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Albuterol treatment in mild asthma
women, despite a more unfavorable risk profile, tended to have a lower case fatality before admission than men. After admission women had a higher fatality rate than men, but after adjustments for confounders (age, smoking, history of cardiac problems, thrombolytic therapy) the odds ratio was reduced from 1.76 to 1.18. Total fatality after 28 days following the acute cardiac event showed no significant difference between men and women. The authors concluded that the higher rate of fatality following admission was explained by history, treatment, and living status.
. . . Commentary: Women with coronary events historically have a longer delay in seeking help. This delay is most often attributed to a lower awareness of the risk of coronary heart disease and its associated symptoms. As they age, a higher percentage of women live alone than men, and this may contribute to the decrease in recognition of symptoms. Regardless, as the ob/gyn cares for increasing numbers of women beyond the menopause, it is important to emphasize the risk that their patients face from coronary artery disease and to be aware of the symptoms of coronary disease. As was found in this study, smoking must also be considered a key confounding variable.
Anorexic Drugs & Pulmonary Hypertension Abenhaim L, Moride Y, Brenot F, Rich S, Benichou J, Kua X, et al. Appetite-suppressant drugs and the risk of primary pulmonary hypertension. N Engl J Med 1996;335: 609-16.
Synopsis: In a case control study the authors assessed 95 patients with primary pulmonary hypertension from 35 centers in Europe and compared them with 355 matched controls. They found the use of fenfluramine was associated with an increased risk of primary pulmonary hypertension (odds ratio 6.3) when compared with controls. For use within the preceding year, the odds ratio was 10.1. When the anorexic drugs were used >3 Cl997 by IhP Ame’lcdl Goliege cf Obsletrlckms and Gm~olqista “ubllshed by Elswer Suence Inc l&85-5862,9i.$l 5C
months, the odds ratio was 23.1. Other risk factors were family history, human immunodeficiency virus infection, cirrhosis, and use of cocaine or intravenous drugs.
. . . Commentary: Obesity is a major public health problem in the developed world. The associated health problems are extensive, and losing weight is difficult. As a result, attempts to reduce weight are extremely prevalent. One of the more common requests to the physician is a pill to reduce appetite. Until recently, the availability of such a medication was limited. A new class of drug is now available; fenfluramine is one such drug. Little has been reported about the medication other than its success. This article was reported widely in the lay press and raised many questions, as it should. However, there are problems with this report. How many patients actually took the medication? It is one thing to create an odds ratio based on controls; it is quite another to perform a randomized controlled study. In how many of these patients was the drug indicated! The manufacturer does not recommend the medication for the minimally obese or for extended therapy. The impact of obesity on the health of the patients as compared with the side effects of the drug must also be considered. A side effect as serious as primary pulmonary hypertension, regardless of its incidence, must be considered strongly before prescribing any drug. This is especially important when the reason for the medication is not an acute event. Therefore, before prescribing an appetite suppressant, the physician must evaluate the clinical rationale carefully.
tients ofwhich 497 (47.8%) were current smokers, 444 (42.7%) were former smokers, and 98 (9.7%) were never smokers. After review of these patients the authors concluded that smoking cessation or less lifetime exposure affects the distribution of histologic subtypes, especially for women. They also found that smoking cessation may postpone the age at which lung cancer occurs. . . . Commentary: This is another in a large number of studies that implicate smoking as a causative factor for developing lung carcinoma. Other articles reviewed in this issue also have identified smoking as a factor in infertility and cardiac disease. Cessation of smoking should be the major health priority in the United States. If it were a bacterial or viral disease, we would be investigating cures vigorously. We should do no less with smoking.
Albuterol Treatment in Mild Asthma Drazen JM, Israel E, Boushey HA, Chinchilli VM, Fahy JV, Fish JE, et al. Comparison of regularly scheduled with as-needed use of albuterol in mild asthma. N Engl J Med 1996;335:841-7.
Synopsis: In a multicenter, doubleblind study, 255 patients with mild asthma were randomly assigned to inhale albuterol on either a regular schedule (126 patients) or only as needed (129 patients). The primary outcome tory air
indicator
Cancer in Former Smokers Tong L, Spitz Lung carcinoma 1996:78:1004-10,
MR, Fueger JJ, Amos CI. in former smokers. Cancer
Synopsis: For this report, the authors conducted a cross-sectional study of lung cancer from January 1986 to December 1990 and January 1992 to December 1993. There were 1039 paMarch/April
was
peak
expira-
flow measured in the morning. There were no clinically significant differences between the two groups. Thus, the authors concluded that inhaled albuterol should be prescribed for patients with mild asthma on an as-needed basis. . . . Commentary: This was a multi-institution study conducted for the National Heart, Lung, and Blood Institute’s
Asthma
Clinical
Research
Network. The conclusion of the study is important for those ob/gyns who have patients with mild asthma in 19’17
l
ACo(;
(:I.INICAL.
