Letters to the Editor

Perioperative Beta Blockers for Patients with Diabetes

TO THE EDITOR: I found Dr. Marks' article, "Perioperative Management of Diabetes,"¹ to be a useful guide for the perioperative management of diabetic medications. Because diabetes is a significant risk factor for cardiac complications, it is important to remind readers that perioperative beta blockers are often indicated in these patients. The use of a perioperative beta blocker in patients with major risk factors for coronary artery disease is a class IIa recommendation by the American College of Cardiology/American Heart Association.² An excellent review³ on the indications, contraindications, and methods of perioperative beta blockade was published recently. Diabetes mellitus requiring insulin therapy is a Cardiac Risk Index Criteria and is an indication for beta blockade. Diabetes that does not require insulin is a minor criteria, and, in conjunction with age greater than 65 years, hypertension, current smoking, or total cholesterol level more than 240, also is an indication for beta blockade.

M. LEE CHAMBLISS, M.D., M.S.P.H.
Moses Cone Family Medicine Residency
1125 N. Church St.
Greensboro, NC 27401

REFERENCES

1. Marks JB. Perioperative management of diabetes. Am Fam Physician 2003;67:93-100.
2. Eagle KA, Gibbons RJ, Antman EM, Berger PB, Calkins H. ACC/AHA guideline update on perioperative cardiovascular evaluation for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Available at: www.acc.org/clinical/guidelines/perio/update/pdf/perio_update.pdf.
3. Auerbach AD, Goldman L. Beta-blockers and reduction of cardiac events in noncardiac surgery: scientific review. JAMA 2002;287:1435-44.

IN REPLY: Dr. Chambliss makes an important point. However, discussion of the use of any medications, other than those directed at maintaining glycemic and metabolic homeostasis in the diabetic perioperative patient, was beyond the scope of my paper. I agree with the use of beta blockers in patients with diabetes who require insulin and are at risk for coronary artery disease. Dr. Chambliss' reminder to review this separate topic is timely.

JENNIFER B. MARKS, M.D.
University of Miami School of Medicine
P.O. Box 016960 (D-110)
Miami, FL 33101

Examinations Should Include Food Allergy Tests

TO THE EDITOR: The article,¹ "Environmental Control of Allergic Diseases," in American Family Physician presents an excellent organized schema for environmental control of common inhalants that contribute to asthma and allergic disease. However, the authors do not mention ingestants that also can trigger reactivity of the respiratory tract. For example, foods induce respiratory symptoms by both reaginic and nonreaginic mechanisms; moreover, food allergies commonly coexist with inhalant allergies. One study² showed that
43 percent of asthmatic patients who were placed on a diet that eliminated common allergens substantially improved compared with only 6 percent of subjects in the control group.

A proper diagnosis of specific food allergies often requires screening tests for evidence of food-specific IgE allergy and proof of reactivity through elimination diets and oral food challenges.³ Double-blind, placebo-controlled food elimination and rechallenge is considered the "gold standard" for diagnosis of food allergies⁴ in contrast to skin prick tests and radioallergosorbent tests, which are sensitive indicators of food-specific IgE antibodies but poor predictors of clinical reactivity.⁵ In many situations, the diagnosis of food allergy may rest simply on a history of an acute onset of typical symptoms, such as wheezing following the isolated ingestion of a suspected food.⁶

ROBERT ANDERSON, M.D.
614 Daniels Dr., N.E
East Wenatchee, WA 98802-4036

REFERENCES

1. German JA, Harper MB. Environmental control of allergic diseases. Am Fam Physician 2002;66:421-6.
2. Hoj L, Osterballe O, Bundgaard A, Weeke B, Weiss M. A double-blind controlled trial of elemental diet in severe, perennial asthma. Allergy 1981;36:257-62.
3. Sampson HA. Food allergy. Part 2: diagnosis and management. J Allergy Clin Immunol 1999;103: 981-9.
4. Eigenmann PA, Sampson HA. Interpreting skin prick tests in the evaluation of food allergy in children. Pediatr Allergy Immunol 1998;9:186-91.
5. Sampson HA, Ho DG. Relationship between food-specific IgE concentrations and the risk of positive food challenges in children and adolescents. J Allergy Clin Immunol 1997;100:444-51.
6. Sicherer SH. Food allergy: when and how to perform oral food challenges. Pediatr Allergy Immunol 1999;10:226-34.

IN REPLY: Dr. Anderson correctly points out that we did not mention in our article¹ that ingestants can trigger reactivity of the respiratory tract. However, the bulk of the literature on this subject indicates that the frequency of significant asthma exacerbation caused by food allergy is low,^2,3 and the vast majority of reactions are caused by a small number of foods such as peanuts, fish, shellfish, eggs, and cow's milk.⁴ Persons tend to outgrow allergies to milk and eggs but not to nuts and fish; peanuts are the most common food allergen in children more than three years of age.⁴ National and international asthma guidelines recognize that food allergy is an uncommon cause of asthma exacerbation.^3,5 Atopic dermatitis is much more likely than asthma to be caused by food allergy. One study⁶ showed that one third of children with refractory atopic dermatitis had clinical reactivity to food proteins.

JEFFREY A. GERMAN, M.D.
MICHAEL B. HARPER, M.D.
Louisiana State University Health Sciences Center
1501 Kings Highway
Shreveport, LA 71130

REFERENCES

1. German JA, Harper MB. Environmental control of allergic diseases. Am Fam Physician 2002;66:421-6.
2. James JM, Bernhisel-Broadbent J, Sampson HA. Respiratory reactions provoked by double-blind food challenges in children. Am J Respir Crit Care Med 1994;149:59-64.
3. National Asthma Education and Prevention Program (National Heart, Lung, and Blood Institute). Guidelines for the diagnosis and management of asthma: expert panel report 2. Bethesda, Md.: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Heart, Lung, and Blood Institute, 1997;NIH Publication no. 97-4051.
4. Rance F, Kanny G, Dutau G, Moneret-Vautrin DA. Food hypersensitivity in children: clinical aspects and distribution of allergens. Pediatr Allergy Immunol 1999;10:33-8.
5. Global Initiative for Asthma. National Heart, Lung, and Blood Institute. Global strategy for asthma management and prevention. Bethesda, Md.: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Heart, Lung, and Blood Institute, 1997; NIH Publication no. 02-3659.
6. Eigenmann PA, Sicherer SH, Borkowski TA, Cohen BA, Sampson HA. Prevalence of IgE-mediated food allergy among children with atopic dermatitis. Pediatrics 1998;101:E8.

Post-Traumatic Stress Disorder As a Cause of Night Sweats

TO THE EDITOR: The article, "Diagnosing Night Sweats,"¹ in American Family Physician mentions anxiety as a cause for night sweats. As a physician in the city of Oxford, England, I care for a large number of refugees from military conflict zones such as Kosovo, Africa, Kashmir, and Afghanistan. The most common cause of night sweats in our practice is not tuberculosis or human immunodeficiency virus, but post-traumatic stress disorder. When patients present with night sweats, they are usually referring to night terrors when they awaken soaking wet and in terror after flashback-nightmares.

WILHELMINA J. RIETSEMA, MRCGP
60 Glebelands
Oxford, OX3 7EN United Kingdom

REFERENCE

1. Viera AJ, Bond MM, Yates SW. Diagnosing night sweats. Am Fam Physician 2003;67:1019-24.

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.