- Email: [email protected]
Treating Sinus Infections
SPOTUGHTON
GENIRAl HEALTH
Hal C. Lawrence, III, MD Guest Editor
From the Mountain Area Health Education Center. Department of Obstetrics and Gynecology. Asheville. NC ->-.
Rape-Related' Pregnancy Holmes MM. Resnick HS. Kilpatrick DG. Best CL. Rape-related pregnancy: Estimates and descriptive characteristics from a national sample of women. Am ] Obstet GynecoI1996;175:320-5.
Synopsis: Within the past year. approximately 700,000 women > 18 years of age have experienced a rape incident. As 60% of all rape cases occur among girls < 18 years of age. the actual incidence would be much higher if adolescents were included. These individuals suffer from both physical and emotional trauma. Nongenital trauma occurs in 25-45% of cases, genital trauma in 20%, sexually transmitted disease in up to 40%, posttraumatic stress disorder in 3550%, and pregnancy in up to 5%. Twelve percent of women in a recent national study indicated they have experienced at least one rape incident in their lifetimes. This study evaluated the medical outcomes and medical treatment received by the rape victims. Only 24% underwent medical examinations, and only 11.7% were examined within 48 hours ofthe rape. Rape-related pregnancy resulted from a single sexual assault in approximately 60% of cases, but 40% of rape-related pregnancies occurred after repetitive assaults, which implies the association of domestic violence. Pregnancy was diagnosed within the first trimester 62% of the time, but 32% of the patients did not discover the pregnancy until the second trimester. As few as 10-20% ofsexual assaults are ever reported to law enforcement authorities.
• • • Commentary: Sexual assault has a major impact on women's health. It
creates a high incidence of trauma, both physically and psychologically. The health care system is often perceived as threatening and is underused by rape victims. As we continue to educate and evaluate patients for domestic violence, the relationship of sexual assault is highly significant. The combination ofpatients' not using the health care system and the lack of prescribed emergency contraception creates one more obstacle in the prevention of unintended pregnancy. The availability and safety of emergency contraception-50 p.,g oral contraceptives, given rwo tablets, 12 hours apart-within the first 72 hours after assault is highly effectivein preventing pregnancy.
• • • Commentary: This study demonstrated that although the age of women at first acute myocardial infarction generally is higher than men's, their gender-adjusted survival rates are the same. The age delay correlates with current thought regarding the protective nature of estrogen and strengthens the recommendation for hormone replacement therapy. This study was undertaken on a homogenous population, as non-Danish citizens were excluded. Ethnic variations may affect other coronary risk factors.
Treating Sinus Infections Sex Differences & Myocardial Infarction Galatius-jensen S. Launbjerg J. Mortensen LS. Hansen JF. Sex related differences in short and long term prognosis after acute myocardial infarction: 10 year follow up of 3073 patients in database of first Danish verapamil infarction trial. BM] 1996;313: 137-40.
Synopsis: The study is a review of 3073 patients admitted with their first acute myocardial infarction between June 1, 1979, and August 15, 1981. Patients were < 76 years of age, 738 (24%) were women, and 2335 (76%) were men. The authors were addressing presumed difference in mortality based on gender. However, their data indicate an early mortality before day 15 for 16% of men and 17% of women. Women were found to be older by an average of 4 years at the time of initial myocardial infarction. Early mortality was found to increase significantly with age but not with gender. The authors clarify that this study evaluated patients in the early '80s when treatment for acute myocardial infarction in Denmark was conservative compared with present methods. The worse prognosis found for women in later studies, they theorized, may reflect a lessvigorous treatment.
1() • ACOC CUl"lCAL REVIEW. [anu.irv/Fcbruarv I ')'J7
Lindhzk M. Hjortdahl P, Johnsen UL-H. Randomised, double blind, placebo controlled trial of penicillin V and amoxycillin in treatment of acute sinus infections in adults. BM] 1996;313:325-9.
