Letters to the Editor
Treatments for Patients Exposed to Bioterrorism Agents
to the editor: I read with interest the article1 on bioterrorism agents in the May 1, 2003 issue of American Family Physician. This timely piece offered useful advice to assist family physicians on an important topic. I would like to recommend some information not included in the article.
First, the method of diagnosis that is described in Table 11 for plague should include culture of bubo aspirate (for bubonic plague) in addition to sputum, blood, and cerebrospinal fluid cultures for pneumonic and septicemic plague.
Second, Table 21 only describes the treatment for inhalational anthrax. There is a separate treatment regimen for cutaneous anthrax.2 Furthermore, clinicians can consider extending the usual 60-day anthrax prophylaxis to 100 days based on the possibility that disease may occur up to 100 days after exposure.3
REFERENCES
1. O'Brien KK, Higdon ML, Halverson JJ. Recognition and management of bioterrorism infections. Am Fam Physician 2003;67:1927-34.
2. Centers for Disease Control and Prevention. Update: Investigation of bioterrorism-related anthrax and interim guidelines for exposure management and antimicrobial therapy, October 2001 (published erratum appears in MMWR Morb Mortal Wkly Rep 2001;50:962). MMWR Morb Mortal Wkly Rep 2001;50:909-19.
3. Centers for Disease Control and Prevention. Additional options for preventive treatment for persons exposed to inhalational anthrax [Notice to readers]. MMWR Morb Mortal Wkly Rep 2001;50: 1142,1151.
in reply: We appreciate Dr. Campos-Outcalt's pointing out the additional information on bioterrorism infections. He correctly notes that a culture of bubo aspirate should be done if a bubo is present. However, in a bioterrorism attack, persons will be more likely to have pulmonic plague rather than bubonic plague, and this is why we chose not to list this culture in Table 1 of our article.1 Cutaneous anthrax treatment is not listed in Table 2 of our article1 because any case of cutaneous anthrax seen during a bioterrorist attack is treated as presumed inhalation anthrax until proven otherwise.
The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Army Medical Department or the U.S. Army Service at large.
REFERENCE
1. O'Brien KK, Higdon ML, Halverson JJ. Recognition and management of bioterrorism infections. Am Fam Physician 2003;67:1927-34.
Alternatives to Ear Syringingfor Removal of Earwax
The following editor's note by Anne D. Walling, M.D., appeared with a "Tips from Other Journals" in the February 15, 2003 issue of American Family Physician.1 The "Letter to the Editor" that follows was chosen from numerous responses we received.
editor's note: Ear syringing is a very common procedure in nursing homes-and the patients hate it! I have heard rumors of removing earwax in children by using liquid stool-softening agents but cannot find references or colleagues who have used this method in adults. If anyone knows a better way to remove earwax, please let us know.-A.D.W.
REFERENCE
1. Walling AD. How effective is ear syringing in improving hearing? [Tips] Am Fam Physician 2003; 67:870.
to the editor: For many years, I have used a mixture of the contents of one capsule of docusate calcium (Surfak, 240 mg) and a few mL of water for removing earwax. I fill the ear canal with this mixture, have the patient lie still for at least 30 minutes, and then irrigate the ear with warm water. This treatment is usually successful. I do not use the docusate calcium solution for anything but removing cerumen.
in reply: Ask and ye shall receive! We would like to thank everyone who sent suggestions on earwax removal. Judging from the number of responses, this is a common and stubborn problem. All of the responses demonstrate that doing unglamorous things well is one hallmark of a being a good family physician.
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Earwax removal is performed for various reasons, including hearing loss, sensation of ear blockage, and visualization of the tympanic membrane. The most common clinical practice is ear syringing, which is limited by patient tolerance and complications. Although syringing is considered the clinical standard, there are no high-quality studies comparing syringing with other methods or no treatment.1
Wax softeners and ceruminolytics are used to improve the success and tolerability of irrigation. They also can be used as solo agents for home therapy. However, studies evaluating ceruminolytics have used inconsistent methods. Thus, there is no clear evidence that one type of softener is superior to another.1,2 Furthermore, most studies lack a "no treatment" group, so it is impossible to discern more than relative efficacy in most cases.1 No studies exist comparing home and office treatment.3
One promising treatment is liquid docusate sodium (Colace). It is more effective than triethanolamine (Cerumenex) for augmenting irrigation. In one study,4 instilling 1 mL of docusate sodium fifteen minutes before irrigation allowed tympanic membrane visualization in 81 percent of study participants. However, another study5 did not find either treatment better than a normal saline control. The accompanying table lists other softening options. For those seeking more information on this common clinical problem, we recommend the following reading (Aung T, Mulley GP. Removal of ear wax. BMJ 2002;325:27, and references 1 and 2).
REFERENCES
1. Browning G. Wax in ear. Clin Evid 2002;7:490-7.
2. Burton MJ, Doree CJ. Ear drops for the removal of ear wax. Cochrane Database Syst Rev 2003;3: CD004400.
3. Wilson SA, Lopez R. What is the best treatment for impacted cerumen? J Fam Pract 2002;51:117.
4. Singer AJ, Sauris E, Viccellio AW. Ceruminolytic effects of docusate sodium: a randomized, controlled trial. Ann Emerg Med 2000;36:228-32.
5. Whatley VN, Dodds CL, Paul RI. Randomized clinical trial of docusate, triethanolamine polypeptide, and irrigation in cerumen removal in children. Arch Pediatr Adolesc Med 2003;157:1181-3.
editor's note: I am particularly grateful to those who referred to or sent copies of the article by Singer and colleagues (Ann Emerg Med 2000;36:228-32). It took some persuasion, but the staff at the nursing home finally agreed to use docusate sodium (Colace), and my elderly patients are grateful. They now complain that they can hear me but can't understand my Scottish accent!-A.D.W.
The article "Hepatitis B" in the January 1, 2004, issue (page 75) contained an error in the pricing of adefovir dipivoxil (Hepsera). On page 80, in Table 7, under the entry for adefovir dipivoxil, the cost of $528 is for one month of therapy, rather than one year of therapy. The online version of this article has been corrected.
The article "Management of Peripheral Arterial Disease" (February 1, 2004, page 525) contained an error in the order in which the authors were listed. The first author should have been listed as Daniela C. Gey, M.D., the second author as Emil P. Lesho, LTC, MC, USA, and the third author as Johannes Manngold, M.D. The online version of this article has been corrected.
The answer block for the "Clinical Quiz" in the February 15, 2004, issue (page 1004) gave an incorrect answer for Question 1, pertaining to the article "New Contraceptive Options," on page 853. The correct answer to this question is C, rather than D. The online version of this quiz has been corrected, and the question is reprinted below.
- Q1. Which one of the following statements about the vaginal contraceptive ring (NuvaRing) is correct?
A.
It requires fitting.- B.
It is slightly less effective than the diaphragm.
- C.
It is associated with a lower incidence of breakthrough bleeding than
levonorgestrel-ethinyl estradiol combination oral contraceptive pills.
- D.
It prevents withdrawal bleeding.
- E.
It requires daily checks for placement.
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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