent) of the patients and was due to ischemic optic neuritis in 31 patients, retinal artery occlusion in two patients and retrobulbar optic neuritis in one patient. Eleven patients had bilateral vision loss. Interestingly, eight of the 34 patients had partial recovery of vision after treatment with corticosteroids. However, if treatment was instituted more than two days after the onset of vision symptoms, there was no improvement. The eight patients with improvement in vision differed only in terms of a shorter interval between the onset of vision loss and the initiation of treatment (a median of 1 day versus 4 days).
Predictors of permanent vision loss in this study included a history of transient vision loss and jaw claudication. Eight patients (3.4 percent) sustained a cerebrovascular accident, with neurologic symptoms usually appearing an average of seven days after the onset of ocular symptoms. Symptoms of arteritis preceded the ischemic event by a median interval of 1.5 months. The stroke involved the vertebral-basilar territory in four patients and the carotid system in four patients. The best predictors of stroke were permanent vision loss and jaw claudication. There were two deaths in patients who sustained a stroke in the vertebral-basilar territory.
The authors conclude that the risk of permanent vision loss from temporal arteritis is increased in patients with transient vision loss or jaw claudication. Vision loss may be prevented or partially improved by prompt diagnosis and administration of corticosteroids. The authors recommend that high-dose corticosteroid therapy be instituted without delay, before biopsy confirms the diagnosis of giant cell arteritis, in patients who present with transient vision loss. Arteritis can be demonstrated in a temporal artery biopsy specimen even after two weeks of corticosteroid therapy.
JEFFREY T. KIRCHNER, D.O.
González-Gay MA, et al. Permanent visual loss and cerebrovascular accidents in giant cell arteritis. Predictors and response to treatment. Arthritis Rheum August 1998;41: 1497-504.
Can Moderate Alcohol Intake Reduce a Woman's Fertility?
Infertility is a common condition that is increasing in incidence. Alcohol consumption has been implicated as a contributory factor. Women with high alcohol intake have increased rates of menstrual disorders, miscarriages, stillbirths, preterm deliveries and placental abruption. Heavy consumption of alcohol is also known to have teratogenic effects. Retrospective studies have found that a high intake of alcohol is associated with reduced fertility in women, but the effect of moderate alcohol intake is unknown. Jensen and colleagues examined the effect of alcohol consumption in couples trying to conceive to prospectively establish the relationship between alcohol intake and fertility.
A total of 430 Danish couples who were trying to conceive for the first time were enrolled in the study when they discontinued use of birth control and were followed for six menstrual cycles or until a pregnancy was confirmed. Couples completed an extensive initial questionnaire on medical, demographic, reproductive and lifestyle factors. Each man provided a semen sample at the beginning of the study and during each of his partner's menstrual cycles. Each woman recorded vaginal bleeding and frequency of intercourse on a daily basis. Tobacco, alcohol and caffeine intake were recorded regularly during the study.
No alcohol intake during all cycles was reported by 73 (17 percent) of the women. Among the women who consumed alcohol, the mean weekly alcohol intake was four drinks. Ten percent of men reported drinking no alcohol; the mean weekly alcohol intake for men who drank was 9.5 drinks. Alcohol intake was associated with their own and their partners' use of cigarettes and caffeine. Among the 280 women who reported drinking less than five drinks per week, 179 (64 percent) conceived within six cycles. Among the 136 women reporting higher intake, 75 (55 percent) conceived in the same time span. Among the men, the comparable figures were 67 percent and 58 percent, respectively. The authors calculated that the adjusted odds ratio for women consuming up to five drinks per week was 0.61, compared with women who reported no alcohol intake. For women consuming more than 10 drinks per week, the adjusted odds ratio was 0.34. No dose-response relationship could be demonstrated for men in this study.
The authors conclude that fecundity is reduced in women who consume alcohol, even in women who have fewer than five alcoholic drinks per week. They encourage women who are trying to conceive to avoid drinking alcohol.
ANNE D. WALLING, M.D.
Jensen TK, et al. Does moderate alcohol consumption affect fertility? Follow up study among couples planning first pregnancy. BMJ August 22, 1998;317:505-10.
Treatment of Periocular Capillary Hemangioma
Capillary hemangiomas are the most common orbital tumors occurring in childhood. They are present in only 1 to 2 percent of newborns, but by one year of age, up to 10 percent of children have these tumors. Thirty-eight percent of affected children have lesions on the head and neck. Girls are more commonly affected than boys, and there is no racial, ethnic or regional predominance. In addition, no inheritance pattern is associated with this condition. Yap and colleagues reviewed the history, diagnosis and management of periocular capillary hemangiomas in infants.
