Letters to the Editor - January 15, 2001 - American Family Physician

Letters to the Editor

Behavioral Medicine in Patients with MVP

TO THE EDITOR: In the article on mitral valve prolapse (MVP),¹ I thought it was great that the authors mentioned the significance of the "subclinical" disorder of "mitral valve prolapse syndrome," in which 2 percent of the population with MVP are symptomatic during a given year. They stated that "reassurance is the major task of management because most patients with MVP are asymptomatic and not at high risk." I believe it is critical, however, that patients who are symptomatic also receive the same reassurance, because the symptoms--especially the chest pain and tachycardia--often feel life-threatening to the patient.

Furthermore, I believe the authors too easily brushed off the association of MVP with panic disorder as being a chance occurrence. Many times, a person's panic disorder is started by MVP symptoms that seem to hit "out of the blue," resulting in a whole series of unfortunate associations that begin a vicious circle of panic and anxiety attacks, ultimately leading to frequent emergency department visits. Treating the anxiety and panic that is often associated with MVP is critical.

In addition, a subpopulation of the 2 percent of symptomatic patients with MVP develop some level of depression (which was at one time called a "neurotic depression"). This may, in part, be precipitated by the patient's long-standing symptoms. These patients are often concerned that they are dying or that something is seriously wrong. These patients go from doctor to doctor and are not diagnosed or treated properly. Both of these subpopulations of the 2 percent of the symptomatic patients respond well to the proper care and concern from their family physician and a couple of visits with a behavioral medicine subspecialist or health psychologist. Often, they require beta-blocker or psychotropic therapy for a short time while they make the necessary lifestyle changes mentioned in the article. I hope that future authors are encouraged by the editors to not miss the relevant aspects of behavioral medicine.

JOSEPH H. MCCOY, PH.D
Family Health Center of Mission
1920 E. Griffin Parkway
Mission, TX 78572

REFERENCES

Bouknight DP, O'Rourke RA. Current management of mitral valve prolapse. Am Fam Physician 2000; 61:3343-50,53-4.

EDITOR'S NOTE: This letter was sent to the authors of "Current Management of Mitral Valve Prolapse," who declined to reply.

A Plan for Patients Who Wish to Quit Smoking

TO THE EDITOR: In my practice, I have found that patients who quit "cold turkey" do the best.

If patients said, "I want to quit smoking," they were successful.

If patients said, "I think I want to quit smoking," they invariably failed. My answer to them was, "You will never quit. You have not made up your mind to do so. When you have made up your mind to decide to quit, you then can, and will."

I provide them with a goal, several goals in fact, called "The Webster Plan":

When you get up in the morning take two one-dollar bills. Light a match. Decide whether you want to burn up those bills now or later: $2 per day = $750 per year. Do you want a raise? You must put that money in the bank--$14 per week--and never spend it because it will be your retirement fund. If the money gains 6 percent annual interest, you will have saved $9,890 in 10 years!

One morning take your pack of cigarettes, remove one and put it aside for tomorrow. Tomorrow, take your pack of cigarettes and remove two. Each day remove one more cigarette from the pack. At the end of three weeks you will no longer be smoking cigarettes.

Take an empty pack of cigarettes and place it in the place you usually kept it before. When you unconsciously reach for a cigarette and find the pack to be empty, say to yourself, "That's right! I am not smoking now." Now, go about your business.

Part of the urge to smoke is partly associated with the need to put something in your mouth. Take one swallow of water to satisfy that urge. The stomach is part of that urge, and the fact you put something in it works.

Avoid groups that are smoking until you are satisfied you have really quit.

Notice that your senses of taste and smell have returned, and your hands do not stink of tobacco.

