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HRT has little effect on acute MI
ing number and is surprising in light of the effort to increase education and public understanding of preventive measures. Few diseases have the distinction of being on a Time magazine cover. The investigators found that women were 45% more likely to be infected than men. Surprisingly, a majority of seropositive individuals had no history of a genital infection. Whether this is true or the result of a lack of recognition could not be determined. It is known, however, that the presence of a lesion may not be the only manifestation of the disease and that shedding of the virus may take place without a visible lesion. These studies reemphasize the need to continue education programs about herpes and other STDs. Until the population accepts the responsibility of disease prevention, the problem will continue to be with us. This is truly a hidden epidemic as described in a recent report from the Institute of Medicine Committee on Prevention and Control of Sexually Transmitted Diseases (Eng TR, Butler WT. ‘The hidden epidemic.’ Confronting sexually transmitted diseases. Washington, DC: National Academic Press, 1997).
HRT Has little Effect on Acute Ml Sidney S, Petitti DB, Quesenberry Cl’ Jr. Myocardial infarction and the use of estrogen and estrogen-progestogen in postmenopausal women. AM Intern Med 1997; 12? 501-K
Synopsis: Using a retrospective case control method, the authors reviewed all women hospitalized at the medical centers of a large, prepaid health care plan who had a diagnosis of acute myocardial infarction (MI), from 1991-1994. There were 685 confirmed cases of acute MI during the time period, and 636 MI patients agreed to be interviewed. The odds ratio for acute MI in current users was 0.96. For past users it was 1.07. The authors concluded that there was no significant decrease in risk . . . Commentary: Although these authors did not find that hormone real998 by lhe AmencanCollegeof Obsielnciansand Gynecolo~~sis PublIshedby ElsewerSciencelnc 10&6662/98/$5 50
placement therapy (HRT) played a large role in the prevention of acute MI, they qualified their finding by stating that there was some effect in reduction of relative risk in current users, and they did not rule out a preventive effect. Many studies are appearing in which the authors attempt to evaluate the benefits and risks of HRT in postmenopausal women. Each of these looks at one specific area. What is needed is an overall picture of the whole woman. We must not be like the proverbial seven blind men describing a camel. When the Women’s Health Initiative is completed, we should have a more complete picture.
Ring Block Is Anesthetic of Choice for Neonatal Circumcision Lander J, Brady-Fryer B, Metcalfe JB, Nazarah S, Muttitt S. Comparison of ring block, dorsaI penile nerve block, and topical anesthesia for neonatal circumcision. JAMA 1997;278:2157-62.
Synopsis: Circumcision of male infants is one of the most frequently performed procedures in the United States. The objective of this study was to compare a variety of local anesthetic approaches with placebo to evaluate the effect on the infant. Physiologic and behavioral monitoring was used. Specific measurements of heart rate, crying, and methemoglobin levels were taken. The authors found infants in the placebo group had a sustained elevated heart rate and high-pitched cry throughout the procedure. They concluded that ring block was the most effective method and recommended its use for circumcision.
Commentany Circumcision of male infants has become controversial. The benefits, or lack thereof, are the subject of much debate. Unfortunately, Judeo-Christian beliefs also form part of the decision. There is little documented eviMay/June
dence for or against the procedure and few large studies. Fortunately, these authors have avoided the issue of whether to circumcise. They simply state that if you plan to perform a circumcision, then a ring block anesthetic is the anesthesia of choice. Many of us were taught that feelings of pain had yet to develop in newborn infants, so circumcision is a painless procedure. These authors, using psychologic data, have shown that it is unlikely that this is true, However, because the infant cannot explain his feeling, we do not know for certain. If we accept the authors’ finding, anesthesia clearly is indicated. If we disagree, is there harm in using the anesthesia? Apparently not, but each physician will need to determine an individual approach.
Trends in Antiiypertensive Presubing Siegel D, Loper J. Trends in antihypertensive drug use in the United States: Do the JNC V recommendations affect prescribing? JAMA 1997;278:1745-8.
