Tips from Other Journals
Antithrombotic Therapy for Atrial Fibrillation
Nonvalvular atrial fibrillation is the most common cardiac disorder causing stroke and systemic emboli. Atrial fibrillation affects approximately 4 percent of adults in the United States. Because its incidence increases with age, the risk of this disorder will increase as the U.S. population ages. An important aspect of treating atrial fibrillation is preventing systemic emboli and stroke. Nademanee and Kosar summarized the findings of five published studies that examined various treatments of atrial fibrillation, including the use of long-term antithrombotic medications alone, aspirin alone and combination therapy.
Risk Factors for Systemic Emboli or Stroke in Patients With Atrial Fibrillation
Previous history of transient ischemic attack or stroke Diabetes mellitus Hypertension Clinical coronary artery disease Heart failure Thyrotoxicosis
Reprinted with permission from Nademanee K, Kosar EM. Long-term antithrombotic treatment for atrial fibrillation. Am J Cardiol 1998;82:37N-42N.Patients with atrial fibrillation typically have thrombi in the left atrial appendage that are most likely caused by circulatory stasis. These thrombi can then embolize. Patients with structural heart disease or other risk factors are at much greater risk for emboli (see the accompanying table). Identification of the optimal treatment for patients with atrial fibrillation has generated much debate. Treatment with warfarin alone has been shown to decrease embolic vascular complications and stroke in patients with atrial fibrillation. In fact, the benefits of warfarin appear to increase when the International Normalized Ratio (INR) was 2 to 3 in patients with a history of stroke. Aspirin appears to be effective in treating nonvalvular atrial fibrillation in patients younger than 65 years who have no risk factors. However, warfarin remains the treatment of choice in most patients, particularly those who have had a previous transient ischemic attack or a minor stroke. Combination therapy using low-intensity, fixed-dose warfarin (target INR: 1.2 to 1.5) and aspirin (dosage: 325 mg per day) is less effective than adjusted-dose warfarin (target INR: 2 to 3), especially in patients with high-risk factors.
The authors conclude that the data from these five studies establish the following parameters: (1) the risk of stroke is very high in patients older than 75 years who have nonvalvular atrial fibrillation and in patients who have other high-risk factors; (2) warfarin is more effective than aspirin in preventing ischemic stroke and systemic emboli; (3) aspirin is effective in younger patients who do not have any other risk factors; and (4) the optimal intensity of warfarin has been established as an INR of 2 to 3.
The authors endorse the recommendations of the American College of Chest Physicians Consensus Conference on antithrombolytic therapy. First, patients younger than 65 years of age with no other risk factors should take aspirin. However, the presence of even one risk factor in patients in this group warrants the use of warfarin (INR: 2 to 3). Second, patients between 65 and 75 years with no risk factors may be treated with either aspirin or warfarin. If one or more risk factors are present, the patient should be treated with warfarin. Third, all patients over 75 years of age should be treated with warfarin (INR: 2 to 3).
An accompanying symposium between the author of this article and other physicians illustrates the many concerns surrounding the treatment of atrial fibrillation. The efficacy of aspirin in the treatment of any patient with atrial fibrillation is supported by only one study (Stroke Prevention in Atrial Fibrillation I and II), and many experts doubt the validity of the results. Another question concerns the duration of anticoagulation therapy with warfarin. Must it be continued for life even if the patient is accurately able to determine the presence or absence of fibrillation? What is the role of the newer antiplatelet medications? The only issue that appears to be clear is that patients with atrial fibrillation should be treated with antithrombotic medication to decrease the risk of systemic embolism and stroke.
RICHARD SADOVSKY, M.D.
Nademanee K, Kosar EM. Long-term antithrombotic treatment for atrial fibrillation. Am J Cardiol November 1998;82:37N-2N.
Treatment of Sore Nipples in Women Who Are Lactating
Nipple soreness is common in women who are breast-feeding and may cause mothers to prematurely wean their infants. Potential complications include secondary nipple infection resulting from skin breakdown. Factors such as recurrent suction trauma to the nipple, oral flora from the infant and a constant fluctuation between wet and dry environments make effective healing difficult. A new treatment approach uses a glycerin-based occlusive dressing that is absorbent and nonadhesive, with bacteriostatic and fungistatic properties. Brent and associates conducted a randomized controlled study to determine the safety and effectiveness of occlusive wound dressings compared with conventional treatment for sore nipples.
Women who presented to a lactation center with cracked, crusting or bleeding nipples, or with pain associated with breast-feeding, were eligible for this study. Those who had an active breast infection or another pain-related condition were excluded from the study. Women were randomly assigned to receive either conventional treatment or treatment with the occlusive dressing. All women received a complete physical examination and specific training in proper breast-feeding techniques and management. Women in the conventional treatment group were instructed to massage their breast milk onto their nipples after feeding, allow the nipples to air-dry and then apply lanolin cream and breast shells. Women in the experimental treatment group followed the same steps but applied occlusive dressing rather than breast shells. A new dressing was applied after each feeding. Patients were seen three times over the next 10 days or until their symptoms resolved, whichever occurred first. The principal outcomes measured included changes in the physical appearance of the nipple and the breast-feeding techniques of the mothers, and changes in patient reports of breast pain.
Forty-two women were included in the study (21 women in each treatment group). Demographic data were similar in both groups. Three women were unavailable for follow-up (one from the conventional treatment group and two from the dressing group), nine women withdrew because of breast infection (two from the conventional group and seven from the dressing group) and one woman from the dressing group withdrew because of dermatitis, leaving 18 women in the conventional treatment group and 11 women in the dressing group.
The appearance of the nipples improved with treatment in both groups. However, women in the conventional treatment group showed a much higher degree of healing at follow-up visits. This difference was statistically significant. There were significantly more infections in the occlusive-dressing group, which resulted in early discontinuation of the study. There were no significant differences between groups in pain behaviors during breast-feeding. Both groups reported less pain during breast-feeding at follow-up, but women in the conventional treatment group reported greater reductions in feeding-related pain. Treatment satisfaction was generally high in both groups of women.
The authors conclude that conventional treatment for nipple soreness, consisting of the application of breast milk, lanolin cream and breast shells, is more effective than the use of occlusive dressings. Conventional treatment for the prevention of sore nipples when combined with instruction on proper breast-feeding technique should remain the treatment of choice for most women.
JEFFREY T. KIRCHNER, D.O.
Brent N, et al. Sore nipples in breast-feeding women. A clinical trial of wound dressings vs conventional care. Arch Pediatr Adolesc Med November 1998;152:1077-82.
