Letters to the Editor
Clarification of Guidelines for the Proper Use of Child Car Seats
TO THE EDITOR: I found the article "Discharge Procedures for Healthy Newborns,"1 in the March 1, 2006, issue of American Family Physician to be a good review of important topics to be addressed with parents before the discharge of their newborn. However, there was one error in the text regarding an issue that I have found to be a common source of confusion. Dr. Langan notes that, with regard to car seat use, an "infant should remain in a rear-facing car seat until he or she weighs more than 20 pounds (9 kg) or is older than one year of age."1 The original guideline from the American Academy of Pediatrics that he references states that, "Children should face the rear of the vehicle until they are at least 1 year of age and weigh at least 20 pounds."2 The article's accompanying figure does not really help clarify this point. Although this is not really a newborn issue, I address it with parents starting when their children are in the six- to nine-month age-range because otherwise I find a general tendency in the parents to try to get children facing forward as soon as possible.
REFERENCES
1. Langan RC. Discharge procedures for healthy newborns. Am Fam Physician 2006;73:849-52.
2. American Academy of Pediatrics Committee on Injury and Poison Prevention. Selecting and using the most appropriate car safety seats for growing children: guidelines for counseling parents. Pediatrics 2002;109:550-3.
Relationship Between Cocaine Use and Cardiovascular Events
TO THE EDITOR: We would like to express our concern regarding the statement in the American Family Physician article "Diagnosis of Acute Coronary Syndrome"1 by Dr. Achar and colleagues that patients who use cocaine and subsequently develop chest pain are at a "low risk" for developing an acute cardiovascular event. In their discussion of cocaine-associated chest pain, the authors cite a study that suggests "only" 2 percent of patients with cocaine-associated chest pain had an acute coronary syndrome (ACS) event.2 Unfortunately, this study was not only of patients with cocaine-related chest pain, but a subset of a larger study of patients presenting to emergency departments with any cocaine-related complaints.2 Because this was not a study of only cocaine-related chest pain, we believe the referenced study dilutes the true incidence of ACS associated with cocaine use.
To better determine the rate of ACS associated with cocaine-related chest pain, we cite a prospective study that evaluated 246 patients with cocaine-associated chest pain.3 Results of this study noted that 5.7 percent of these patients sustained a myocardial infarction (95% confidence interval, 2.7 to 8.7).3 A review of this topic concluded that these patients should indeed be evaluated for possible myocardial damage.4
A threefold increase from 2 percent risk of ACS (one in 50 patients) as suggested by Dr. Achar and colleagues to what we believe is a more accurate incidence of nearly 6 percent (one in 18) is not inconsequential and may change physicians' thoughts as to whether cocaine-associated ACS is truly a low-risk condition.
REFERENCES
1. Achar SA, Kundu S, Norcross WA. Diagnosis of acute coronary syndrome. Am Fam Physician 2005;72:119-26.
2. Feldman JA, Fish SS, Beshansky JR, Griffith JL, Woolard RH, Selker HP. Acute cardiac ischemia in patients with cocaine-associated complaints: results of a multicenter trial. Ann Emerg Med 2000;36:469-76.
3. Hollander JE, Hoffman RS, Gennis P, Fairweather P, DiSano MJ, Schumb DA, et al. Prospective multicenter evaluation of cocaine-associated chest pain. Cocaine Associated Chest Pain (COCHPA) Study Group. Acad Emerg Med 1994;1:330-9.
4. Carley S, Ali B. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Acute myocardial infarction in cocaine induced chest pain presenting as an emergency. Emerg Med J 2003;20:174-5.
in reply: Drs. Joslin and Dachs note an important difference in the incidence of acute coronary syndrome (ACS) in patients who have chest pain following cocaine use. In the study they cite by Hollander and colleagues "fourteen of 246 patients (5.7 percent; 95% confidence interval [CI], 2.7 to 8.7) had myocardial infarction, as diagnosed by elevated CK-MB [MB isoenzyme of creatine kinase] isoenzyme levels."1 Two of the patients, mean age of 33, actually died. Although a relatively high proportion of patients who had myocardial infarction were cigarette smokers (83.3 percent), these results are statistically and clinically significant and should remind physicians to look carefully for signs of ACS in patients who admit to cocaine use and complain of chest pain.
Drs. Joslin and Dachs also reference a study2 by Feldman and colleagues that did not specifically look at cocaine-associated symptoms. Rather, the study was a substudy of all patients who presented to the emergency department with chest pain. Another difference was the inclusion of 'cocaine-related complaints." Of these 293 patients, six had a diagnosis of ACS, two had acute myocardial infarctions, and none died. Although admission rates of patients with chest pain with or without cocaine exposure were approximately the same, patients with cocaine-induced chest pain or related symptoms were much less likely to have had confirmed unstable angina (1.4 versus 9.3 percent, P <.001) or acute myocardial infarction (0.7 versus 8.6 percent, P <.001).2
Although these two studies1,2 differ on the degree of risk that cocaine-induced chest pain confers for ACS, decisions about hospitalization and treatment should be made based on the same risk factor analysis, examination, electrocardiogram criteria, cardiac markers, and advanced testing that is included in our article.3
REFERENCES
1. Hollander JE, Hoffman RS, Gennis P, Fairweather P, DiSano MJ, Schumb DA, et al. Prospective multicenter evaluation of cocaine-associated chest pain. Cocaine Associated Chest Pain (COCHPA) Study Group. Acad Emerg Med 1994;1:330-9.
2. Feldman JA, Fish SS, Beshansky JR, Griffith JL, Woolard RH, Selker HP. Acute cardiac ischemia in patients with cocaine-associated complaints: results of a multicenter trial. Ann Emerg Med 2000;36:469-76.
3. Achar SA, Kundu S, Norcross WA. Diagnosis of acute coronary syndrome. Am Fam Physician 2005;72:119-26.
The article "Urinalysis: A Comprehensive Review" (March 15, 2005, page 1153) contained two errors. First, in the second paragraph of the right-hand column of page 1158, the time necessary for the dipstick reagent test to change color was incorrectly listed as five minutes instead of 30 seconds to two minutes. The sentence should have read as follows: "To detect significant pyuria accurately, 30 seconds to two minutes should be allowed for the dipstick reagent strip to change color, depending on the brand used." Second, the first sentence of the second paragraph in the left-hand column on page 1160 should have read as follows: "Under high-powered magnification, gram-negative rods, streptococci, and staphylococci can be distinguished by their characteristic appearance." The online version of this article has been corrected.
Send letters to Kenny Lin, M.D., Contributing Editor, American Family Physician, e-mail: afplet@aafp.org. Letters submitted via regular mail should be sent (on disk) to: 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-6272.
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