ROBERT M. WEBSTER, M.D.
18 Hummingbird Lane 20826
Jasper, GA 30143

Diagnostic Curettage in the Evaluation of Ectopic Pregnancy

TO THE EDITOR: Central to the diagnostic algorithm for ectopic pregnancy provided in the article by Dr. Tenore¹ is the concept of the discriminatory zone, which the author accurately defines, asserting that viable intrauterine pregnancy is excluded as a possibility in the presence of nondiagnostic findings on a transvaginal ultrasound (TVS) when the beta-subunit of human chorionic gonadotropin (b-hCG) level is higher than 1,500 mIU per mL. Diagnostic curettage is presented as a method used to further differentiate diagnostic possibilities in the face of indeterminate sonographic results.

I agree that suspicion for ectopic pregnancy is increased when an empty uterus is seen on TVS and the b-hCG level is greater than 1,500 to 2,000 mIU per mL. However, the literature demonstrates that viable intrauterine pregnancy is not excluded in such circumstances. Consequently, a "diagnostic curettage" performed with this indication may actually be an unintended, induced abortion.

Bateman and colleagues² reported two such exceptions in a study population of approximately 74 women eventually diagnosed with viable intrauterine pregnancy. One woman with uterine cavity distortion from myomas had negative findings on TVS and a b-hCG level of 3,774 mIU per mL. Subsequently, a gestational sac was seen when the b-hCG level was at 5,660 mIU per mL. Another woman with twins showed no sac on TVS when the b-hCG level was 3,504 mIU per mL and demonstrated two sacs at 11,800 mIU per mL.

Ankum and colleagues³ reported two exceptions to this discriminatory zone assumption in a study population of approximately 200 women with various outcomes of pregnancy--73 were eventually found to have viable intrauterine pregnancy. Both of these were noted to have thickened endometrium with suspicious adnexal findings on TVS. No gestational sac was seen. Serum b-hCG levels were 2,090 mIU per mL and 3,900 mIU per mL at the time of TVS. Curettage was not part of their diagnostic algorithm, and viable intrauterine pregnancy was diagnosed four to five days later. What would have been the result had "diagnostic curettage" been accomplished? These are given as examples and do not represent the total number of diagnostic failures reported in the literature.

Another oversight of Dr. Tenore's article is any discussion of the difference in standard preparations according to which hCG activity is compared and the significant variability of results when accomplished by different techniques even when compared with the same standard.^4,5

The last problem with the author's discussion is the recognition that the discriminatory zone she cites was established in research centers with sonographers likely to have substantial exposure to often unclear first-trimester TVS findings. Are these same results obtained in small community hospital radiology suites so that we can approach our patients confidently with this algorithm in hand?⁶

Ectopic pregnancy can be a disaster, and there is a need for methods to diagnose this problem as early as possible to prevent serious sequelae of infertility or worse, maternal mortality. We must not, in our zeal to save some lives, risk others. The diagnostic algorithm presented is in the main helpful; however, I dispute the role of "diagnostic curettage" and the assumptions on which it is based.

JEFFREY S. MCCOLLUM, M.D.
Truman Medical Center East
7900 Lee's Summit Rd.
Kansas City, MO 64139

REFERENCES

Tenore JL. Ectopic pregnancy. Am Fam Physician 2000;61:1080-8.

Bateman BG, Nunley WC Jr, Kolp LA, Kitchin JD 3d, Felder R. Vaginal sonography findings and hCG dynamics of early intrauterine and tubal pregnancies. Obstet Gynecol 1990;75(3 pt 1):421-7.

Ankum WM, Van der Veen F, Hamerlynck JV, Lammes FB. Laparoscopy: a dispensable tool in the diagnosis of ectopic pregnancy? Hum Reprod 1993;8:1301-6.

Smikle CB, Sorem KA, Wians FH Jr, Hankins GD. Measuring quantitative serum human chorionic gonadotropin. Variations in levels between kits.
J Reprod Med 1995;40:439-42.

ACOG Practice Bulletin. Medical management of tubal pregnancy. ACOG Practice Bulletin no. 3. 1998. Clinical management guidelines for obstetrician-gynecologists. American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet 1999;65:97-103.

Emerson DS, McCord ML. Clinician's approach to ectopic pregnancy. Clin Obstet Gynecol 1996;39: 199-222.