Rotavirus Vaccine as a Routine Immunization in Infants
Rotavirus is the most serious cause of diarrheal illness in infants six to 24 months of age and is responsible for more than 54,000 hospital admissions and up to 40 infant deaths annually in the United States. The National Institutes of Health developed an oral tetravalent rotavirus vaccine (RV-TV) against the four human serotypes responsible for most rotaviral disease. Markwick and associates evaluated RV-TV coadministered with oral poliovirus vaccine (OPV) and a combined diphtheria-tetanus-pertussis and Haemophilus influenzae type b vaccine (DTP/ Hib) in healthy infants to see if it would significantly diminish the immunogenicity of the other vaccines.
Healthy infants between six and 12 weeks of age were eligible for this multicenter trial. Exclusion criteria included previous administration of OPV, DTP or Hib, residence in a household with an immunosuppressed person and active participation in another clinical trial. Infants were randomized to receive either three doses of RV-TV or a placebo concurrently with their regularly scheduled DTP/Hib and OPV vaccines at approximately two, four and six months of age. The safety of the RV-TV vaccine was documented in two ways. First, the infant's caregiver recorded the infant's temperature, any respiratory or gastrointestinal symptoms, and activity level on a diary card for five days following the vaccination. Second, the caregiver was interviewed at each visit to determine whether any adverse events occurred following the previous vaccination. In addition, blood samples were obtained at baseline and three to six weeks after the third dose of vaccines.
A total of 267 infants were enrolled in the study; 133 were randomized into the RV-TV group and 134 were randomized into the control group. Demographic characteristics were similar between groups. Eighty-five percent of the infants receiving RV-TV seroconverted as measured by antirotaviral IgA antibodies. The percentage of infants who attained protective antibody titers against H. influenzae type b, diphtheria toxoid and tetanus toxoid did not differ between the two groups. The incidence of most side effects did not differ significantly between groups; however, infants in the RV-TV group experienced more wheezing, decreased appetite, and decreased activity than did patients in the placebo group, but these events were not considered clinically significant.
The authors conclude that RV-TV could easily be incorporated into the routine well-child schedule and can be safely coadministered with three doses of DTP/Hib and OPV without diminishing an infant's serum antibody response to these vaccines.
RICHARD SADOVSKY, M.D.
Markwick AJ, et al. Oral tetravalent rotavirus vaccine can be successfully coadministered with oral poliovirus vaccine and a combined diphtheria, tetanus, pertussis and Haemophilus influenzae type b vaccine. Pediatr Infect Dis J October 1998;17:913-8.
Use of Pergolide for Treatment of Restless Legs Syndrome
Restless legs syndrome (RLS) affects 2 to 15 percent of the population. The symptoms of RLS contribute to disturbed sleep and profound daytime sleepiness. In recent open-labeled trials, pergolide, a dopamine-receptor agonist, has shown efficacy in treating RLS. Earley and colleagues studied the effectiveness of pergolide in the management of RLS.
Sixteen patients who met the criteria for RLS as outlined by the International RLS Study Group and who had a minimum of 15 periodic limb movements of sleep per hour on standard polysomnography were included in the randomized, double-blind, placebo-controlled study. Patients were assigned to treatment with pergolide or placebo and were permitted to increase the dosage during the 14-day study period until the benefits of the medication were believed to be adequate, the maximum dosage was reached or adverse effects occurred.
The final dosage of pergolide ranged from 0.1 mg to 0.65 mg per day. Subjective patient assessment as well as objective sleep data were used to measure efficacy. The primary outcome measures were the number of periodic limb movements of sleep per hour (obtained by all-night polysomnography), percentage of sleep efficiency (the amount of time sleeping divided by the amount of time in bed), number of hours per day with RLS symptoms and global improvement score (both from subjective patient assessment).
The mean sleep efficiency for patients in the pergolide group rose from 61 percent to 79 percent. The average hourly number of periodic limb movements of sleep dropped from 48.9 to 14.5. The average number of hours with RLS symptoms decreased from 7.0 hours per day to 1.8 hours per day. The average global improvement scale was 61 percent for pergolide compared with 19 percent for placebo. The placebo group showed no statistically significant change from baseline for any of the four outcome variables.
The authors conclude that pergolide helps improve both subjective and objective measures of RLS. Patients who used the drug had increased sleep efficiency and decreased periodic limb movements of sleep while displaying no worsening of symptoms in the hours preceding the next dose.
TODD OTTESON, B.A., B.S.
Earley CJ, et al. Randomized, double-blind, placebo-controlled trial of pergolide in restless legs syndrome. Neurology December 1998;51:1599-1602.
Physical Training for Patients with Severe Osteoarthritis
Osteoarthritis is a common disease, and its prevalence increases with age. Osteoarthritis may lead to complaints of joint stiffness and pain, instability and loss of function. Because of knee involvement, patients with osteoarthritis may have significant difficulty rising from a chair, climbing stairs, kneeling, standing, walking and maintaining stability. Røgind and colleagues studied the impact of physical training in patients with severe osteoarthritis of the knee. They also observed the impact of this training on the patient's general fitness, lower-extremity strength, agility, balance and coordination.
The study population consisted of outpatients who fulfilled the American College of Rheumatology criteria for osteoarthritis of the knee and had positive radiographic evidence of severe arthritis. All patients enrolled in the study underwent a baseline evaluation of physical function before the study. The study subjects were randomly assigned to an intervention group or a control group. Patients in the intervention group underwent training by a physiotherapist twice weekly for three months. The training sessions focused on lower-extremity mobility, muscle strengthening, flexibility and ability to balance and coordinate the body. Members of both groups were reassessed for pain and stiffness symptoms, maximum walking distance and ability to perform activities of daily living at three and 12 months. Evaluation of the lower extremities included physical examination, basic function testing, postural sway and muscle strength.
The intervention group participated in 77.9 percent of the training sessions. After three months, these patients had better clinical parameters, lower pain scores (particularly at bedtime), and improved basic functioning and muscle strength than those in the nonintervention group. No change in postural sway was evident between the two groups. The most pronounced impact on the physical training group was the increase in lower-extremity muscle strength. These improvements persisted at the 12-month re-evaluation despite the fact that the organized training sessions had stopped after three months. The only adverse outcome noted was that the group that underwent physical training had an increased incidence of knee effusion during the study.
The authors conclude that physical training can have a significant positive benefit in patients with osteoarthritis. They also note that patients will comply with a structured program. These improvements may create a lasting benefit and improve the level of functioning in patients with osteoarthritis of the knee and decrease their pain as well.
KARL MILLER, M.D.
Røgind H, et al. The effects of a physical training program on patients with osteoarthritis of the knees. Arch Phys Med Rehabil November 1998;79:1421-7.
Strategies for Perioperative Medical Management
Since medical problems are common in surgical patients, optimal perioperative management is a part of clinical practice. Practices are often based on inconclusive evidence or extrapolated from understanding of physiology. Cheng reviewed guidelines and practices for four perioperative situations: (1) endocarditis prophylaxis; (2) perioperative anticoagulation in patients with mechanical heart valves; (3) perioperative glucose control in diabetic patients; and (4) the use of beta-adrenergic blocking agents to prevent postoperative cardiac complications.