Initially, superficial capillary hemangiomas appear as flat, circumscribed lesions. Within weeks, the lesions become raised, nodular and red. They are stable in size for about six months, then begin spontaneous involution during the child's second year of life. In 76 percent of children, involution is complete by seven years of age. However, lesions around the eyes, on the eyelids or in the orbit can cause strabismus or proptosis. These lesions require prompt treatment to prevent visual loss from amblyopia. Pressure from an eyelid hemangioma can permanently change the curvature of the eye, causing astigmatism.
Diagnosis of a superficial hemangioma is usually confirmed by inspection alone. Deep capillary hemangiomas may require imaging to distinguish them from other types of tumors and to ensure that they are not impinging on the optic nerve. In children with orbital hemangiomas, a thorough examination for associated lesions in the head or neck is required. Large capillary hemangiomas can ulcerate and become infected, or they can cause serious coagulopathies and hemolytic anemia, but these situations are rare.
Most patients with capillary hemangiomas require no treatment. Lesions that threaten a child's life or sight can be treated with corticosteroids. In most cases, oral prednisone can decrease tumor size within two weeks. However, when steroids are discontinued, rebound growth may occur. As a result, treatment with oral corticosteroids may often be continued for several months, and side effects may develop. Rather than continue treatment with systemic steroids, intralesional steroids are often preferred. Depending on the size of the tumor and the weight of the infant, 1 to 2 mL of a 50:50 mixture of 1 mL of triamcinolone (40 mg per mL) and 1 mL of betamethasone (6 mg per mL) can be injected into the lesion, under general anesthesia if necessary. Results are usually apparent after one week. A second injection can be given four to six weeks later, if necessary. Second-line treatments include surgical excision, radiation and interferon.
CLARISSA C. KRIPKE, M.D.
Yap EY, et al. Periocular capillary hemangioma: a review for pediatricians and family physicians. Mayo Clin Proc August 1998;73:753-9.
Unopposed Estrogen Therapy and the Raynaud Phenomenon
In women with Raynaud phenomenon, the increased severity of symptoms between menarche and menopause suggest that hormonal factors may have an important role in the pathophysiology of the disorder. Fraenkel and associates conducted a cross-sectional study to examine the association between hormone replacement therapy and Raynaud phenomenon in postmenopausal women participating in the Framingham Offspring Study.
Eight hundred women participated in an examination designed to evaluate the heritability of osteoarthritis. These women were also asked if they experienced unusual sensitivity to cold and change of color (specifically white, blue or red) in their fingers. Participants were defined as having Raynaud phenomenon if they met the criteria in the validated survey instrument or if they described their fingers as being unusually sensitive to cold and turning at least two colors. Women who did not meet either of these criteria were classified as control subjects. Postmenopausal women were defined as women who had undergone natural menopause (no menses for one year or more as a result of natural causes), had bilateral oophorectomy or hysterectomy, and were older than 49 years of age at the fifth examination.
Forty-nine of the 497 women who were postmenopausal were classified as having the Raynaud phenomenon (9.9 percent). None of these patients was classified by the examiners as having a collagen vascular disease, and only two patients had clear evidence of atherosclerotic disease. The prevalence of the Raynaud phenomenon was 8.4 percent among women who were not receiving hormone replacement therapy, 19.1 percent among women receiving estrogen alone and 9.8 percent among women receiving estrogen plus progesterone. This difference was not significant, although the adjusted odds ratio for Raynaud phenomenon was 2.5 in patients taking estrogen alone and 0.9 in patients taking estrogen plus progesterone.
The authors conclude that there is a positive association between unopposed estrogen replacement therapy in postmenopausal women and Raynaud phenomenon. This association is not seen in women who receive combined hormone replacement therapy. Further research using a larger study population is needed to confirm these findings and, if they are confirmed, the authors advise that combined hormone therapy rather than unopposed estrogen therapy should be recommended for postmenopausal women with established Raynaud phenomenon.
RICHARD SADOVSKY, M.D.
Fraenkel L, et al. The association of estrogen replacement therapy and the Raynaud phenomenon in postmenopausal women. Ann Intern Med August 1, 1998; 129:208-11.
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