Letters to the Editor

Hypertension Should Be Confirmed Before Treatment

TO THE EDITOR: I would like to thank Dr. Niedfeldt and American Family Physician for the fine article, "Managing Hypertension in Athletes and Physically Active Patients."¹ However, I would like to add a point to this statement: "If (hypertension) is diagnosed, appropriate treatment should be started to reduce the risk of morbidity and mortality associated with cardiovascular disease."¹ I believe that it is important to be sure that the patient does indeed have hypertension. Some athletes have extra large or extra small upper arms and have been screened with an inappropriately sized cuff when taking their blood pressure.² Other athletes exhibit "white coat" hypertension.³ Therefore, when diagnosing hypertension, physicians should use appropriately sized cuffs for those "extra" sized athletes. I have found that the use of ambulatory pressure monitors has saved many athletes with white coat hypertension from taking unnecessary medication.

JOHN PHILIP SHERROD, M.D.
University of North Carolina at Chapel Hill
Department of Family Medicine
Manning Dr.
Chapel Hill, NC 27514

REFERENCES

1. Niedfeldt MW. Managing hypertension in athletes and physically active patients. Am Fam Physician 2002;66:445-52.
2. Zitelli BJ, Davis HW (eds). Atlas of pediatric physical diagnosis. 3d ed. St. Louis: Mosby-Wolfe, 1997.
3. Noble J, Greene HL. Textbook of primary care medicine. 2d ed. St. Louis: Mosby, 1996.

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Early Diagnosis and Treatment Vital in Cases of Foot Fractures

TO THE EDITOR: I read with great interest the article, "Foot Fractures Frequently Misdiagnosed as Ankle Sprains,"¹ which provided a thorough discussion of the various types of talus fractures and how they can be missed initially on physical examination. This is of particular importance in children, because talus fractures in children are extremely rare^2-4 and may lead to lifelong morbidity unless they are diagnosed and treated appropriately. Furthermore, a large percentage of confirmed talus fractures are read as normal on initial radiographs.^1,3

During a seven-year period, only 15 patients (average age: five years, five months) were identified at our institution who had either a talar head, neck, or body fracture (avulsion fractures and osteochondral fractures were excluded).² The most common mechanism of injury was a motor vehicle crash, and the second most common was a fall from a height. Additionally, in 12 of these patients, the talar fracture occurred in conjunction with other ipsilateral lower extremity fractures. The initial radiographic diagnosis of these fractures was missed in 33 percent of the cases in the emergency department, which is similar to results found by Drs. Judd and Kim in the literature concerning lateral process fractures of the talus in adults.¹

Talus fractures in children often present with concomitant injuries to the lower limb, causing them to be missed on initial examination. Even though they are rare, it is important for the physician to have a high index of suspicion for these injuries and to perform a complete history and physical examination of every child. A clear understanding of the epidemiology of these injuries, as well as appropriate radiologic studies of the foot and ankle, are necessary to help ensure positive clinical outcomes in children and adults.

WILLIAM M. STRUB, M.D.
University of Cincinnati College of Medicine
Department of Radiology
234 Goodman St. ML 0761
Cincinnati, OH 45219

REFERENCES

1. Judd DB, Kim DH. Foot fractures frequently misdiagnosed as ankle sprains. Am Fam Physician 2002; 66:785-94.
2. Strub WM, Mehlman CT, Todd LT Jr. Talus fractures in children. J Am Osteopath Acad Orthop 2000; 37:38-41.
3. Letts RM, Gibeault D. Fractures of the neck of the talus in children. Foot Ankle 1980;1:74-7.
4. Louw JA, Grabe RP. Fracture of the talus in childhood. A case report. S Afr Med J 1985;68:598-9.

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Importance of Colorectal Cancer Screening

TO THE EDITOR: I read with great interest the article "Recent Developments in Colorectal Cancer Screening and Prevention,"¹ in American Family Physician. This article hit home on a personal level since my father died of colorectal cancer in 2001. The article¹ provided an excellent literature update that confirmed that screening for colorectal cancer by fecal occult blood testing (FOBT), flexible sigmoidoscopy, double-contrast barium enema, or colonoscopy is cost-effective when compared with no screening. Screening with colonoscopy alone every 10 years, or with the combination of flexible sigmoidoscopy and FOBT, were the most effective strategies in terms of life-years saved.¹