IN REPLY: I appreciate Dr. McCollum's insightful comments in his letter. I have taken the liberty of extracting the essence of his comments and responded accordingly.

Dr. McCollum's first comment can be summarized by his sentence: "Consequently, a 'diagnostic curettage' performed with this indication may actually be an unintended, induced abortion."

I agree completely with Dr. McCollum's comment. As with any diagnostic procedure or test, there are inherent risks and benefits. It behooves any physician to counsel each patient about these risks and act appropriately to each circumstance.

His second comment can be summarized by: "The last problem with the author's discussion is the recognition that the discriminatory zone she cites was established in research centers with sonographers likely to have substantial exposure to often unclear first-trimester TVS findings. Are these same results obtained in small community hospital radiology suites so that we can approach our patients confidently with this algorithm in hand?" Unfortunately, this is a common problem in research. Findings are not necessarily generalizable--no studies in the literature compare the findings obtained in large research centers with those of smaller community radiology suites. In addition, the diagnosis from ultrasonographic findings is dependent on the quality of the equipment and the technical and interpretive expertise of the sonographer. Thus, at this time, we cannot say for certain whether the findings discussed in the article are applicable in smaller communities.

JOSIE L. TENORE, M.D., S.M.
Glenbrook Family Care Center
2050 Pfingsten Road, Ste. 200
Glenview, IL 60025

Smoking and Age-Related Macular Degeneration

TO THE EDITOR: The recent article entitled "Age-related Macular Degeneration: Update for Primary Care"¹ is a good overview of the subject, but it underemphasizes the role that smoking plays as a risk factor for age-related macular degeneration (AMD). Of the potential risk factors for AMD, only smoking has been demonstrated to be associated with the disease consistently across studies of different design and within different populations.² Another recent study³ on cardiovascular risk factors and AMD reported that the only factors significantly associated with age-related maculopathy included smoking (odds ratio: 4.1) and family history (odds ratio: 4.2). Many other studies confirm the strong association between smoking and AMD.

Smoking cessation is, therefore, potentially of great benefit in preventing AMD. Because the risk of AMD conferred by smoking remains strong even up to 20 years after smoking cessation,⁴ physicians should discuss the potential for smoking-related AMD as a risk factor early on in our attempts to help patients stop smoking.

TOM HOUSTON, M.D.
Director, Science and Public Health Advocacy Programs
American Medical Association
515 North State St.
Chicago, IL 60610

REFERENCES

Fong DS. Age-related macular degeneration: update for primary care. Am Fam Physician 2000; 61:3035-42.

Hawkins BS, Bird A, Klein R, West SK. Epidemiology of age-related macular degeneration. Mol Vis 1999;5:26.

Smith W, Mitchell P, Leeder SR, Wang JJ. Plasma fibrinogen levels, other cardiovascular risk factors, and age-related maculopathy: the Blue Mountains Eye Study. Arch Ophthalmol 1998;116:583-7.

Delcourt C, Diaz JL, Ponton-Sanchez A, Papoz L. Smoking and age-related macular degeneration. The POLA Study. Pathologies Oculaires Liees a l'Age. Arch Ophthalmol 1998;116:1031-5.

IN REPLY: I agree with Dr. Houston that smokers should be counseled about the dangers of smoking. As discussed in Table 1 of my article,¹ smoking is an established risk factor for age-related macular degeneration (AMD). Prevention of AMD is one additional reason why patients who smoke should stop.

DONALD S. FONG, M.D., M.P.H.
Southern California Permanente Medical Group
Baldwin Park, CA 91706

REFERENCE

Fong DS. Age-related macular degeneration: update for primary care. Am Fam Physician 2000; 61:3035-42.

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672; fax:913-906-6080; e-mail: afplet@aafp.org. Please include your complete address, telephone number and fax number. Letters should be double-spaced, fewer than 500 words and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter constitutes transfer of copyright to the American Academy of Family Physicians. The editors may edit letters to meet style and space requirements.

Copyright © 2001 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

January 15, 2001 Contents | AFP Home Page | AAFP Home | Search