REVIEW’
.
1I
their practice. Patients asthma are characterized 12-55 years old, using no ications, having a forced volume 970%, and using of albuterol per week.
with mild as being other rnedexpiratory 6-56 puffs
Colon Cancer Slattety ML, Friedman GD, Potter JD, Edwards S, Caan BJ, Samowitz W. A description of age, sex, and site distributions of colon carcinoma in three geographic areas. Cancer 1996;78:1666-70.
Synopsis: Data from three distinct geographic areas (Utah, Minnesota, and Northern California) were used to describe rates of colon carcinoma and distribution. Colon carcinomas from a 3-year period, 1991-1994, were included. The proximal segment of the colon was the site of 50% of the carcinomas. Proximal cancers and those diagnosed after age 50 were more likely to be in advanced stages. More men than women were diagnosed in all three areas. Women were >70 when diagnosed with colon cancer in 44% of the cases. The more advanced tumors occurred in younger patients. . . . Commentary: Colon cancer is one of the more common cancers of older women. As a result, oblgyns should be alert to the need for screening in their patients. Because these tumors are more likely to occur in the proximal colon, they can be diagnosed more easily. As part of a regular health checkup, the patient should be asked whether she has had a colon evaluation.
Urethral Diverticulum Jensen LM, Aabech J, Lundvall F, Iverson H-G. Female urethral diverticulum: Clinical aspects and a presentation of 15 cases. Acta
Obstet Gynecol Sand 1996;75:748-52. Synopsis: This is a report of a retrospective analysis of 15 cases of diverticulum managed from 1985 to 1994. The median age was 54. Tenderness was present in 75% of the patients, and in 14 of the 15, a suburethral mass was noted. 12 . ACXX;
C:I.IiVICpIL
REVIEW
. M
. . . Commentary: This small review of urethral diverticula in women points out some of the more objective symptomatology. A key feature is the onset of symptoms of a lower urinary tract disorder. Most common among these symptoms are pain, swelling, and dysuria. On examination, the authors found 14 of the 15 had a suburethral mass. A diverticulum is an unusual finding. However, the clinician should be alert constantly for its possibility whenever a patient complains of lower urinary tract problems, especially if the complaint is recurrent cystitis. On examination, the palpation of the mass, the presence of sitespecific tenderness, and the expulsion of purulent material and urine when the mass is compressed should establish the diagnosis. Treatment is surgical excision.
Age at Menarche Cooper C, Kuh D, Egger P, Wadsworth M, Barker D. Childhood growth and age at menarche. Br J Obstet Gyoaecol 1996;103: 814-7.
Synopsis: The authors studied 1471 girls and reviewed the influence of birth weight and weight and height at 7 years on the age of menarche. They found girls who were heavier at age 7 to have earlier menarche. Girls in the highest 20% of weight distribution at 7 years experienced menarche 7.3 months earlier than did girls in the lowest 20% of weight distribution, In contrast, girls who were in the highest 20% of weight distribution at birth had the onset of menses 2.2 months later than did girls in the lowest 20%. The authors concluded that the age at menarche is related to patterns of hormone release established in utero when the hypothalamus is imprinted and is modified subsequently by weight gain.
. . . Commentary: The authors of this article attempt to correlate birth weight and subsequent weight gain with menarche. A cohort of girls born in March 1946 were the participants. I’)‘)7
The median age of menarche was 13 years. The authors have done extensive statistical analysis of their data. Data derived from studying children born in the immediate post-World War II years (50 years ago) have little relevance to today’s children. The report was based on 2548 girls examined in 1960 and 1961. The confounding variables that could have occurred during the preceding 14 years and their impact were not considered. Although the authors of this article attempt to add to our knowledge base, their results would be more meaningful if they were compared with data derived from those born in 1980 or 1981.
Women & Smoking Kendrick smoking:
Obstet
JS, Merritt RK. Women and An update for the 1990s. Am J Gyoecol 1996;175:528-35.