Further work needs to be done to improve the specificity of FOBT while preserving its sensitivity for detecting curable cancers and smaller polyps. Although the findings of one trial² suggest that FOBT can reduce the incidence of colorectal cancer, FOBT has many limitations, including a low sensitivity for polyps, especially the smaller ones. Many screens are false positive, and the test has a low sensitivity for detecting cancers located in the proximal colon. In addition, the topography of colorectal cancer varies by race, which creates racial differences in the utility of such screening tests as flexible sigmoidoscopy and FOBT.³

Furthermore, patients have preferences for colorectal cancer screening techniques that are modestly sensitive to information about test performance and strongly sensitive to the out-of-pocket cost.⁴

The screening and prevention of colorectal cancer will continue to be an important issue for family physicians. It is vital that training programs for family physicians and students stress the importance of screening for colorectal cancer. Colorectal cancer screening should be offered based on national guidelines and on shared decision-making between the patient and the physician.

JOSEPH S. HURST, M.D.
Columbus Regional Family Practice Residency Program
1900 10th Ave., Suite 100
Columbus, GA 31901

REFERENCES

1. Pignone M, Levin B. Recent developments in colorectal cancer screening and prevention. Am Fam Physician 2002;66:297-302.
2. Mandel JS, Church TR, Bond JH, Ederer F, Geisser MS, Mongin SJ, et al. The effect of fecal occult-blood screening on the incidence of colorectal cancer. N Engl J Med 2000;343:1603-7.
3. Theuer CP, Taylor TH, Brewster WR, Campbell BS, Becerra JC, Anton-Culver H. The topography of colorectal cancer varies by race/ethnicity and affects the utility of flexible sigmoidoscopy. Am Surg 2001;Dec;67:1157-61.
4. Pignone M, Bucholtz D, Harris R. Patient preferences for colon cancer screening. J Gen Intern Med 1999;14:432-7.

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Possible Side Effects Should Be Discussed with Patients

TO THE EDITOR: I enjoyed reading the article, "Managing Hypertension in Athletes and Physically Active Patients,"¹ in American Family Physician. As a primary care physician, I concur with the importance of screening this target group of athletes and other physically active persons for high blood pressure, and the emphasis on lifestyle modifications. The article¹ provided an extensive review of pharmacologic therapy, including various drug side effect profiles. However, in my experience with treating patients, sexual dysfunction is a major side effect of antihypertensive medicine that is especially relevant to athletes and physically active patients and is a significant cause of patient noncompliance with medication regimens.^2,3 Up to 25 percent of cases of sexual dysfunction, especially erectile dysfunction, are related to medication side effect.⁴ High blood pressure medicines are commonly associated with various types of sexual dysfunction.

All patients should be informed of the possible side effect of sexual dysfunction, especially athletes and physically active patients, because this may have a tremendous impact on their lives. Family physicians need to be prepared to discuss this issue with patients to avoid noncompliance.

JOY ADEGBILE, M.D., M.P.H.
Associate Director
Columbus Regional Family Practice Residency Program
1900 10th Ave., Suite 100
Columbus, GA 31901

REFERENCES

1. Niedfeldt MW. Managing hypertension in athletes and physically active patients. Am Fam Physician 2002;66:445-52.
2. Brock GB, Lue TF. Drug-induced male sexual dysfunction. An update. Drug Saf 1993;8:414-26.
3. Finger WW, Lund M, Slagle MA. Medications that may contribute to sexual disorders. A guide to assessment and treatment in family practice. J Fam Pract 1997;44:33-43.
4. NIH Consensus Conference. Impotence. NIH Consensus Development Panel on Impotence. JAMA 1993;270:83-90.

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Update on Prescribing Information for Pantoprazole

TO THE EDITOR: This letter is in response to the article, "Proton Pump Inhibitors: An Update."¹ Pantoprazole (Protonix) was approved by the U.S. Food and Drug Administration (FDA) for the acute treatment of erosive esophagitis in February 2000 and for the maintenance of healing of erosive esophagitis in June 2001.² Additionally, both oral and intravenous formulations received approval by the FDA for the treatment of pathologic hypersecretory conditions.^2,3

The article¹ contained a few inaccuracies in the review of drug interactions for pantoprazole. In the review,¹ pantoprazole was documented to have an unknown effect on clarithromycin (Biaxin) and increase the absorption of digoxin and nifedipine (Procardia). As per the current prescribing information, pantoprazole has no clinically relevant drug interactions with clarithromycin, digoxin, or nifedipine.^2,3 We have provided this information so that your readers have the most accurate information on pantoprazole.

