Am Fam Physician. 1998;57(7):1688-1692
ACOG Report on External Cephalic Version
The overall rate of cesarean delivery is generally thought to be too high. Because breech presentations are associated with cesarean delivery, the American College of Obstetricians and Gynecologists (ACOG) has evaluated results of studies on external cephalic version and made recommendations on its use in obstetric practice (ACOG Practice Pattern No. 4, 1997). The report discusses which patients are candidates for external cephalic version, risks and benefits of the procedure, predictive factors of its success or failure, use of tocolysis, and cost implications of the procedure.
External cephalic version involves applying pressure to the mother's abdomen to turn the fetus in either a forward or backward somersault to achieve a vertex presentation. According to ACOG, external cephalic version can be performed with minimal risk to the mother and fetus but should only be attempted in settings in which cesarean delivery services are readily available. ACOG recommends assessment of the fetus before and after the procedure is performed.
Other summary points in the ACOG report include the following:
Patients should have completed 36 weeks of gestation before external cephalic version is attempted.
Insufficient evidence is available at this time to recommend attempted external cephalic version during early labor.
Cost-effectiveness depends on use of vaginal breech deliveries and costs of the version protocol at a particular institution.
All women near term with breech presentations should be offered a version. This recommendation is based on the evidence that the risk of adverse events is small and successful version lowers the rate of cesarean sections in these women.
For more information on ACOG Practice Patterns, ACOG Committee Opinions and ACOG Technical Bulletins, contact ACOG, 409 12th St., S.W., Washington, D.C. 20090-6920; telephone: 800-762-2264.
Pocket Version of ACC/AHA Noncardiac Surgery Guidelines
A new reference guide to help assess when a heart patient needs coronary evaluation and/or treatment before undergoing noncardiac surgery has been released by the American College of Cardiology (ACC) and the American Heart Association (AHA). The pocket-size guide is an abridged version of the ACC/AHA “Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery” that was published by the ACC and AHA in March 1996.
Specifically, the guidelines are meant to help the physician decide when advanced preoperative noninvasive or invasive evaluation is helpful in an individual patient. An algorithm in the guide is designed to recommend the use of high-cost tests and treatments only when solid, scientific evidence supports such use.
Copies of the pocket guidelines can be obtained from ACC Educational Services at 800-253-4636 in the United States or 301-697-5400 outside the United States, ext. 694.
Inhaled Antibiotic for Cystic Fibrosis
The first inhaled antibiotic for the treatment of patients with cystic fibrosis has been approved by the U.S. Food and Drug Administration. Tobramycin solution for inhalation (Tobi) is used to suppress Pseudomonas aeruginosa in the airways of patients with cystic fibrosis.
In two double-blind, placebo-controlled clinical trials conducted for 24 weeks, 520 patients ages six to 63 years with cystic fibrosis and P. aeruginosa lung infections were divided into two groups—those receiving placebo plus standard cystic fibrosis therapy and those receiving tobramycin plus standard therapy. The drug was administered in a regimen of 28 days on drug therapy and 28 days without drug therapy to reduce the potential for drug resistance. Compared with the patients receiving placebo plus standard therapy, the patients receiving tobramycin had improved lung function, fewer days in the hospital and fewer days requiring antipseudomonal antibiotics.
The inhaled tobramycin was well tolerated. Adverse events included voice alteration (13 percent) and ringing in the ears (3 percent). Caution should be used in patients receiving tobramycin inhalation therapy who are known or suspected to have kidney, hearing or neuromuscular problems, are pregnant or may become pregnant, or are receiving intravenous aminoglycoside treatment.
AIDS in Persons 50 Years of Age and Older
Even though the incidence of acquired immunodeficiency syndrome (AIDS) during 1996 was higher for persons aged 13 to 49 years (89 percent) than for older persons, the proportion accounted for by persons aged 50 years or older (11 percent) was substantial, according to a report in the January 23, 1998, issue of Morbidity and Mortality Weekly Report. The report describes the characteristics of persons aged 50 years and older with AIDS reported in 1996 and presents trends in the incidence of AIDS-related opportunistic illness diagnosed during 1991-1996 in persons aged 50 years and older.