Prevention of Bacterial Endocarditis*
Prophylaxis recommended
• High risk
--Prosthetic valves, including bioprostheses
--Previous endocarditis
--Surgically created systemic pulmonary shunts
--Complex cyanotic congenital heart defects
• Moderate risk
--Most other congenital heart defects
--Acquired valve dysfunction
--Hypertrophic cardiomyopathy
--Mitral valve prolapse with regurgitationProphylaxis not recommended
• Isolated secundum atrial septal defect
• Atrial septal defect, ventricular septal defect or patent ductus arteriosus repaired at least six months previously without sequelae
• Coronary artery bypass grafts, pacemaker, implanted defibrillator
• Mitral valve prolapse without regurgitation
• Physiologic or functional murmurs
• Rheumatic fever or Kawasaki's disease without valve dysfunction
*--Based on 1997 recommendations from the American Heart Association.
Reprinted with permission from Cheng HQ. Controversies in perioperative medicine. West J Med 1998;169:351-5.
Since many invasive procedures cause transient bacteremia, patients with cardiac abnormalities may be more likely to develop bacterial endocarditis. Rates of bacteremia seem highest following dental work and other procedures involving the oropharynx (often associated with alpha-hemolytic Streptococcus species, particularly Streptococcus viridans), and procedures of the genitourinary and gastrointestinal tracts (often associated with Enterococcus species). The American Heart Association 1997 guidelines for endocarditis prophylaxis recommend prophylaxis only in patients with a moderate- or high-risk cardiac abnormality (see the accompanying table) who are undergoing a high-risk procedure. Examples of high-risk procedures include dental extraction, dental work in which bleeding is anticipated, tonsillectomy and adenoidectomy, surgery involving the biliary tract or intestinal mucosa, prostate surgery and cystoscopy. The standard regimen for dental, esophageal and upper respiratory tract procedures is amoxicillin, in a dosage of 2 g orally one hour before the procedure and, before gastrointestinal or genitourinary procedures, 2 g of ampicillin administered intravenously or intramuscularly, plus gentamicin, in a dosage of 1.5 mg per kg (up to 120 mg), within 30 minutes of the procedure and followed in six hours by ampicillin, in a dosage of 1 g intravenously or intramuscularly, or amoxicillin, in a dosage of 1 g orally.
Concerning perioperative anticoagulation in patients with mechanical valve prostheses, more recent valve designs are less thrombogenic. Routine perioperative heparinization in patients with aortic valve prostheses seems unjustified. Since a mechanical mitral valve incurs a greater risk of thromboembolism, heparinization should be considered in these patients, especially those who have older valve designs. The role of low-molecular-weight heparin is uncertain.
Diabetic patients have an increased risk of surgical wound complications, especially infections. Data are insufficient to advocate tight perioperative control, although a reasonable goal would be to keep glucose levels below 250 mg per dL (13.87 mmol per L). The method of insulin delivery depends on patient-specific criteria even though intravenous administration of insulin allows tighter glucose control than subcutaneous administration.
Based on the concept of surgical stress causing increased sympathetic tone with tachycardia and hypertension, beta-adrenergic blocking medications have been used to decrease perioperative cardiac risk in patients undergoing noncardiac surgery. Although parameters for usage are less clear in patients who have only risk factors for coronary artery disease, evidence confirms the value of presurgical beta-blocking agents in patients with known coronary artery disease or uncontrolled hypertension.
RICHARD SADOVSKY, M.D.
Cheng HQ. Controversies in perioperative medicine. West J Med December 1998;169:351-5.
Addition of Ipratropium for Acute Asthma in Children
Children who present to the emergency department during a severe exacerbation of asthma are typically treated with inhaled beta agonists and corticosteroids. Despite optimal use of these agents, many children require hospital admission for continued treatment. Several studies have shown that pulmonary function improves when the anticholinergic agent ipratropium bromide is given with a beta agonist, such as albuterol. Qureshi and colleagues conducted a randomized, double-blind, placebo-controlled trial to evaluate whether the addition of inhaled ipratropium decreased hospitalization rates in children who presented to the emergency department with an acute episode of asthma.
Children between the ages of two and 18 years who presented to the emergency department with an acute episode of asthma were eligible for the study. The severity of the asthma at presentation was classified according to the predicted peak expiratory flow rate. A peak expiratory flow rate of more than 70 percent was classified as mild, 50 to 70 percent of predicted value was classified as moderate and less than 50 percent of predicted value was considered severe. Only those with moderate or severe exacerbations were included in the study.
All children participating in the study were initially treated with three doses of either 2.5 or 5.0 mg of nebulized albuterol, depending on weight, and 2 mg per kg of oral prednisone with the second dose of nebulized albuterol. Patients in the treatment group received 500 mg of ipratropium with the second and third doses of albuterol, while those in the control group received 2.5 mL of normal saline solution. Peak expiratory flow rates, asthma score, respiratory rate, pulse rate and oxygen saturation were assessed at baseline and recorded after each treatment. After 60 minutes, additional albuterol was given at the physician's discretion until a decision was made to admit or discharge the patient. The decision to admit the patient was made on the basis of clinical and pulmonary function, along with an oxygen saturation level within a specific range.
A total of 434 children completed the study. Mean age was 8.3 years, and approximately 75 percent of the patients were black. The proportion of girls was higher in the treatment group than in the control group, but otherwise there were no significant differences between the two groups. Overall hospitalization rates were lower in the treatment group (27.4 percent) than in the control group (36.5 percent). There was no significant difference in hospitalization rates between groups in children with moderate asthma. However, among children with severe asthma, 37.5 percent of the treatment group was hospitalized, compared with 52.6 percent of the control group. The absolute reduction in the rate of hospitalization between the two groups was 15.1 percent, which means that approximately seven children would need to be given ipratropium to prevent one hospitalization. None of the children experienced increased heart rate, decreased respiratory function or any other adverse event that required the study protocol to be discontinued.
The authors conclude that the addition of ipratropium bromide to treatment with albuterol and corticosteroids significantly decreases the rate of hospitalization in children with acute exacerbations of severe asthma. Although approximately seven children would have to be treated with ipratropium to prevent one hospitalization, this rate still represents a significant savings, as ipratropium costs approximately $3 per 500-mg dose, compared with an average hospitalization cost per child of $3,267 at the study institution.
JEFFREY T. KIRCHNER, D.O.
Qureshi F, et al. Effect of nebulized ipratropium on the hospitalization rates of children with asthma. N Engl J Med October 8, 1998;339:1030-5.
Does the Addition of Acarbose to Metformin Lower HbA1c?