ROBYN G. KARLSTADT, M.D.
Wyeth Pharmaceuticals
555 East Lancaster Ave.
St. Davids, PA 19087

KELLI WALKER, R.PH., M.S.
Wyeth Pharmaceuticals
150 Radnor-Chester Rd.
St. Davids, PA 19087

REFERENCES

1. Vanderhoff BT, Tahboub RM. Proton pump inhibitors: an update. Am Fam Physician 2002;66: 273-80.
2. Protonix delayed-release tablets. Package insert. Wyeth-Ayerst Pharmaceuticals. Philadelphia, Pa.: 2002. Retrieved February 2003, from www.wyeth. com/content/ShowFile.asp?id=135.
3. Protonix IV for injection. Package insert. Wyeth-Ayerst Pharmaceuticals. Philadelphia, Pa.: 2002. Retrieved February 2003, from www.wyeth.com/ content/ShowFile.asp?id=136.

IN REPLY: We appreciate the comments of Dr. Karlstadt and Ms. Walker concerning the drug interactions for pantoprazole (Protonix). In our article,¹ pantoprazole was noted to have an unknown effect on clarithromycin (Biaxin) and to increase the absorption of digoxin and nifedipine (Procardia) based on information in two articles.^2,3 These interactions may not be clinically relevant as is mentioned in the package insert for pantoprazole. Nevertheless, we believed it is prudent to share this information with family physicians who are frequently faced with the daunting task of managing a patient who is receiving a large number of medications, often in clinical situations unlike those typically included in drug trials.

RUNDSARAH M. TAHBOUB, M.D.
BRUCE T. VANDERHOFF, M.D.
4160 Mumford Ct.
Columbus, OH 43220

REFERENCES

1. Vanderhoff BT, Tahboub RM. Proton pump inhibitors: an update. Am Fam Physician 2002;66: 273-80.
2. Welage LS, Berardi RR. Evaluation of omeprazole, lansoprazole, pantoprazole, and rabeprazole in the treatment of acid-related diseases. J Am Pharm Assoc (Wash) 2000;40:52-62.
3. Reilly JP. Safety profile of the proton-pump inhibitors. Am J Health Syst Pharm 1999;56(23 Suppl 4):S11-7.

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Identifying and Diagnosing the Adult Neck Mass

to the editor: I read with pleasure the article, "The Adult Neck Mass,"¹ in American Family Physician. I would like to add a few facts that family physicians might find useful.

In patients with thyroglossal cysts, a physical examination usually reveals a midline mass at or below the hyoid bone that moves with protrusion of the tongue and swallowing. As many as 62 percent of these ducts contain ectopic thyroid tissue.² Other neck swellings moving with protrusion of the tongue include subhyoid bursitis and a plunging ranula.

Although rare, the carotid body tumor (chemodectoma), a lateral neck swelling, is the most common extra-adrenal paraganglioma. Examination reveals a rubbery, nontender mass at the level of the carotid bifurcation, along the anterior border of the sternomastoid, more mobile laterally than vertically. Innervated by the glossopharyngeal nerve, it is poorly encapsulated. Many exhibit transmitted pulsations from the carotid vessels or, less commonly, expand themselves, reflecting their extreme vascularity. A bruit that disappears with carotid compression may be heard. Neurologic examination may reveal deficits of the lower cranial nerves. Most paragangliomas secrete catecholamines, although few patients become symptomatic.² Metastatic disease, which occurs more frequently, dictates a thorough evaluation for head and neck primaries. Open and percutaneous biopsy should be avoided because of risk of hemorrhage. Duplex ultrasound, computed tomography, or carotid angiography is diagnostic; carotid angiography estimates the size of the tumor, bilaterality, possible involvement of the external and internal carotid arteries, and evaluation of primary atherosclerotic disease. Surgery with vascular reconstruction is the procedure of choice, although the low incidence of malignancy and the chronic nature of the tumor favor a more conservative approach in asymptomatic, elderly, or high-risk patients.

A pulsatile lateral neck swelling is the most common presentation of a carotid artery aneurysm; other symptoms include pain, transient ischemic attack, stroke, hoarseness, and dysphagia.³ A carotid duplex scan is confirmatory, although arteriography still remains the gold standard.