Synopsis: The authors of this report reviewed the prevalence of smoking, its effects on women, and quitting and prevention techniques. They reported that 23.1% of women and 14.6% of pregnant women smoked. Women 25-44 years old had the highest prevalence. The authors reviewed the physician’s role and the resources available. Because only 3.3% of physicians smoke, they can serve as good role models. . . . Commentary: This review article summarizes the status of women smoking in the United States. Highlights of the article are not surprising: Smoking is second only to obesity as a serious threat to the health of our patients, smoking cessation has immediate health benefits, former smokers live longer and have less chronic disease than current smokers, and pregnant women who stop before or early in pregnancy have a reduced rate of low birth weight infants. Unfortunately, studies on teenage smoking are showing an increasing frequency of smoking. This is a trend we should make every effort to reverse. For the clinician who wishes a comprehensive review, this article is recommended. PII SlCRlS-6B62197M0008-3
. . . Commentary: Women with coronary events historically have a longer delay in seeking help. This delay is most often attributed to a lower awareness of the risk of coronary heart disease and its associated symptoms. As they age, a higher percentage of women live alone than men, and this may contribute to the decrease in recognition of symptoms. Regardless, as the ob/gyn cares for increasing numbers of women beyond the menopause, it is important to emphasize the risk that their patients face from coronary artery disease and to be aware of the symptoms of coronary disease. As was found in this study, smoking must also be considered a key confounding variable.
Anorexic Drugs & Pulmonary Hypertension Abenhaim L, Moride Y, Brenot F, Rich S, Benichou J, Kua X, et al. Appetite-suppressant drugs and the risk of primary pulmonary hypertension. N Engl J Med 1996;335: 609-16.
Synopsis: In a case control study the authors assessed 95 patients with primary pulmonary hypertension from 35 centers in Europe and compared them with 355 matched controls. They found the use of fenfluramine was associated with an increased risk of primary pulmonary hypertension (odds ratio 6.3) when compared with controls. For use within the preceding year, the odds ratio was 10.1. When the anorexic drugs were used >3 Cl997 by IhP Ame’lcdl Goliege cf Obsletrlckms and Gm~olqista “ubllshed by Elswer Suence Inc l&85-5862,9i.$l 5C
months, the odds ratio was 23.1. Other risk factors were family history, human immunodeficiency virus infection, cirrhosis, and use of cocaine or intravenous drugs.
. . . Commentary: Obesity is a major public health problem in the developed world. The associated health problems are extensive, and losing weight is difficult. As a result, attempts to reduce weight are extremely prevalent. One of the more common requests to the physician is a pill to reduce appetite. Until recently, the availability of such a medication was limited. A new class of drug is now available; fenfluramine is one such drug. Little has been reported about the medication other than its success. This article was reported widely in the lay press and raised many questions, as it should. However, there are problems with this report. How many patients actually took the medication? It is one thing to create an odds ratio based on controls; it is quite another to perform a randomized controlled study. In how many of these patients was the drug indicated! The manufacturer does not recommend the medication for the minimally obese or for extended therapy. The impact of obesity on the health of the patients as compared with the side effects of the drug must also be considered. A side effect as serious as primary pulmonary hypertension, regardless of its incidence, must be considered strongly before prescribing any drug. This is especially important when the reason for the medication is not an acute event. Therefore, before prescribing an appetite suppressant, the physician must evaluate the clinical rationale carefully.
tients ofwhich 497 (47.8%) were current smokers, 444 (42.7%) were former smokers, and 98 (9.7%) were never smokers. After review of these patients the authors concluded that smoking cessation or less lifetime exposure affects the distribution of histologic subtypes, especially for women. They also found that smoking cessation may postpone the age at which lung cancer occurs. . . . Commentary: This is another in a large number of studies that implicate smoking as a causative factor for developing lung carcinoma. Other articles reviewed in this issue also have identified smoking as a factor in infertility and cardiac disease. Cessation of smoking should be the major health priority in the United States. If it were a bacterial or viral disease, we would be investigating cures vigorously. We should do no less with smoking.
Albuterol Treatment in Mild Asthma Drazen JM, Israel E, Boushey HA, Chinchilli VM, Fahy JV, Fish JE, et al. Comparison of regularly scheduled with as-needed use of albuterol in mild asthma. N Engl J Med 1996;335:841-7.
Synopsis: In a multicenter, doubleblind study, 255 patients with mild asthma were randomly assigned to inhale albuterol on either a regular schedule (126 patients) or only as needed (129 patients). The primary outcome tory air
indicator
Cancer in Former Smokers Tong L, Spitz Lung carcinoma 1996:78:1004-10,
MR, Fueger JJ, Amos CI. in former smokers. Cancer
Synopsis: For this report, the authors conducted a cross-sectional study of lung cancer from January 1986 to December 1990 and January 1992 to December 1993. There were 1039 paMarch/April
was
peak
expira-
flow measured in the morning. There were no clinically significant differences between the two groups. Thus, the authors concluded that inhaled albuterol should be prescribed for patients with mild asthma on an as-needed basis. . . . Commentary: This was a multi-institution study conducted for the National Heart, Lung, and Blood Institute’s
Asthma
Clinical
Research
Network. The conclusion of the study is important for those ob/gyns who have patients with mild asthma in 19’17
l
ACo(;
(:I.INICAL.
REVIEW’
.