Acarbose, an alpha-glucosidase inhibitor, controls postprandial hyperglycemia by slowing carbohydrate digestion and absorption. The slowing is accomplished by competitive enzyme inhibition at the brush border of the small intestine. Rosenstock and colleagues studied the effect of acarbose added to metformin in the treatment of persons with type 2 diabetes (formerly known as noninsulin-dependent diabetes) not adequately controlled by either agent alone.
A total of 168 patients with type 2 diabetes who exhibited inadequate glucose control with diet plus 2,000 or 2,500 mg metformin daily were included in the study. In this multicenter, double-blind, placebo-controlled study, patients were randomized to receive metformin and either placebo or 25 mg of acarbose three times a day, taken orally at the beginning of each meal. Four weeks after randomization, the acarbose was increased to 50 mg three times a day. After eight weeks, the dosage was raised to 100 mg three times a day if the one-hour postprandial blood glucose level was greater than 160 mg per dL (8.88 mmol per L). This became the dosage that study patients received throughout the study. Test meals were given at randomization and at weeks 4, 12 and 24. Blood samples were obtained at zero, 60, 90 and 120 minutes after the meal to determine plasma glucose, serum insulin and triglyceride levels. Blood samples for determination of glycosylated hemoglobin (HbA1c) levels were also taken during screening and randomization, and at all study visits.
Of the 147 patients whose results were evaluable, the 73 patients in the acarbose and metformin arm of the study had an initial mean HbA1c level of 8.46 percent and a mean decrease of 0.57 percent, while the mean HbA1c level in the patients taking placebo and metformin was initially 8.17 percent, and the mean increase was 0.08 percent. The mean fasting plasma glucose level at end point increased 1.8 mg per dL (0.10 mmol per L), from 195.2 mg per dL (10.83 mmol per L), in the placebo-treated patients and decreased 12.7 mg per dL (0.71 mmol per L), from 203.7 mg per dL (11.31 mmol per L), in the acarbose-treated patients. Plasma glucose levels were significantly lower at 60, 90 and 120 minutes after the standard meals in patients in the acarbose group compared with patients in the placebo group. A positive clinical response was defined as an HbA1c value of 7 percent or less, associated with a reduction from baseline of at least 1 percent. Such a response was noted in 36 percent of the acarbose group compared with 16 percent of the placebo group. No significant differences in liver transaminase elevations were observed between patients treated with acarbose and those treated with placebo.
The authors conclude that the addition of acarbose therapy in patients already receiving metformin reduced postprandial plasma glucose levels. Control of these postprandial glucose levels ultimately lowered HbA1c levels. The authors caution that 12 percent of the patients receiving acarbose withdrew from the study because of diarrhea, flatulence and abdominal pain.
TODD OTTESON, B.A., B.S.
Rosenstock J, et al. Efficacy and safety of acarbose in metformin-treated patients with type 2 diabetes. Diabetes Care December 1998;21:2050-5.
EDITOR'S NOTE: Although a number of patients taking acarbose and metformin experienced modest improvement in HbA1c and plasma glucose levels, many of them had significant gastrointestinal complaints, particularly flatulence. Acarbose may have a therapeutic role in certain specific circumstances, but its use may be limited by side effects.
T.O.
Obesity as a Cause of Dyspnea in Otherwise Healthy Men
Obesity often appears to affect respiratory function; however, few medical references include obesity as a cause of dyspnea. Obesity has been shown to reduce expiratory reserve volume and functional residual capacity because of alterations in chest wall mechanics. Obese persons may also experience exertional dyspnea because of the metabolic load placed on their gas transport system upon exertion. Despite these observations, obesity alone has not been shown to cause dyspnea in persons at rest. In an attempt to answer this question, Sahebjami conducted a prospective, open study to evaluate baseline dyspnea in otherwise "healthy" obese men and to see whether their pulmonary function test profiles differed from those of obese men without dyspnea.
All men seen during a three-month period at the Cincinnati Veterans Affairs Medical Center who had a body mass index (BMI) of 28 kg (61.6 lb) per m2 or greater were screened for the study. Patients were first asked to sit in a chair for 10 minutes on arrival at the clinic, and then to complete a written questionnaire that asked whether they had any difficulty breathing at rest and, if so, to quantify the degree of difficulty on a scale of zero to 10 (referred to as the Borg Scale Dyspnea Index [BSDI]). The men then underwent pulmonary function tests, including forced expiratory volume (FEV1) and forced vital capacity (FVC). Those with values greater than 80 percent of predicted value were screened further for potential entry to the study. Clinical records, including medical history and chest radiographs or electrocardiograms, were reviewed. Exclusion criteria included the presence of cardiopulmonary disease, malignancy, neuromuscular disorders, recent surgery or any serious systemic illness. Those who remained eligible then underwent extensive pulmonary function testing, including flow rates, lung volumes and single-breath carbon monoxide diffusing capacity (DLco). In addition, arterial blood gas samples were obtained from the radial artery of all patients at rest while breathing room air.
Twenty-three men met the criteria for the study. Of these, 15 reported dyspnea at rest (dyspneic group), and eight denied any shortness of breath at rest (nondyspneic group). Age and height of the men were similar in both groups. However, BMI, BSDI scores and body weights were significantly greater in the dyspneic group. In addition, 86.6 percent of men in the dyspneic group had a smoking history, compared with 62.5 percent of men in the nondyspneic group. Baseline arterial blood gas parameters did not differ between groups. FVC, FEV1 and FEV1/FVC ratio were within normal limits in both groups. In addition, lung volume and gas exchange patterns were similar between groups. FEV1, maximum voluntary ventilation and maximum static expiratory mouth pressure (Pemax) were significantly reduced in the group with dyspnea.
The author concludes that obesity alone, without the presence of underlying lung disease, can be a cause of dyspnea at rest in otherwise healthy men. In this study, obese patients with dyspnea weighed more, had lower Pemax levels and lower maximum voluntary ventilation than patients without dyspnea. These factors are most likely responsible for the sensation of dyspnea in these persons.
JEFFREY T. KIRCHNER, D.O.
Sahebjami H. Dyspnea in obese healthy men. Chest November 1998;114:1373-7.
Distinguishing Epileptic vs. Nonepileptic Staring in Children
Staring spells are common in children and may be epileptic (e.g., absence or complex partial seizures) or nonepileptic (e.g., inattention or daydreaming). The diagnosis is typically based on parental reports of the episode and results of electroencephalography (EEG). Other diagnostic information includes abnormal results on neuroimaging, focal findings on neurologic examination or the presence of other seizure types in addition to the staring spells. Confirming a diagnosis can be difficult when staring is the only symptom and the results of the EEG are within normal limits. Rosenow and associates sought to increase the diagnostic certainty of the parental interview by identifying questions specific and sensitive for nonepileptic and epileptic staring spells.
