Contraceptive efficacy and safety of DMPA-SC.

DMPA-SC 104 mg/0.65 mL is a new, low-dose subcutaneous (SC) formulation of Depo-Provera contraceptive injection (150 mg/mL medroxyprogesterone acetate injectable suspension) that provides efficacy, safety and immediacy of onset equivalent to Depo-Provera intramuscular (IM) injection. Two large, open-label, Phase 3 studies assessed the 1-year contraceptive efficacy, safety and patient satisfaction with DMPA-SC administered every 3 months (12-13 weeks). Zero pregnancies were reported in both studies, which included a total of 16,023 woman-cycles of exposure to DMPA-SC and substantial numbers of overweight or obese women. DMPA-SC was well-tolerated and adverse events were similar to those reported previously with Depo-Provera IM. Thus, DMPA-SC offers women a new, highly effective and convenient long-acting contraceptive option.

Challenging questions in treating bronchitis.

Whatever facts we gather and no matter how many we have, you and I must eventually put the journal down and pick up our stethoscope, pen, and prescription pad and go to work. Hopefully we can do better than, "Therapy is not uniform and specific antibiotic regimens are usually selected based on local tribal custom." We can discard an old paradigm, "The absence of data bears no relation to the strength of opinion." Personally, I have used these new scientific data before I reached my conclusion. I have developed 10 points to structure my new approach. I invite you to compare my conclusions to yours. 1. In acute bronchitis, in otherwise healthy adults, my preference is to not prescribe an antibiotic. If I do, it is not over the phone. You should want to see and examine the patient. If there are no helpful hints to etiology, I choose a newer macrolide for those under age 50 and use a short course, five-seven days. For patients over age 50, especially if they are "healthy smokers," consider a short course of cefuroxime. (You can see, even in these acute bronchitis patients, you want an antibiotic effective against today's pathogens.) 2. In all chronic bronchitis patients, prevention of further damage to the airways should be attempted by instituting a program of smoking cessation and appropriate immunizations against influenza and pneumococcus. 3. Treatment outcomes will also improve if we recognize that in some patients the progressing SOB, cough, and increasing sputum production are due to congestive heart failure and not due to infection. I try to think about congestive heart failure in all of my patients, but especially in those with known heart disease and cardiomegaly on their chest x-ray. 4. Routine pulmonary function testing is important in smoking patients. Physicians underestimate the degree of obstruction present when they rely on physical exam alone. Hopefully long before the patient's acute illness you have established whether or not obstruction is present. This information helps identify the high risk patient for not only recurrent bouts of infection but also those at increased risk for lung cancer. 5. We will have more success in treating AECB when we elect to use an antibiotic only for patients with at least two of the following three cardinal symptoms: increased dyspnea, increased sputum production, and increased purulent sputum. COPD patients have many days when they feel more SOB. To use this or any one sign as the sole indication for starting an antibiotic has been proven not to make a statistically significant difference in outcome in most patients. Also, the value of prophylactic antibiotic therapy has not been established. 6. When airflow obstruction is moderately severe or more pronounced, AECB should usually be treated with oral steroids. Other measures such as chronic bronchodilator therapy, supplemental and home oxygen use, and pulmonary rehabilitation have been extensively reviewed elsewhere.

Are you "missing the boat" in modern asthma therapy?

I hope this brief update helps you feel more confident that you are current in your asthma management practices. I feel that you definitely will be if you follow the Pocket Guide for Asthma Management, if you are using inhaled steroids in the majority of your patients, and if you are considering the use of long-lasting B2-agonists and more potent inhaled steroids in at least some of your asthma patients who reach steps three and four of therapy. Continue to be vigilant for further progress in asthma management. Best wishes for 1997 in your professional lives and specifically in managing your asthma patients.

Angiosarcoma of the heart: review of the literature and report of two cases that illustrate the broad spectrum of the disease.

Two patients with primary angiosarcoma of the heart were treated. The first patient presented with spinal cord compression syndrome secondary to metastatic angiosarcoma of the lumbar spine. The primary tumour was found to be a right atrial mass. In contrast, the second patient presented with repeated episodes of pleural and pericardial hemorrhage resulting in effusive constrictive pericardial physiology. Repeated diagnostic attempts failed, and an open thoracotomy found an infiltrative type of pericardial angiosarcoma involving the right atrial wall. For both patients, the angiosarcoma proved to be rapidly fatal. The clinical spectrum of these two cases and a review of the literature suggest two major clinicopathological forms most commonly arising from the right atrium: a large obstructing mass and a less common, less symptomatic, locally infiltrative tumour, offering a greater diagnostic challenge. The prognosis is usually poor. However, a more aggressive diagnostic approach -- especially in the locally infiltrative tumours -- may offer hope for improving survival.

Radiocontrast-induced nephropathy. Prevention is better than cure.

The principal predisposing factor in radiocontrast-induced nephropathy appears to be underlying renal insufficiency. Identifying patients at risk is of paramount importance when a diagnostic study is being chosen. Contrast-reliant studies should be avoided, if possible, in high-risk patients. If challenge with a contrast medium is essential, appropriate risk stratification and adequate patient preparation should be done beforehand. Ultimately, prevention is a better approach than cure.

Hemoptysis: a manifestation of pulmonary disease confidently managed by military physicians.

Military physicians can confidently manage hemoptysis with a systematic approach and optimal timing of consultation. Begin with a thorough history, physical examination, and chest x-ray. In our series of 177 cases, a cause for hemoptysis was found in 78% of those with abnormal chest x-rays but in only 21% of those with normal chest x-rays. All 36 cases of bronchogenic carcinoma were associated with an abnormal chest x-ray. A normal chest x-ray was associated with no cause found for the hemoptysis (44 cases) or bronchitis (25 cases), with no carcinomas developing upon a 2-year follow-up. Hospitalization is indicated with excessive bleeding or to allay patient or physician) anxiety. Diagnostic bronchoscopy is usually indicated, especially to localize the bleeding in massive hemoptysis (greater than 600 cc per 24 hours) when surgery may be indicated. Prompt referral should be the rule with bleeding from a mycetoma, diffuse bronchiectasis, or with recurrent significant hemorrhage (greater than 200 cc). In an active-duty population, these instances are fortunately rare, and conservative management and elective referral are the norm.

Clinically stable asthmatics have highly reproducible pulmonary function tests.

The reproducibility of standard function tests was evaluated in a group of ten stable asthmatics over a 10-day period. Relationships between repeated measures of pulmonary functions examined by analysis of variance at the 95% confidence level were comparable to studies in normal subjects. This precision helps validate the recommendations of the Committee on Emphysema for assessment of reversibility in airway obstruction.

Double-blind crossover study of five bronchodilator medications and two delivery methods in stable asthma. Is there a best combination for use in the pulmonary laboratory?

The effects of five bronchodilator drugs and two methods of delivery (nebulizer vs metered-dose inhalers) on pulmonary function were studied in ten subjects with stable asthma. All subjects demonstrated statistically significant improvements (p less than 0.05) in pulmonary function relative to baseline and placebo effects after each medication, regardless of method of delivery; however, there was no statistically significant difference between the changes in pulmonary function caused by medication, method, or medication-method combination (p greater than 0.05). The choice of medication and device for delivery would appear to depend on the budget and time available in the laboratory.