Synopsis: For this study, the authors evaluated 130 patients with sinusitis confirmed by computed tomography and randomly assigned them to treatment groups; penicillin V, amoxycillin, and placebo. Treatment regimens were penicillin V, 1320 mg, three times a day for 10 days, amoxycillin, 500 mg three times a day for 10 days, or placebo, three times a day for 10 days. In addition, all patients received nasal decongestants and mild analgesics. The authors found that 42% of patients had normal flora on their bacteriologic cultures, 25% had Streptococcus pneumoniae, 13% had Haemophilus influenzae, 11% had Staphylococcus aureus, 4% had hemolytic streptococci group A, 4% had Moraxella catarrhalis, and 1% had Escherichia coli. Subsequent patient follow-up and symptomatic survey revealed that by day 10, 86% of patients receiving antibiotic therapy considered themselves to have recovered or be much improved, whereas only 25 (57%) of the placebo thought so. The amoxycillin group had a mean duration of sinusitisof 9 days,whereasthe peni;:)1997by the Amencan Published nv
of Obstetnc.ans ana Gynecologists
SCience Irc. 1085-6862/97·$4 50
cillin V group's mean duration was 11 days, and the placebo group's was 17 days.
• • • Commentary: This report reviewed the potential benefit of antibiotic therapy in early acute sinus infections. The fact that only 58% were positive for infecting organisms supports the confusion in this arena. However, patient symptomatology was markedly improved in the antibiotic-treated group. Newer but more expensive antimicrobial therapy was not a part of this study.
Conservation Therapy for Breast Cancer Forrest AP, Stewart HJ, Everington D, Prescott RJ, McArdle CS, Harnett AN, et al. Randomised controlled trial of conservation therapy for breast cancer: 6-year analysis of the Scottish trial. Lancet 1996;
348:708-13.
Synopsis: Results of a randomized controlled trial of 585 patients <70 years old with primary breast cancer of <4 ern in size were reported from four specialists' units and seven other hospitals in Scotland. After rhe tumors were excised wirh 1-cm negative margins and an axillary node dissection, all patients received systemic therapy with either oral tamoxifen, 20 mg daily, or six 3-weekly intravenous bolus injections of cyclophosphamide, 600 mg, methotrexate, 50 mg, and fluorouracil, 600 mg per m-, depending on the estrogen receptor concentration in the primary rumor. These patients were then randomly allocated to postoperative radical radiotherapy, 5000 Gy to the breast with boost to the tumor bed, or to no further local treatment. Systemic chemotherapy was found to have been inappropriately assigned by estrogen receptor status in 121 patients, leaving a subsidiary analysis of 464 patients. When the estrogen receptor concentration was 220 fmol/mg protein, tamoxifen, 20 mg daily, was of ObsIRtclC18"S 3Cn G'!",,,oIOCls;s 1085-G8tJ2;g7i'S~
administered for at least 5 years; when it was <20 fmol/mg protein, the six 3-weekly intravenous bolus cyclophosphamide! methotrexate! fluorouracil chemotherapy was used. When the estrogen receptor status was unknown, patients received tamoxifen. The authors documented statistically significant improvement in event-free survival in the irradiated patients largely due to fewer locoregional relapses. The study concluded that radiotherapy to the residual breast tissue is advisable even when selective adjuvant systemic therapy is given.
• • • Commentary: This review did suffer from a break in protocol with the initial study. However, the authors corrected for this in their subsequent analysis, and the data were equally significant with the residual 464 patients. A dramatic decrease in ipsilateral breast recurrence with 14 (5%) in the irradiated group versus 51 (17%) in the nonirradiated group is significant. The applicability of these results is compromised by the authors inclusion of breast tumors up to 4 ern in size. However, when looking at those tumors of ::::2 em, there is still a dramatic difference of 4% in the irradiated group versus 26% in the nonirradiated group with local or regional recurrence. Because ofthe this, the authors did not think that the local regional relapse rate was related to size or to the menstrual status of the patient at the time of surgery. Even with node-negative patients, there was a difference of 4% in the radiation therapy group versus 21.2% in the nonirradiated group of local or regional relapse. This study offers strong evidence in support of the use of adjuvant radiation therapy in addition to chemotherapy in patients treated with conservative breast surgery.