Branchial cysts manifest most commonly in persons 20 to 39 years of age. In patients older than 40 years, branchial cysts should be treated as malignant until proven otherwise.⁴ Consider the possibility of the branchio-oto-renal syndrome, a distinct entity with branchial arch anomalies (e.g., cysts, sinuses, fistulas, auricular pits, deafness, cleft palate/ uvula, renal anomalies).

Any cervical adenopathy should prompt an examination of the axillary, epitrochlear, mediastinal, external iliac, and inguinal chains. The presence of supraclavicular lymphadenopathy should focus on examination and possible imaging of the thorax, abdomen, and pelvis (breast, lung, liver, pancreas, gastrointestinal tract, genitalia) for primaries. The left supraclavicular lymph node (Virchow's node) receives, through the thoracic duct, the lymph drainage below the diaphragm, thus reflecting infradiaphragmatic disease. Hodgkin's disease in children usually presents as asymptomatic cervical or supraclavicular lymphadenopathy, which may fluctuate over time.⁵ Two thirds of patients will have mediastinal adenopathy, which may produce symptoms of tracheal or bronchial compression.

The authors¹ identified six clinical covariates that independently predicted the need for lymph node biopsy,⁶ including age of at least 40 years, tenderness on palpation, increasing size, generalized pruritus, supraclavicular location, and hard consistency.

KALYANAKRISHNAN RAMAKRISHNAN, M.D.
900 NE 10th St.
Oklahoma City, OK 73104

REFERENCES

1. Schwetschenau E, Kelley DJ. The adult neck mass. Am Fam Physician 2002;66:831-8.
2. LiVolsi VA, Perzin KH, Savetsky L. Carcinoma arising in median ectopic thyroid (including thyroglossal duct tissue). Cancer 1974;34:1303-15.
3. Mokri B, Piepgras DG, Sundt TM Jr, Pearson BW. Extracranial internal carotid artery aneurysms. Mayo Clin Proc 1982;57:310-21.
4. Granstrom G, Edstrom S. The relationship between cervical cysts and tonsillar carcinoma in adults. J Oral Maxillofac Surg 1989;47:16-20.
5. Hudson MM, Donaldson SS. Hodgkin's disease. Pediatr Clin North Am 1997;44:891-906.
6. Vassilakopoulos TP, Pangalis GA. Application of a prediction rule to select which patients presenting with lymphadenopathy should undergo a lymph node biopsy. Medicine 2000;79:338-47.

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Use of Sildenafil for Patients with Penile Hypotonia

TO THE EDITOR: Penile hypotonia caused by congenital spinal cord conditions or spinal cord injuries is a common complication and presents as a problem during the placement of a condom catheter in patients who are incontinent.

A 35-year-old man with neurogenic incontinence caused by cerebral palsy had persistent problems with the use of condom catheters because of penile hypotonia. The patient was prescribed 50 mg of sildenafil 30 minutes before the placement of the condom catheter. Follow-up revealed that he was more successful in the placement and maintenance of the catheter and had a documented decrease in the number of episodes of cystitis and genital irritation as compared with the results before the administration of sildenafil.

If used with caution and in patients without underlying heart disease, sildenafil (Viagra) may be an option for some patients who are experiencing problems with condom catheter placement because of penile hypotonia. This may prevent the use of more invasive techniques like indwelling catheter placement and suprapubic cystostomy, which is associated with increased risks, such as bleeding and infection. A search of the literature did not reveal any studies using sildenafil and the placement of condom catheters.

The high cost and possible lack of prescription benefits to cover sildenafil may preclude frequent use; however, our experience suggests that sildenafil may be useful for difficult catheterizations in men with penile hypotonia.

DEEPA VASUDEVAN, M.D.
6410 Fannin St., Suite 250
Houston, TX 77030

Corrections

The article "Lactose Intolerance" (May 1, 2002, page 1845) contained an error regarding intestinal transit time. On page 1846, the first complete sentence should read: "Secondary or acquired hypolactasia can follow any gastrointestinal illness that damages the brush border or significantly decreases transit time in the jejunum mucosa."

The article "Controlling Hypertension in Patients with Diabetes" (October 1, 2002, page 1209) contained an error in the description of diltiazem. On page 1211, the first sentence under the subheading "Calcium Channel Blockers" should have described diltiazem as a benzothiazepine calcium channel blocker rather than as a dihydropyridine calcium channel blocker.

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Pkwy., 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 submitted on disk, 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 will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.

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