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Letters to the Editor
Treating Periungual Warts with Adhesive Tape
TO THE EDITOR: I enjoyed the article on nail disorders.1 The authors state that periungual warts are difficult to treat due to their proximity to the nail bed growth plate. The use of harsh chemicals, electrosurgery or cryosurgery may disrupt nail growth permanently.
For the past decade or so I have been using a technique about which I read many years ago in Cutis.2 The author suggested treating these warts by occlusion using ordinary white adhesive tape (the old-fashioned type, now used mostly for ankle taping). A large part of therapy is the psychologic component. The author used an ordinary roll of tape, but labeled it "WART TAPE." This was wrapped around the finger with much ceremony. The tape is to be left on for six days, removed on a set day of the week (I usually choose Sunday), then replaced the next morning. After four weeks I've seen about an 80 percent cure rate.
You can have the patient return to the office for each re-taping or simply have the patient or parent do it at home. The cost is minimal, other than the office visit, and the therapy is essentially risk-free; there is no real damage to the nail bed matrix.
GORDON WALBROEHL, M.D.
Dept. of Family Medicine
Wright State University School of Medicine
Dayton, OH 45435REFERENCES
- Noronha PA, Zubkov B. Nails and nail disorders in children and adults. Am Fam Physician 1997; 55:2129-40.
- Litt JZ. Don't excise--exorcise: treatment for subungual and periungual warts. Cutis 1978;22:673-6.
Use of Serum Markers in Myocardial Infarction
TO THE EDITOR: The article by Dr. Chesebro1 provides useful and timely information regarding the often difficult diagnosis of myocardial infarction. Two points should be made regarding the use of cardiac troponin I (c-TnI) in this setting. First, rapid assays are available for c-TnI; they are currently in use at our institution. The turn-around time for c-TnI is equivalent to that of MB isoenzyme of creatine kinase (CK-MB) assays. Second, elevated c-TnI levels do not seem to be found in patients with renal failure (as Dr. Chesebro correctly points out), unlike CK-MB and cardiac troponin T, though the data to support this conclusion is lacking. We have found that c-TnI is a more accurate predictor of myocardial injury than CK-MB assays in patients with renal failure [Martin GS. February 1997. Unpublished data.], and that non-specific elevations of c-TnI do not seem to occur. Moreover, our data for patients with renal failure support Antman's conclusion2 about the population in general--that elevated c-TnI levels are associated with increased short-term mortality. With rapid c-TnI assays available, immediate decisions can be made regarding diagnosis of chest pain as well as stratifying patient risk. Cardiac troponin I and CK-MB complement each other because of their respective kinetics (rising in tandem, with CK-MB falling within 36 hours and c-TnI remaining positive for four to 10 days). As c-TnI assays become more widely available, evaluation of patients with suspected myocardial injury should become both simpler and more precise.
GREG S. MARTIN, M.D.
T-1217 Medical Center North
Vanderbilt University Medical Ctr.
Nashville, TN 37232REFERENCES
- Chesebro MJ. Using serum markers in the early diagnosis of myocardial infarction. Am Fam Physician 1997;55:2667-74.
- Antman EM, Tanasijevic MJ, Thompson B, Schactman M, McCabe CH, Cannon CP, et al. Cardiac-specific troponin I levels to predict the risk of mortality in patients with acute coronary syndromes. N Engl J Med 1996;335:1342-9.
IN REPLY: I appreciate Dr. Martin's letter, as well as correspondence from Spectral Diagnostics, Inc., regarding their product, the Cardiac STATus Troponin I test kit, which uses seven to eight drops of whole blood, serum or plasma and gives results within 15 minutes. The improved predictive values, both positive and negative, of using c-TnI can improve our diagnostic capabilities when symptoms suggest acute myocardial infarction, and this improved capability can save lives through early intervention. Unfortunately, we are not readily discarding the older, less specific tests as the newer, more specific types become available. We may be creating more confusion by keeping the older tests (such as creatine phosphokinase [CPK] and CPK-MB), and combining them with myoglobin, troponin T and troponin I than if we relied on one or two with better positive and negative predictive values.
MARCIA J. CHESEBRO, M.D.
University of Alabama School of Medicine
201 Governors Dr.
Huntsville, AL 35801
Auscultation Method fo Diagnosis of Bone Fractures
TO THE EDITOR: As budget restraints increase, clinical tools are regaining attractiveness.1 Some years ago, Carter2 published in a letter to the editor a simple clinical method to diagnose bone fractures of the femur and pelvis, based on physical laws of sound transmission. I undertook an investigation to prospectively evaluate the feasibility and validity of the auscultatory technique in 102 consecutive cases of bone fractures.
Bone is a better sound transmitter than muscle or fatty tissue and dampens sound transmission less. To evaluate possible fractures of various tubular bones, the stethoscope is positioned in close proximity to the suspected fracture. Distal to the suspected region, sounds are elicited by tapping a fingernail or fingertip against prominent bony structures, the fingernails or the toenails of the patient. The elicited sounds are then compared with the same procedure on an anatomically comparable region.
Overall Sensitivity, Specificity and Validity Values of the Auscultation Value All fractures
Sensitivity
Positive predictive value
Specificity
Negative predictive value
True positives
True negatives
False-positives
False-negatives91.5%
97.4%
75.0%
46.2%
76.0*
6.0*
2.0*
7.0*
*--N=91.After defining the suspected fracture region by means of this test, results were noted on a chart. Then, radiographs were reviewed in order to confirm or falsify the test results.