Risks for Urinary Tract Infections Hooton TM, Scholes D, Hughes JP, Winter C, Roberts PL, Stapleton AE, et al. A pro-
spective study of risk factors for symptomatic urinary tract infection in young women.
N EnglJMed 1996;335:468-74.
Synopsis: For this study, 796 women maintained daily diaries for a 6-month period to evaluate risk factors of urinary tract infections: 348 with a mean age of 23 from a university cohort and 448 with a mean age of 29 from a health maintenance organization cohort. Women in the university cohort had a risk of 0.7 urinary tract infections per person year, and women in the health maintenance organization had a risk of0.5 per person year. Identified risk factors for urinary tract infection were use of a diaphragm with spermicide (relative risk [RR] for 1, 3, and 5 days of use in the past week was 1.42, 2.83, and 5.68, respectively, in the university cohort [P<.OOOl] and 1.29,2.14, and 3.54, respectively, in the health maintenance organization cohort [P = .04]), recent sexual intercourse (RR for 1, 3, and 5 days with intercourse in the past week was 1.37, 2.56, and 4.81, respectively, in the university cohort [P< .001] and 1.24,1.91, and 2.96, respectively, in the health maintenance organization cohort [P = .002]). A history of recurring infection provided a relative risk of 5.58 in the university cohort and 2.10 in the health maintenance cohort. The authors concluded that recent sexual intercourse and recent use of diaphragm with spermicide, along with a history of recurrent urinary tract infections, provide an increased risk in this patient population.
• • • Commentary: Sexual activity has long been recognized as a potentiator of urinary tract infection. "Honeymoon cystitis" has long been an acknowledged problem. Other factors thought to be associated include de-
Januarv/Fehruarv 1997 • ACOG CLINICAL REVIEW. 11
GENIRAl HEALTH
Hal C. Lawrence, III, MD Guest Editor
From the Mountain Area Health Education Center. Department of Obstetrics and Gynecology. Asheville. NC ->-.
Rape-Related' Pregnancy Holmes MM. Resnick HS. Kilpatrick DG. Best CL. Rape-related pregnancy: Estimates and descriptive characteristics from a national sample of women. Am ] Obstet GynecoI1996;175:320-5.
Synopsis: Within the past year. approximately 700,000 women > 18 years of age have experienced a rape incident. As 60% of all rape cases occur among girls < 18 years of age. the actual incidence would be much higher if adolescents were included. These individuals suffer from both physical and emotional trauma. Nongenital trauma occurs in 25-45% of cases, genital trauma in 20%, sexually transmitted disease in up to 40%, posttraumatic stress disorder in 3550%, and pregnancy in up to 5%. Twelve percent of women in a recent national study indicated they have experienced at least one rape incident in their lifetimes. This study evaluated the medical outcomes and medical treatment received by the rape victims. Only 24% underwent medical examinations, and only 11.7% were examined within 48 hours ofthe rape. Rape-related pregnancy resulted from a single sexual assault in approximately 60% of cases, but 40% of rape-related pregnancies occurred after repetitive assaults, which implies the association of domestic violence. Pregnancy was diagnosed within the first trimester 62% of the time, but 32% of the patients did not discover the pregnancy until the second trimester. As few as 10-20% ofsexual assaults are ever reported to law enforcement authorities.
• • • Commentary: Sexual assault has a major impact on women's health. It
creates a high incidence of trauma, both physically and psychologically. The health care system is often perceived as threatening and is underused by rape victims. As we continue to educate and evaluate patients for domestic violence, the relationship of sexual assault is highly significant. The combination ofpatients' not using the health care system and the lack of prescribed emergency contraception creates one more obstacle in the prevention of unintended pregnancy. The availability and safety of emergency contraception-50 p.,g oral contraceptives, given rwo tablets, 12 hours apart-within the first 72 hours after assault is highly effectivein preventing pregnancy.