Synopsis: There are approximately 50 million people in the United Sates who have hypertension and require medication. In 1993, the Fifth Joint National Committee on the Detection, Evaluation, and Treatment of High Blood Pressure recommended diuretics and p-blockers as the first line of therapy. These authors explored the prescribing patterns between 1992 and I995 and the influence of the Joint National Committee. All of the prescriptions dispensed by 35,000 retail pharmacies were reviewed from 1992 to 1995. The use of calcium channel blockers and angiotensinconverting enzyme inhibitors increased, whereas the use of diuretics and p-blockers decreased. The authors concluded that the Joint National Committee had little effect on treatment. . . . Commentaryz The impact of a national recommendation is often a subject for debate. First and foremost is 1998
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HRT Has little Effect on Acute Ml Sidney S, Petitti DB, Quesenberry Cl’ Jr. Myocardial infarction and the use of estrogen and estrogen-progestogen in postmenopausal women. AM Intern Med 1997; 12? 501-K
Synopsis: Using a retrospective case control method, the authors reviewed all women hospitalized at the medical centers of a large, prepaid health care plan who had a diagnosis of acute myocardial infarction (MI), from 1991-1994. There were 685 confirmed cases of acute MI during the time period, and 636 MI patients agreed to be interviewed. The odds ratio for acute MI in current users was 0.96. For past users it was 1.07. The authors concluded that there was no significant decrease in risk . . . Commentary: Although these authors did not find that hormone real998 by lhe AmencanCollegeof Obsielnciansand Gynecolo~~sis PublIshedby ElsewerSciencelnc 10&6662/98/$5 50
placement therapy (HRT) played a large role in the prevention of acute MI, they qualified their finding by stating that there was some effect in reduction of relative risk in current users, and they did not rule out a preventive effect. Many studies are appearing in which the authors attempt to evaluate the benefits and risks of HRT in postmenopausal women. Each of these looks at one specific area. What is needed is an overall picture of the whole woman. We must not be like the proverbial seven blind men describing a camel. When the Women’s Health Initiative is completed, we should have a more complete picture.
Ring Block Is Anesthetic of Choice for Neonatal Circumcision Lander J, Brady-Fryer B, Metcalfe JB, Nazarah S, Muttitt S. Comparison of ring block, dorsaI penile nerve block, and topical anesthesia for neonatal circumcision. JAMA 1997;278:2157-62.
Synopsis: Circumcision of male infants is one of the most frequently performed procedures in the United States. The objective of this study was to compare a variety of local anesthetic approaches with placebo to evaluate the effect on the infant. Physiologic and behavioral monitoring was used. Specific measurements of heart rate, crying, and methemoglobin levels were taken. The authors found infants in the placebo group had a sustained elevated heart rate and high-pitched cry throughout the procedure. They concluded that ring block was the most effective method and recommended its use for circumcision.
Commentany Circumcision of male infants has become controversial. The benefits, or lack thereof, are the subject of much debate. Unfortunately, Judeo-Christian beliefs also form part of the decision. There is little documented eviMay/June
dence for or against the procedure and few large studies. Fortunately, these authors have avoided the issue of whether to circumcise. They simply state that if you plan to perform a circumcision, then a ring block anesthetic is the anesthesia of choice. Many of us were taught that feelings of pain had yet to develop in newborn infants, so circumcision is a painless procedure. These authors, using psychologic data, have shown that it is unlikely that this is true, However, because the infant cannot explain his feeling, we do not know for certain. If we accept the authors’ finding, anesthesia clearly is indicated. If we disagree, is there harm in using the anesthesia? Apparently not, but each physician will need to determine an individual approach.
Trends in Antiiypertensive Presubing Siegel D, Loper J. Trends in antihypertensive drug use in the United States: Do the JNC V recommendations affect prescribing? JAMA 1997;278:1745-8.
Synopsis: There are approximately 50 million people in the United Sates who have hypertension and require medication. In 1993, the Fifth Joint National Committee on the Detection, Evaluation, and Treatment of High Blood Pressure recommended diuretics and p-blockers as the first line of therapy. These authors explored the prescribing patterns between 1992 and I995 and the influence of the Joint National Committee. All of the prescriptions dispensed by 35,000 retail pharmacies were reviewed from 1992 to 1995. The use of calcium channel blockers and angiotensinconverting enzyme inhibitors increased, whereas the use of diuretics and p-blockers decreased. The authors concluded that the Joint National Committee had little effect on treatment. . . . Commentaryz The impact of a national recommendation is often a subject for debate. First and foremost is 1998
l
ACOG
CLINICAL
REVIEW
l
11