1I
their practice. Patients asthma are characterized 12-55 years old, using no ications, having a forced volume 970%, and using of albuterol per week.
with mild as being other rnedexpiratory 6-56 puffs
Colon Cancer Slattety ML, Friedman GD, Potter JD, Edwards S, Caan BJ, Samowitz W. A description of age, sex, and site distributions of colon carcinoma in three geographic areas. Cancer 1996;78:1666-70.
Synopsis: Data from three distinct geographic areas (Utah, Minnesota, and Northern California) were used to describe rates of colon carcinoma and distribution. Colon carcinomas from a 3-year period, 1991-1994, were included. The proximal segment of the colon was the site of 50% of the carcinomas. Proximal cancers and those diagnosed after age 50 were more likely to be in advanced stages. More men than women were diagnosed in all three areas. Women were >70 when diagnosed with colon cancer in 44% of the cases. The more advanced tumors occurred in younger patients. . . . Commentary: Colon cancer is one of the more common cancers of older women. As a result, oblgyns should be alert to the need for screening in their patients. Because these tumors are more likely to occur in the proximal colon, they can be diagnosed more easily. As part of a regular health checkup, the patient should be asked whether she has had a colon evaluation.
Urethral Diverticulum Jensen LM, Aabech J, Lundvall F, Iverson H-G. Female urethral diverticulum: Clinical aspects and a presentation of 15 cases. Acta
Obstet Gynecol Sand 1996;75:748-52. Synopsis: This is a report of a retrospective analysis of 15 cases of diverticulum managed from 1985 to 1994. The median age was 54. Tenderness was present in 75% of the patients, and in 14 of the 15, a suburethral mass was noted. 12 . ACXX;
C:I.IiVICpIL
REVIEW
. M
. . . Commentary: This small review of urethral diverticula in women points out some of the more objective symptomatology. A key feature is the onset of symptoms of a lower urinary tract disorder. Most common among these symptoms are pain, swelling, and dysuria. On examination, the authors found 14 of the 15 had a suburethral mass. A diverticulum is an unusual finding. However, the clinician should be alert constantly for its possibility whenever a patient complains of lower urinary tract problems, especially if the complaint is recurrent cystitis. On examination, the palpation of the mass, the presence of sitespecific tenderness, and the expulsion of purulent material and urine when the mass is compressed should establish the diagnosis. Treatment is surgical excision.
Age at Menarche Cooper C, Kuh D, Egger P, Wadsworth M, Barker D. Childhood growth and age at menarche. Br J Obstet Gyoaecol 1996;103: 814-7.
Synopsis: The authors studied 1471 girls and reviewed the influence of birth weight and weight and height at 7 years on the age of menarche. They found girls who were heavier at age 7 to have earlier menarche. Girls in the highest 20% of weight distribution at 7 years experienced menarche 7.3 months earlier than did girls in the lowest 20% of weight distribution, In contrast, girls who were in the highest 20% of weight distribution at birth had the onset of menses 2.2 months later than did girls in the lowest 20%. The authors concluded that the age at menarche is related to patterns of hormone release established in utero when the hypothalamus is imprinted and is modified subsequently by weight gain.
. . . Commentary: The authors of this article attempt to correlate birth weight and subsequent weight gain with menarche. A cohort of girls born in March 1946 were the participants. I’)‘)7
The median age of menarche was 13 years. The authors have done extensive statistical analysis of their data. Data derived from studying children born in the immediate post-World War II years (50 years ago) have little relevance to today’s children. The report was based on 2548 girls examined in 1960 and 1961. The confounding variables that could have occurred during the preceding 14 years and their impact were not considered. Although the authors of this article attempt to add to our knowledge base, their results would be more meaningful if they were compared with data derived from those born in 1980 or 1981.
Women & Smoking Kendrick smoking:
Obstet
JS, Merritt RK. Women and An update for the 1990s. Am J Gyoecol 1996;175:528-35.
Synopsis: The authors of this report reviewed the prevalence of smoking, its effects on women, and quitting and prevention techniques. They reported that 23.1% of women and 14.6% of pregnant women smoked. Women 25-44 years old had the highest prevalence. The authors reviewed the physician’s role and the resources available. Because only 3.3% of physicians smoke, they can serve as good role models. . . . Commentary: This review article summarizes the status of women smoking in the United States. Highlights of the article are not surprising: Smoking is second only to obesity as a serious threat to the health of our patients, smoking cessation has immediate health benefits, former smokers live longer and have less chronic disease than current smokers, and pregnant women who stop before or early in pregnancy have a reduced rate of low birth weight infants. Unfortunately, studies on teenage smoking are showing an increasing frequency of smoking. This is a trend we should make every effort to reverse. For the clinician who wishes a comprehensive review, this article is recommended. PII SlCRlS-6B62197M0008-3