A 25-item questionnaire exploring the types and setting of symptoms for staring spells was given to the parents or guardians of 40 children who presented with staring spells. Questions focused on physical behaviors that characterized the staring episode, such as arrest of activity, unresponsiveness, eye blinking, upward eye rolling, myoclonic twitches, body stiffening, dropping of the head or jaw and body rocking. Other questions addressed patient age at onset, duration and frequency of the episodes, the presence of learning difficulties and the person who initially identified the episodes.
Of the 40 patients identified for the study, 17 had absence seizures with generalized seizure patterns seen on routine EEG, and 23 had nonepileptic staring spells diagnosed after a full clinical evaluation by a specialist. Children with nonepileptic staring spells had normal findings on routine EEG. Questions regarding the features of the staring episode were not useful, as both types of episodes were characterized by a dazed or vacant expression, sudden onset and abrupt cessation. Learning problems were identified with equal frequency in both groups. A family history of staring spells or epileptic seizures was more common among the children in the absence-seizure group, but the difference was not statistically significant.
Of the items on the questionnaire, only a few showed significant differences between the two groups. Children in the nonepileptic-staring group were more responsive to touch, did not interrupt play and were first identified as having a staring spell by a teacher or a health professional. Body rocking was reported exclusively in this group, but in only 13 percent of patients. Features that were highly specific for absence seizures included limb twitching, upward eye movements and urinary incontinence during staring episodes.
The authors conclude that in uncomplicated cases in which the physical behaviors suggest a nonepileptic-staring episode, asking parents or guardians the proper questions can help the physician confirm the diagnosis without the expense of an EEG. Compared with nonepileptic staring, staring spells of epileptic etiology occur much less frequently and can be confirmed by the presence of specific neurologic abnormalities on EEG. By asking parents about the presence of specific physical behaviors that characterize nonepileptic staring episodes and ascertaining the absence of behaviors that suggest epileptic staring episodes, physicians may defer ordering an EEG in selected cases.
RICHARD SADOVSKY, M.D.
Rosenow F, et al. Staring spells in children: descriptive features distinguishing epileptic and nonepileptic events. J Pediatr November 1998;133:660-3.
Choice of HRT Regimen and Postmenopausal Symptoms
Apart from its use for the relief of vasomotor symptoms (hot flushes and night sweats), little is known about the effect of hormone replacement therapy (HRT) on signs and symptoms associated with menopause. Studies have been complicated by a high placebo effect and by variations in the types of HRT used. In particular, the relative contributions of estrogen and progestin are difficult to estimate, and progestin is frequently prescribed in different formulations and regimens. Greendale and colleagues assessed the effects of estrogen alone, placebo, and three estrogen-progestin regimens on postmenopausal symptoms in a large multicenter trial.
The study enrolled 875 women from 45 to 64 years of age who had been postmenopausal for one to 10 years and had no major medical contraindications to hormone use. These patients were randomly assigned to receive placebo or conjugated equine estrogen, in a dosage of 0.625 mg daily, alone or as one of three combinations of estrogen and progestin. The progestin combinations included medroxyprogesterone acetate in a dosage of 2.5 mg daily or medroxyprogesterone acetate in a dosage of 10 mg taken 12 days per month, or 200 mg of micronized progesterone taken 12 days per month. All medications were identical in appearance, and the study was double-blinded. Data about demographic variables, medical history, physical activity, use of cigarettes and alcohol, and symptoms were collected at baseline, and symptom information was collected again at 12 and 36 months.
During the three-year study period, 210 women (24 percent) stopped treatment. Approximately one quarter of these withdrawals (51 women) were mandated because of endometrial abnormalities or other medical complications. Eleven women withdrew because of health concerns, and 21 cited "personal reasons." The remaining 127 women cited various symptoms as the reason for withdrawal, the most common being vaginal bleeding, premenstrual syndrome, vasomotor symptoms, headaches, anxiety/depression and breast tenderness.
When analyzed by original assignment and adherence to therapy, active treatment was statistically superior to placebo in the relief of vasomotor symptoms. The addition of progestin did not appear to change the relief of vasomotor symptoms. Patients receiving progestin did, however, report significantly more breast discomfort than women taking placebo or estrogen alone. Women taking estrogens and those taking progestins reported less weight gain than did those taking placebo. No differences were found between the treatment groups in anxiety, cognitive-affective or musculoskeletal symptoms. When only women who adhered to treatment were considered, benefit was apparent in relief of musculoskeletal symptoms in women taking progestins and, to a lesser extent, in those taking estrogen alone. The effects of HRT on headache and forgetfulness were complicated. Women with headache before the trial reported improvement with estrogen alone compared with placebo or progestin-containing regimens. Conversely, women who did not report headache initially were more likely to develop the symptom during treatment with estrogen than other regimens.
The authors conclude that all forms of HRT benefit vasomotor symptoms but appear to have little effect on anxiety, cognition or affect. They further conclude that the addition of progestin to HRT is associated with breast discomfort.
ANNE D. WALLING, M.D.
Greendale GA, et al. Symptom relief and side effects of postmenopausal hormones: results from the postmenopausal estrogen/progestin interventions trial. Obstet Gynecol December 1998;92:982-8.
Is Sertraline Effective in the Treatment of Panic Disorder?
Panic disorder is a common psychiatric condition with significant associated morbidity and disability. Both psychopharmacologic agents and cognitive-behavioral therapies have been shown to be successful treatments. Recent research has promoted selective serotonin reuptake inhibitors (SSRIs) as first-line therapy for panic disorder, specifically sertraline, because of its effectiveness in treating depression and obsessive-compulsive disorder. Pollack and associates conducted a randomized, double-blind, flexible-dose study to determine the effectiveness of varying dosages of sertraline in the treatment of patients with panic disorder.
Patients eligible for the study were at least 18 years of age and met the criteria for panic disorder, with or without agoraphobia, as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R). They had to have experienced panic attacks before the study and during a two-week placebo washout period before treatment commenced. In addition, patients in the study had a minimum score of 18 on the Hamilton Anxiety Scale and no signs of substantial depression. Patients were excluded if they had a history of other psychiatric conditions, such as major depression, bipolar disorder or schizophrenia, and a recent history of substance abuse or regular use of benzodiazepines.
Patients were randomized to receive either 25 or 50 mg of sertraline or placebo. Dosages were gradually adjusted weekly, depending on the patient's response, to a maximum dosage of 200 mg per day. Follow-up visits were scheduled weekly for the first month and biweekly for the remainder of the 10-week study period. Laboratory studies, including hematology and serum chemistries, were performed at baseline and at the end of weeks 2 and 10.