• • • Commentary: This study demonstrated that although the age of women at first acute myocardial infarction generally is higher than men's, their gender-adjusted survival rates are the same. The age delay correlates with current thought regarding the protective nature of estrogen and strengthens the recommendation for hormone replacement therapy. This study was undertaken on a homogenous population, as non-Danish citizens were excluded. Ethnic variations may affect other coronary risk factors.
Treating Sinus Infections Sex Differences & Myocardial Infarction Galatius-jensen S. Launbjerg J. Mortensen LS. Hansen JF. Sex related differences in short and long term prognosis after acute myocardial infarction: 10 year follow up of 3073 patients in database of first Danish verapamil infarction trial. BM] 1996;313: 137-40.
Synopsis: The study is a review of 3073 patients admitted with their first acute myocardial infarction between June 1, 1979, and August 15, 1981. Patients were < 76 years of age, 738 (24%) were women, and 2335 (76%) were men. The authors were addressing presumed difference in mortality based on gender. However, their data indicate an early mortality before day 15 for 16% of men and 17% of women. Women were found to be older by an average of 4 years at the time of initial myocardial infarction. Early mortality was found to increase significantly with age but not with gender. The authors clarify that this study evaluated patients in the early '80s when treatment for acute myocardial infarction in Denmark was conservative compared with present methods. The worse prognosis found for women in later studies, they theorized, may reflect a lessvigorous treatment.
1() • ACOC CUl"lCAL REVIEW. [anu.irv/Fcbruarv I ')'J7
Lindhzk M. Hjortdahl P, Johnsen UL-H. Randomised, double blind, placebo controlled trial of penicillin V and amoxycillin in treatment of acute sinus infections in adults. BM] 1996;313:325-9.
Synopsis: For this study, the authors evaluated 130 patients with sinusitis confirmed by computed tomography and randomly assigned them to treatment groups; penicillin V, amoxycillin, and placebo. Treatment regimens were penicillin V, 1320 mg, three times a day for 10 days, amoxycillin, 500 mg three times a day for 10 days, or placebo, three times a day for 10 days. In addition, all patients received nasal decongestants and mild analgesics. The authors found that 42% of patients had normal flora on their bacteriologic cultures, 25% had Streptococcus pneumoniae, 13% had Haemophilus influenzae, 11% had Staphylococcus aureus, 4% had hemolytic streptococci group A, 4% had Moraxella catarrhalis, and 1% had Escherichia coli. Subsequent patient follow-up and symptomatic survey revealed that by day 10, 86% of patients receiving antibiotic therapy considered themselves to have recovered or be much improved, whereas only 25 (57%) of the placebo thought so. The amoxycillin group had a mean duration of sinusitisof 9 days,whereasthe peni;:)1997by the Amencan Published nv
of Obstetnc.ans ana Gynecologists
SCience Irc. 1085-6862/97·$4 50
cillin V group's mean duration was 11 days, and the placebo group's was 17 days.
• • • Commentary: This report reviewed the potential benefit of antibiotic therapy in early acute sinus infections. The fact that only 58% were positive for infecting organisms supports the confusion in this arena. However, patient symptomatology was markedly improved in the antibiotic-treated group. Newer but more expensive antimicrobial therapy was not a part of this study.
Conservation Therapy for Breast Cancer Forrest AP, Stewart HJ, Everington D, Prescott RJ, McArdle CS, Harnett AN, et al. Randomised controlled trial of conservation therapy for breast cancer: 6-year analysis of the Scottish trial. Lancet 1996;
348:708-13.