Of the 102 patients, 91 had fractures localized at one bone, as demonstrated by radiographs. The remaining 11 patients had other alterations, including joint effusions (N=3), lesions of ligaments (N=3), consolidated fractures (N=3), osteomyelitic bone disease (N=1) and pseudarthrosis (N=1). Of the patients with fractures, 80 had single fractures and 11 had multiple fractures. In two patients with wrist involvement, fractures were detected only after repeated radiologic examination, but the auscultation test was negative for the lesions in both cases. The fractures included 19 of the femur, 14 of the radius, 10 of the finger bones and mid-hand, nine of the humerus, six of the tibia or lower leg, five of the ribs, three of the clavicle, three of the mid-foot and two of the elbow, with the remaining fractures at other sites.
Inspection was the only clinical information-gathering modality used besides the auscultation test; palpation or questioning was not permitted. In 24 cases the fracture location was evident from inspection, and it could be suspected in 21 cases. In the other 57 cases, no visible lesion was apparent. Based on these findings, the overall specificity and sensitivity of the auscultation method were calculated (see table) as well as the same values for the 57 cases with nonvisible fractures. Auscultation in cases with nonvisible fractures showed a sensitivity of 89.5 percent and a specificity of 66.6 percent. The auscultation method was even more reliable in diagnosing fractures of the main tubular bones; no false-negative or false-positive diagnoses were made for femur, humerus, radius, tibia or rib fractures.
These findings demonstrate the usefulness of a simple auscultation test in detecting fractures of various tubular bones. Although regarded as the standard, radiology sometimes has limitations,3 as does the auscultation method.4 When the bony (and cartilaginous) continuum is physically broken, e.g. by joint effusion, it is impossible to differentiate fractures from these alterations.
KURT LAEDERACH-HOFMANN, M.D.
Internal Medicine Outpatient Dept.
University of Berne, Inselspital
CH-3010 Berne
SwitzerlandREFERENCES
- Stagnaro-Green A, Packman C, Baker E, Elnicki DM. Ambulatory education: expanding undergraduate experience in medical education. A CDIM commentary. Am J Med 1995;99:111-5.
- Carter MC. A reliable sign of fractures of the hip or pelvis [Letter]. N Engl J Med 1981;305:1220.
- Waeckerle JF. A prospective study identifying the sensitivity of radiographic findings and the efficacy of clinical findings in carpal navicular fractures. Ann Emerg Med 1987;16:733-7.
- Peters A. [Sound transmission in the human tibia. A study of fracture healing with the acoustic percussion technic]. [Danish]. Ugeskr Laeger 1984; 146(28):2072-6.
Video Documentation
of Atypical NeviTO THE EDITOR: Atypical nevus syndrome is commonly seen in primary care. While most people have 30 to 40 nevi on their bodies, those with atypical nevus syndrome often have hundreds. To make matters more difficult, many of these nevi are quite atypical in appearance and meet the American Cancer Society criteria for concern, namely asymmetry, border irregularity, color variegation and diameter greater than 6 mm (the ABCD criteria).
Many systems of photo documentation have been described, but the logistics of whole-body photography exceed the capacity of most family physicians.
In 1990, I began using a videocassete recorder equipped with a macro lens to document the skin condition of these patients and to provide a basis for periodic follow-up. I have found this technique to be effective and efficient for managing scores of patients with this condition.
Before the video is made, the patient's skin is thoroughly examined from scalp to sole. All nevi of concern are marked with a simple inked rubber stamp 1 to 3 cm in length that is placed close to the lesion. The current date is programmed onto the videocassette recorder and a systematic video recording of the entire skin surface is completed. All marked nevi are also magnified with the macro lens, providing great detail for each worrisome lesion. The ability of the videocassette recorder to zoom in and out on these lesions allows for unambiguous localization. A monitoring screen is coupled to the videocassette recorder during the taping to assure video quality. The completed video is then given to the patient for safekeeping.
In three to six months, depending on the degree of concern, the patient is again examined, and all suspicious lesions are restamped. The original skin scan is then reviewed and the "freeze frame" mode is used to capture the best magnified image of each lesion. Simple headset magnification loupes enhance adequate comparison of lesion size, shape, color and symmetry. The initial videotape soundtrack recording of the examiner's impressions is also of great benefit. This process of skin review is then repeated every six months for patients with a history of melanoma and every six to 12 months for those with atypical nevus syndrome.
Changes in established skin lesions are very apparent and easy to follow with this technique. Surprisingly, many nevi become smaller and less pigmented as the patient avoids sun exposure. Some atypical nevi disappear altogether. New nevus growth is also easily detected with this procedure. Markedly atypical lesions and aggressively changing nevi are immediately removed. The higher the pathologic grade of atypia, the more frequently the examination is performed.
I have found this to be a satisfactory means of monitoring these patients. It has significantly minimized the need for excisional biopsies and has greatly reduced the concern that important nevus changes will be missed. The cost of the equipment is nominal. With practice, the initial study takes 30 to 45 minutes and follow-up studies somewhat less.
SCOTT SATTLER, M.D.
Eureka Family Practice
2675 Harris St.
Eureka, CA 95503The editors of AFP welcome input concerning topics of current medical interest and feedback in response to articles and other material published in AFP. Send letters to Jay Siwek, M.D., Editor, American Family Physician, 8880 Ward Pkwy., Kansas City, MO 64114; fax: 816-333-0303; 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. Letters submitted for publication in AFP must not be submitted to any other publication. Letters pertaining to AFP subject matter must be received within two months of publication. Any financial associations or other 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 reserve the right to edit correspondence to meet style and space requirements.
Copyright © 1998 by the American Academy of Family Physicians.
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