A total of 176 patients were included in the study (88 patients in each group). There were no significant differences in baseline demographics or severity of depression among the study participants. Compared with patients in the placebo group, patients in the treatment group experienced a significant reduction in panic attacks by the end of the second week; this pattern continued through the end of the study. These patients also had a greater reduction in anxiety ratings as measured by several instruments, both during and at the end of the study. There were no significant differences in the overall incidence of adverse effects between patients treated with placebo and those treated with sertraline.
The authors conclude that sertraline is a safe, effective and well-tolerated short-term treatment for patients with panic disorder, with or without agoraphobia. Sertraline reduced the frequency of panic attacks and the global severity of the illness. While few adverse effects developed, the authors suggest initiating therapy with 25 mg of sertraline per day to minimize early treatment withdrawal related to side effects. Future research that examines the effectiveness of longer-term therapy is needed to evaluate whether the observed clinical benefits are maintained.
JEFFREY T. KIRCHNER, D.O.
Pollack MH, et al. Sertraline in the treatment of panic disorder. A flexible-dose multicenter trial. Arch Gen Psych November 1998;55:1010-6.
EDITOR'S NOTE: This study adds to a growing body of literature that supports the efficacy and tolerability of SSRIs in the treatment of panic disorder, as well as other symptoms of anxiety. The difficulty in clinical practice has been maintaining patients until the correct dosage of the SSRI is attained and clinical benefit occurs. Some physicians have successfully overlapped therapy with a short course of a benzodiazepine while titrating the dose of the SSRI.
J.T.K.
Can Local Anesthesia Reduce Post-laparoscopic Pain?
Laparoscopy has become very common, but the return to normal activities is frequently delayed by postoperative pain. Although local anesthetic agents are widely used before and after incision to prevent pain, no studies evaluating the use of pre-emptive analgesia in laparoscopy have been conducted. Ke and colleagues studied the effect of local anesthesia on postoperative pain, particularly the influence of the timing of infiltration of local anesthetic agent.
Fifty-seven healthy women between 18 and 45 years of age who were scheduled for elective laparoscopy were studied. All of the laparoscopic procedures used the same techniques, and members of the surgical staff were blinded as to the use of local anesthesia. All patients received local infiltration before the incision and at incisional closure, but the patients were randomly assigned to one of three groups before induction of anesthesia. Patients in group A received 10 mL of 0.5 percent bupivacaine in the pre-incisional infiltration and saline in the post-incisional infiltration. Patients in group B received saline in the pre-incisional infiltration and bupivacaine in the post-incisional infiltration. Both pre-incisional and post-incisional infiltrations in group C contained saline.
Postoperative pain was assessed by nurse interview using a standardized pain intensity scoring scale 30 minutes after incisional closure and then at two, four and 24 hours. The use of pain medication was recorded in the recovery room, and patients were asked to record their analgesic use for the first 24 hours following surgery.
The three groups did not differ significantly in pain scores at 30 minutes, two hours or four hours following incisional closure. Patients in group A (pre-incisional bupivacaine) had the lowest pain scores and tolerated a longer delay before requesting analgesia, but these differences were not statistically significant. At 24 hours, the patients in group A reported significantly lower mean pain scores than those receiving post-incisional anesthetic or placebo. Group A patients also required less analgesia in the 24-hour period following surgery, but this difference was not statistically significant. Patients receiving post-incisional anesthetic reported greater mean pain scores at four and 24 hours than patients receiving placebo.
The authors conclude that pre-incisional infiltration of bupivacaine decreases post-laparoscopic pain and reduces the need for analgesics. However, they also conclude that the popular practice of infiltrating local anesthetic at the time of incisional closure has no beneficial effect on postoperative pain.
ANNE D. WALLING, M.D.
Ke RW, et al. A randomized, double-blinded trial of preemptive analgesia in laparoscopy. Obstet Gynecol December 1998;92:972-5.
Suppression of Genital Herpes With Famciclovir
Genital herpes simplex virus infection is associated with frequent symptomatic recurrences. These recurrences are often painful and pruritic, and may be psychologically disturbing. Various antiviral agents, including famciclovir, are approved for treatment of acute recurrences of genital herpes. However, episodic treatment may not be sufficient in patients with frequent recurrences. Diaz-Mitoma and associates conducted a randomized, double-blind, placebo-controlled trial to assess the safety and efficacy of famciclovir given for suppression of genital herpes simplex virus recurrences.
Adults with a history of recurrent genital herpes were recruited from 30 centers in Canada and Europe. Patients who had not been treated with acyclovir in the 12 months before the study were required to have had at least six recurrences in the preceding year; patients who had been treated with acyclovir were included in the study if they had had at least six recurrences during a 12-month period in the preceding two years.
Patients were randomized to receive either placebo or one of three doses of famciclovir: 125 mg three times daily, 250 mg two times daily or 250 mg three times daily. The treatment lasted for one year. After a few recurrences, patients were given the option of taking 250 mg of open-label famciclovir three times daily. Information about side effects and recurrence of lesions was collected.
A total of 455 patients were available for analysis. About one half of these patients had received acyclovir on an episodic basis for genital herpes. Fifty-five percent of patients in the placebo group withdrew from the study because of lack of efficacy, compared with 16 percent who withdrew from the treatment groups. Patients who received the active drug had a significantly longer time until first recurrence than those receiving placebo. The groups receiving dosages of 250 mg two or three times daily had first recurrences more than 10 months after beginning the study, compared with seven months in the lowest-dose famciclovir group and about seven weeks in those receiving placebo. More patients in the famciclovir groups remained free of recurrences than those in the placebo group. This difference continued throughout the 52 weeks of treatment, with about three times more patients in the famciclovir groups remaining free of recurrence than patients in the placebo group.
The authors conclude that suppression of genital herpes simplex virus recurrences is conveniently, safely and effectively achieved by taking 250 mg of famciclovir twice daily. This dosage is associated with a median recurrence-free period of 11 months and with 80 percent fewer recurrences than placebo.
GRACE BROOKE HUFFMAN, M.D.
Diaz-Mitoma F, et al. Oral famciclovir for the suppression of recurrent genital herpes. A randomized controlled trial. JAMA September 9, 1998;280:887-92.
Prevention and Treatment of Postherpetic Neuralgia
Approximately 10 percent of cases of herpes zoster infection result in significant postherpetic neuralgia. The incidence of postherpetic neuralgia rises dramatically with age, with over one half of all cases of herpes zoster in patients older than 60 years resulting in this end-stage disorder. Three distinct types of pain are associated with postherpetic neuralgia: steady burning pain, lancinating episodic pain and allodynia (i.e., pain on stimulation of the skin). Postherpetic neuralgia becomes permanent or persists for many years in about one half of those affected, and most cases are refractory to treatment. Watson reviews the management of postherpetic neuralgia.