Synopsis: Results of a randomized controlled trial of 585 patients <70 years old with primary breast cancer of <4 ern in size were reported from four specialists' units and seven other hospitals in Scotland. After rhe tumors were excised wirh 1-cm negative margins and an axillary node dissection, all patients received systemic therapy with either oral tamoxifen, 20 mg daily, or six 3-weekly intravenous bolus injections of cyclophosphamide, 600 mg, methotrexate, 50 mg, and fluorouracil, 600 mg per m-, depending on the estrogen receptor concentration in the primary rumor. These patients were then randomly allocated to postoperative radical radiotherapy, 5000 Gy to the breast with boost to the tumor bed, or to no further local treatment. Systemic chemotherapy was found to have been inappropriately assigned by estrogen receptor status in 121 patients, leaving a subsidiary analysis of 464 patients. When the estrogen receptor concentration was 220 fmol/mg protein, tamoxifen, 20 mg daily, was of ObsIRtclC18"S 3Cn G'!",,,oIOCls;s 1085-G8tJ2;g7i'S~
administered for at least 5 years; when it was <20 fmol/mg protein, the six 3-weekly intravenous bolus cyclophosphamide! methotrexate! fluorouracil chemotherapy was used. When the estrogen receptor status was unknown, patients received tamoxifen. The authors documented statistically significant improvement in event-free survival in the irradiated patients largely due to fewer locoregional relapses. The study concluded that radiotherapy to the residual breast tissue is advisable even when selective adjuvant systemic therapy is given.
• • • Commentary: This review did suffer from a break in protocol with the initial study. However, the authors corrected for this in their subsequent analysis, and the data were equally significant with the residual 464 patients. A dramatic decrease in ipsilateral breast recurrence with 14 (5%) in the irradiated group versus 51 (17%) in the nonirradiated group is significant. The applicability of these results is compromised by the authors inclusion of breast tumors up to 4 ern in size. However, when looking at those tumors of ::::2 em, there is still a dramatic difference of 4% in the irradiated group versus 26% in the nonirradiated group with local or regional recurrence. Because ofthe this, the authors did not think that the local regional relapse rate was related to size or to the menstrual status of the patient at the time of surgery. Even with node-negative patients, there was a difference of 4% in the radiation therapy group versus 21.2% in the nonirradiated group of local or regional relapse. This study offers strong evidence in support of the use of adjuvant radiation therapy in addition to chemotherapy in patients treated with conservative breast surgery.
Risks for Urinary Tract Infections Hooton TM, Scholes D, Hughes JP, Winter C, Roberts PL, Stapleton AE, et al. A pro-
spective study of risk factors for symptomatic urinary tract infection in young women.
N EnglJMed 1996;335:468-74.
Synopsis: For this study, 796 women maintained daily diaries for a 6-month period to evaluate risk factors of urinary tract infections: 348 with a mean age of 23 from a university cohort and 448 with a mean age of 29 from a health maintenance organization cohort. Women in the university cohort had a risk of 0.7 urinary tract infections per person year, and women in the health maintenance organization had a risk of0.5 per person year. Identified risk factors for urinary tract infection were use of a diaphragm with spermicide (relative risk [RR] for 1, 3, and 5 days of use in the past week was 1.42, 2.83, and 5.68, respectively, in the university cohort [P<.OOOl] and 1.29,2.14, and 3.54, respectively, in the health maintenance organization cohort [P = .04]), recent sexual intercourse (RR for 1, 3, and 5 days with intercourse in the past week was 1.37, 2.56, and 4.81, respectively, in the university cohort [P< .001] and 1.24,1.91, and 2.96, respectively, in the health maintenance organization cohort [P = .002]). A history of recurring infection provided a relative risk of 5.58 in the university cohort and 2.10 in the health maintenance cohort. The authors concluded that recent sexual intercourse and recent use of diaphragm with spermicide, along with a history of recurrent urinary tract infections, provide an increased risk in this patient population.
• • • Commentary: Sexual activity has long been recognized as a potentiator of urinary tract infection. "Honeymoon cystitis" has long been an acknowledged problem. Other factors thought to be associated include de-
Januarv/Fehruarv 1997 • ACOG CLINICAL REVIEW. 11