In 1996, of 68,473 persons aged 13 years and older reported with AIDS, 7,459 (11 percent) were 50 years of age and older. Of these persons, 48 percent were aged 50 to 54 years, 26 percent were aged 55 to 59 years, 14 percent were aged 60 to 64 years and 12 percent were over 65 years. Men accounted for 84 percent of cases, and blacks accounted for the highest proportion by race/ethnicity (43 percent). In 1996, persons 50 years of age and older were more likely than those aged 13 to 49 years to be reported as having an AIDS-related opportunistic infection than to be reported with severe immunosuppression and without an AIDS-related opportunistic infection.
The proportionate increase in incident cases of AIDS-related opportunistic infections was higher in persons aged 50 years and older than in persons aged 13 to 49 years. From 1991 to 1996, the number of incident cases of AIDS-related opportunistic infections among men aged 50 years and older who have sex with men remained stable, while incident cases in men whose risk was heterosexual contact increased 94 percent and incident cases in men reporting injecting drug use increased 53 percent. Among women aged 50 years and older, cases attributed to heterosexual contact and injecting drug use increased 106 percent and 75 percent, respectively.
The findings in this report suggest that persons aged 50 years and older should be promptly tested for human immunodeficiency virus (HIV) infection following the onset of HIV-related illness. According to the report, one reason for later diagnosis among persons aged 50 years and older is that physicians may be less likely to suspect HIV infection in this age group. The report notes that these persons also may not perceive themselves to be at risk for HIV infection. In 1994, the prevalence of reported condom use was lower in sexually active persons aged 50 years and older who engaged in high-risk behaviors, and a higher proportion of these persons had never been tested for HIV, compared with younger persons. The report emphasizes that prevention efforts must be directed at adults who engage in high-risk sexual and drug-use behaviors. Many of the persons who were diagnosed with AIDS when they were over age 50 were probably infected as younger adults.
Publications on Hepatitis for Health Care Professionals
The National Digestive Diseases Information Clearinghouse (NDDIC) has produced two new publications on hepatitis: a one-page reference card concerning vaccination for hepatitis A and B that indicates vaccination schedules and doses for these diseases, and a booklet titled “Chronic Hepatitis C: Current Disease Management” that has the latest information about managing hepatitis C. The booklet has discussions on risk factors and transmission, clinical symptoms and signs, serologic tests, liver biopsy, immunostaining, diagnosis, treatment and the future of hepatitis C research. The publications are indicated for health care professionals.
Health care professionals can order a total of 25 copies of each publication free of charge from the NDDIC, attn: HEP, 2 Information Way, Bethesda, MD 20892-3570; telephone: 301-654-3810; fax: 301-907-8906; e-mail: nddic@info.niddk.nih.gov. The materials are also available on the Internet at http://www.niddk.nih.gov (then click on “Digestive Diseases”).
The NDDIC is an information dissemination service of the National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health.
Screening for Retinopathy in Children with Diabetes
The American Academy of Pediatrics (AAP) has published a policy statement establishing an evaluation schedule for retinopathy screening that provides optimal preventive care and management in pediatric patients with type 1 (insulin-dependent) diabetes. The statement was published in the February 1998 issue of Pediatrics.
The AAP recommends referral to an ophthalmologist for retinopathy screening three to five years after diagnosis of type 1 diabetes if the patient is nine years of age and older. The AAP believes that an ophthalmologist is more likely than a non-ophthalmologist to detect changes of diabetic retinopathy and that the ophthalmologist can play an important role in preventive care by counseling the patient and family on the importance of good control and early intervention.
The table shows the recommended examination schedule for the pediatric patient (up to 20 years of age) with type 1 diabetes who is asymptomatic (without known ophthalmologic disease).
Becaplermin for Diabetic Foot Ulcers
The U.S. Food and Drug Administration has approved becaplermin (Regranex Gel), the first biotechnology product indicated for the treatment of lower extremity diabetic neuropathic ulcers that extend into the subcutaneous tissue or beyond and have an adequate blood supply. When used as an adjunct to good ulcer care practices including initial sharp debridement, pressure relief and infection control, the use of becaplermin increases the incidence of complete healing of the ulcers.
The new gel, which contains genetically engineered platelet-derived growth factor, is the first prescription biologic agent that actively stimulates the body to grow new tissue to heal these wounds. This growth factor, normally found in the blood, is produced in a laboratory by inserting a gene into yeast.
Clinical trials have shown that a once-daily topical application of becaplermin in addition to good ulcer care resulted in the healing of more diabetic ulcers after 20 weeks of treatment than did the use of placebo gel plus good ulcer care.
Becaplermin is generally well tolerated. In clinical trials, rash was reported in 2 percent of the patients who used becaplermin.