In summarizing studies of treatment for postherpetic neuralgia, the author emphasizes that total relief of symptoms is rarely achieved and that most patients report significant side effects from the analgesic or antidepressant medications studied. To date, studies have involved relatively small numbers of patients (24 to 41 subjects), and significant individual variation has been noted in response to treatment. Some antidepressants that have the ability to inhibit neurotransmitters for pain pathways have been studied for their analgesic effect in postherpetic neuralgia. Studies of amitriptyline resulted in reports of poor or no response to therapy in 33 to 53 percent of patients, compared with 84 to 100 percent of those receiving placebo. A study in which amitriptyline was combined with maprotiline also resulted in a report of poor or no response in 53 percent of patients, but another study in which amitriptyline was combined with or substituted for nortriptyline resulted in poor or no response in only 32 percent of patients. Desipramine given as sole therapy resulted in poor or no response in 54 percent of patients. It is recommended that antidepressant therapy for postherpetic neuralgia begin with small dosages and increase incrementally to achieve the optimal balance of benefit and adverse effects.
Narcotic analgesics are frequently used in the management of postherpetic neuralgia. A study of oxycodone resulted in reports of poor or no response in 45 percent of those treated compared with 82 percent of patients who received placebo. Regional anesthesia may help to control acute pain but has not been systematically studied. It is not known if the vaccination of older adults would attenuate or prevent herpes zoster infection and thus reduce the number of cases of postherpetic neuralgia. Since cell-mediated immunity is believed to play a significant role in the pathogenesis of postherpetic neuralgia, vaccination could theoretically confer protection.
The author concludes that the best approach to minimizing the risk of postherpetic neuralgia is early, aggressive treatment of herpes zoster. Patients should be educated to recognize the signs and symptoms of the condition and should be made aware of the importance of early presentation for medical evaluation. Antiviral therapy with valacyclovir or famciclovir should begin within 72 hours of onset of pain or rash.
ANNE D. WALLING, M.D.
Watson CP. Postherpetic neuralgia: the importance of preventing this intractable end-stage disorder. J Inf Dis November 1998;178:S91-4.
Recognition and Prevention of Carbon Monoxide Poisoning
About 600 accidental deaths from carbon monoxide poisoning occur each year, making it one of the most common causes of morbidity from poisoning in the United States. About five to 10 times as many intentional deaths from carbon monoxide are reported. Exposure occurs from a variety of sources, particularly motor vehicle exhaust. The number of accidental deaths caused by carbon monoxide poisoning from motor vehicle exhaust is higher in the North and peaks during the winter months. Ernst and Zibrak reviewed the clinical aspects of carbon monoxide poisoning, including signs and symptoms, diagnostic tests, treatment and prevention strategies.
Acute Symptoms of Carbon Monoxide Exposure Reported by 196 Patients
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. The clinical signs and symptoms of carbon monoxide poisoning are nonspecific (see the accompanying table) and are often mistaken for a simple viral illness. Patients typically present with tachycardia and tachypnea, and may complain of headache, nausea and vomiting. However, patients rarely have the classic findings of cyanosis, retinal hemorrhage and cherry-red lips.
Symptom severity ranges from mild (constitutional symptoms) to severe (coma, respiratory depression and hypotension) and is not associated with serum levels of carboxyhemoglobin, although duration of exposure is an important factor. Not all patients exhibit signs and symptoms immediately after exposure. In some patients, neuropsychiatric symptoms, including cognitive and personality changes, may develop anywhere from three days to eight months after exposure. The mechanism for these conditions is unknown, but hypoxia alone is not sufficient to explain the observed clinical manifestations.
Because carbon monoxide poisoning has no pathognomonic signs or symptoms, a high level of suspicion is needed to confirm the diagnosis. Measuring the level of carbon monoxide in the exhaled air of a patient can be diagnostic, but a blood sample should be obtained to measure carboxyhemoglobin levels and any coexisting acidosis. A detailed neurologic examination, including psychologic testing, is recommended to document any abnormal findings, which are often subtle. The Carbon Monoxide Neuropsychological Screening Battery is a frequently used tool that takes about 30 minutes to administer and helps to establish a baseline for assessing the patient's mental status.
The most important steps in treatment are removing the patient from the source of poisoning and administering 100 percent oxygen. Oxygen should be given until the patient's carboxyhemoglobin level returns to normal. Hospitalization should also be considered for patients with severe poisoning or serious underlying medical problems. Indications for hyperbaric oxygen therapy are not clear, except that it is undisputedly indicated in unconscious patients.
The authors conclude that public awareness of the dangers of carbon monoxide is key to decreasing morbidity and mortality from carbon monoxide poisoning. Carbon monoxide detectors are inexpensive and widely available, but there are no standard recommendations regarding their use in the home or the workplace.
JEFFREY T. KIRCHNER, D.O.
Ernst A, Zibrak JD. Carbon monoxide poisoning. N Engl J Med November 26, 1998;339:1603-8.
Azithromycin for Treatment of Pneumonia in Children
Erythromycin is commonly used in the treatment of pneumonia in children. However, the pharmacokinetic properties of azithromycin, including its prolonged serum half-life of 11 to 14 hours, sustained tissue concentrations, prolonged serum concentration after completion of therapy and high intracellular concentrations make it a suitable alternative. These properties allow once-daily dosing and only five days of treatment for pneumonia compared with erythromycin, which is usually given three to four times daily for 10 days. Intracellular concentrations of azithromycin remain above the mean inhibitory concentration for many common respiratory pathogens for more than seven days after the drug is discontinued. Harris and associates conducted a multicenter, double-blind study to compare the safety and efficacy of a five-day course of azithromycin with a 10-day course of amoxicillin or erythromycin in the treatment of community-acquired pneumonia in children.
Children from six months to 16 years of age with radiologic findings of an acute infiltrate and the presence of tachypnea accompanied by either fever or an elevated white blood cell count were eligible to receive one of the study medications. Patients in the azithromycin group received 10 mg per kg of the drug on the first day, followed by 5 mg per kg on days 2 through 5. Depending on their age, patients in the conventional therapy group received either amoxicillin or erythromycin oral suspension in a dosage of 40 mg per kg per day in three divided doses. Patients were evaluated at baseline, once during days 2 through 5 of the study period, once during days 15 through 19 of the study period and once four to six weeks after therapy. Culture or polymerase chain reaction testing was done at baseline and at days 15 to 19 for bacteria, Chlamydia pneumoniae and Mycoplasma pneumoniae. Serology for C. pneumoniae and M. pneumoniae was done at baseline and four to six weeks posttherapy.
Data from 420 patients were evaluated. There were 285 patients in the group receiving azithromycin and 135 in the group receiving conventional treatment. The clinical presentation of pneumonia was similar in both groups at baseline. Clinical success (defined as the percentage of patients who experienced clinical improvement or cure) at the primary evaluation (days 15 to 19) and at four to six weeks posttherapy was also similar across groups. Treatment failures were highest among children under five years of age. This finding was independent of treatment group. Treatment-related side effects occurred significantly less often in the group receiving azithromycin. Vomiting and diarrhea were the most common side effects, followed by rash in children younger than five years and abdominal pain in those older than five years.
The authors conclude that the five-day course of azithromycin is just as effective in the treatment of community-acquired pneumonia in children as the conventional 10-day regimen with either amoxicillin or erythromycin. Patients taking azithromycin experienced significantly fewer side effects than patients taking either amoxicillin or erythromycin. Treatment with azithromycin appears to be appropriate in children six months of age or older. The significantly higher failure rate in children younger than five years may have been caused by a higher number of cases of pneumonia of viral etiology in this age group.
RICHARD SADOVSKY, M.D.
Harris JS, et al. Safety and efficacy of azithromycin in the treatment of community-acquired pneumonia in children. Pediatr Infect Dis J October 1998;17:865-71.
A Cost-Effective Strategy for Diagnosing Vaginal Candidiasis
Accurate and efficient laboratory confirmation of vulvovaginal candidiasis is problematic. Potassium hydroxide (KOH) preparations of vaginal secretions may fail to identify candidiasis in as many as one half of patients with cultures positive for Candida albicans. In addition, wet mount preparations may not distinguish between the organism as a vaginal commensal and as a pathogen for vulvovaginal infection. Eckert and colleagues assessed risk factors and clinical manifestations of vulvovaginal candidiasis to identify a better way to establish the diagnosis of vulvovaginal candidiasis.
The study included 774 women 16 to 50 years of age who presented to a sexually transmitted disease clinic with symptoms of infection. Patients who were pregnant, had received oral antibiotics or vaginal medications in the previous 14 days, had undergone hysterectomy, had a severe mental or physical handicap or could not speak English well were excluded from the study.
In addition to demographic characteristics, other data obtained included the patient's medical, reproductive and contraceptive history, current symptoms, findings on physical and pelvic examination, and the results of vaginal pH determination, KOH and saline preparations of vaginal secretions, and culture of vaginal specimens for Candida. The authors used the term "wet mount" to describe a combination of saline and KOH preparations. Vaginal specimens were first examined in saline for clue cells, trichomonads and white blood cells. KOH was then added to the preparation for microscopic detection of hyphae. Vaginal specimens were also collected for culture of C. albicans.
The organism was identified in 186 of the 774 women (24.0 percent). Of those with positive cultures, 104 (55.9 percent) also had wet mount examinations positive for C. albicans. An additional 15 patients were found to have cultures positive for other Candida species; all of the latter women had negative wet mount results.
Statistical analysis of the data demonstrated that women with positive cultures were significantly more likely to present with the chief complaint of vulvar itching or burning and, when asked, to report symptoms of vulvar dysuria and pruritus. Although signs of vulvar edema, fissures, excoriations and vaginal erythema, or a thick, curdy discharge were infrequent, these signs, when present, correlated strongly with positive cultures. Patients with positive cultures were more likely to be nulligravid, to report using condoms as their method of birth control, to have sexual intercourse more than four times per month, to present in the second half of their menstrual cycle and to report antibiotic use in the previous 15 to 30 days. Current bacterial vaginosis, gonorrhea, chlamydial infection and vaginal trichomoniasis were associated negatively with a positive C. albicans culture.
On the basis of the statistical analysis, the authors devised a clinical algorithm that would allow reliable and cost-effective investigation of symptomatic vulvovaginal candidiasis. They recommend that wet mount preparation of vaginal secretions be obtained in all women with symptoms or signs of vulvovaginal candidiasis. Treatment of candidiasis should be initiated if the wet mount preparations are positive. If the results are negative despite a clinical presentation that suggests vulvovaginal candidiasis, culture for C. albicans should be obtained, and treatment should be initiated in patients with positive cultures. The authors note that implementation of such a management strategy would result in treatment of 90 percent of women who meet the definition of vulvovaginal candidiasis while it would limit the expense of potentially unnecessary cultures. The authors note that vaginal discharge is a particularly poor indicator of the need for over-the-counter therapy for vulvovaginal candidiasis.
ANNE D. WALLING, M.D.
Eckert LO, et al. Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm. Obstet Gynecol November 1998;92:757-65.
Cesarean vs. Vaginal Delivery of Infants in Breech Presentation
The role of cesarean delivery of infants in breech presentation remains controversial. Lee and colleagues analyzed birth data for the years 1989, 1990 and 1991, published by the National Center for Health Statistics, to compare neonatal mortality among infants with breech presentation who were delivered vaginally and by cesarean.
The authors examined data on 371,692 singleton live births of infants with breech presentation whose birth weight and method of delivery were known. Infants weighing less than 500 g (1 lb, 2 oz) at birth were excluded. The births included in the study were categorized into four delivery groups: primary cesarean section, repeat cesarean section, vaginal delivery and vaginal delivery after cesarean section. The overall rate of cesarean delivery in the study population was 85.5 percent.
The predominant mode of delivery varied with the weight of the infant. Vaginal delivery, including vaginal birth after cesarean section, was the method of delivery in 55.4 percent of the infants with birth weights under 749 g (1 lb, 10 oz). In contrast, cesarean section was the mode of delivery in 86.3 percent of the infants who weighed over 2,500 g (5 lb, 8 oz).
In each category of birth weight, the neonatal mortality rate was much lower in the infants delivered by cesarean section than in those delivered vaginally. The differences in mortality rates were most marked in the first hour of life, ranging from a nearly threefold difference in infants weighing 2,000 to 2,499 g (4 lb, 6 oz to 5 lb, 7 oz) to a nearly 13-fold difference in infants weighing 2,500 g or more.
The observed differences in the mortality rate could not be explained by congenital malformations or other causes of mortality. After statistical adjustments were made for the variations in birth weight, a 3.8-fold higher risk of death in the first day was demonstrated in the infants delivered vaginally compared with the risk in infants delivered by primary cesarean section. For up to 28 days after birth, the weight-adjusted risk of neonatal mortality for infants with breech presentation was 2.6-fold greater for the vaginal delivery group than for the cesarean delivery group.
The authors also identified the limitations of their study, including the shortcomings of using data from linked birth and death certificates and the limited availability of information about other factors that could have influenced the choice of delivery mode. They mention that the increased mortality rate associated with vaginal births could reflect a lack of experience in vaginal breech delivery among American physicians. In spite of these concerns, the authors conclude that infants with breech presentation delivered by cesarean section had lower birth weightspecific neonatal mortality compared with vaginal deliveries.
ANNE D. WALLING, M.D.
Lee KS, et al. Relationship of cesarean delivery to lower birth weightspecific neonatal mortality in singleton breech infants in the United States. Obstet Gynecol November 1998;92:769-74.
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