Articles | Departments | Patient Information

Letters to the Editor

Cookouts and the Seasonal Peak of Escherichia coli Infection

TO THE EDITOR: Upon reading the article on Escherichia coli,¹ I was a bit surprised when the authors stated, "For unknown reasons, the rate of infection follows a seasonal pattern, with a peak incidence from June through September."

Out here in the Midwest, a lot of folks cook out from June through September. Not surprisingly, many of them cook hamburgers, a wonderful reservoir for E. coli. Since folks at cookouts tend to be impatient, many of them eat hamburger meat that is undercooked. This is, to my simplistic view, a logical explanation for the seasonal peak from June through September.

GORDON WALBROEHL, M.D.
Department of Family Medicine
Wright State University School of Medicine
Dayton, OH 45435

REFERENCE

1. Koutkia
2. P, Mylonakis E, Flanigan T. Enterohemorrhagic Escherichia coli O157:H7--an emerging pathogen. Am Fam Physician 1997;56:853-6.

IN REPLY: We appreciate Dr. Walbroehl's comments on our article. The importance of undercooked hamburgers in the epidemiology for E. coli O157:H7 infection is well-described in the literature and has been referred to as "barbecue syndrome."¹ This association was actually noted two paragraphs after the phrase that Dr. Walbroehl mentioned; it was also noted in the patient information handout accompanying the article.²

We believe that the epidemiology of E. coli O157:H7 is very important. However, little is known about the actual risk factors. The observation regarding cookouts has been tested in a large and well-documented epidemiologic study,¹ and there was no statistical significance noted with barbecued hamburgers. Although there are studies explaining the epidemiology of E. coli O157:H7-associated gastroenteritis, it is still not fully explained why this infection peaks during the summer.^1,3-5 Also, it was recently noted that the "seasonal variation of E. coli O157:H7 infection may reflect the ecology of the organism, variation in the consumption of ground beef or some other factor."⁶

More studies are needed to evaluate the seasonal pattern of this disease.

POLYXENI KOUTKIAK, M.D.
ELEFTHERIOS MYLONAKIS, M.D., PH.D.
TIMOTHY FLANIGAN, M.D.
Department of Medicine
Miriam Hospital
164 Summit Ave.
Providence, RI 02906

REFERENCES

1. Bryant HE, Athar MA, Pai CH. Risk factors for Escherichia coli O157:H7 infection in an urban community. J Infect Dis 1989;160:858-64.
2. Koutkia P, Mylonakis E, Flanigan T. Escherichia coli O157:H7 infection [Patient information handout]. Am Fam Physician 1997;56:859-61.
3. Pai CH, Ahmed N, Lior H, Johnson WM, Sims HV, Woods DE. Epidemiology of sporadic diarrhea due to verocytoxin-producing Escherichia coli: a two-year prospective study. J Infect Dis 1988;157:1054-7.
4. Su C, Brandt LJ. Escherichia coli O157:H7 infection in humans. Ann Intern Med 1995;123:698-714.
5. Griffin PM, Ostroff SM, Tauxe RV, Greene KD, Wells JG, Lewis JH, et al. Illnesses associated with Escherichia coli O157:H7 infections. A broad clinical spectrum. Ann Intern Med 1988;109:705-12.
6. Boyce TG, Swerdlow DL, Griffin PM. Escherichia coli O157:H7 and the hemolytic-uremic syndrome. N Engl J Med 1995;333:364-8.

Comparing Family Physicians: Canada and the United States

TO THE EDITOR: I moved to the United States in 1993 after enjoying my first six years of practice in Canada. Before 1993, I had felt moments of jealousy when I communicated with my U.S. family practice counterparts. They had larger homes, posh offices and fine cars--which is, embarrassingly, probably the main reason Canadian physicians go south.

However, after starting family practice work in the United States, I found out that many primary care physicians here had saved relatively little, carried significant loans and, in many cases, had meager retirement portfolios. Their job futures seemed uncertain. Their outside interests (apart from work and family) seemed minimal by Canadian standards. Much of the U.S. physicians' extra time was taken up by meetings and more meetings, many of these generated by "the private health care and HMO runaround." I often wondered whether U.S. physicians were involved in running the healthcare system or were simply being dictated to.

I read that disability insurance companies were less willing to take on primary care physicians because their potential longevity was felt to be much shorter than it had been. Older U.S. physicians spoke of the "good old days," when professional independence was commonplace.

My two-year stay in the United States as an attending physician introduced me to many hard-working, dedicated physicians and devoted allied health professionals. They were friendly and supportive, but they had accepted the fact that their jobs were heavily controlled by others. Independence as a primary care physician seemed to be an option for only a few.

I didn't meet a lot of primary care physicians who seemed satisfied with a full-time practice. Many were frequently changing jobs or considering administrative options, research, teaching or faculty work. The rate of burnout was high.

Primary care physicians are in many ways the engine running the system--generating tests, referrals and jobs. We answer to patients, families, lawyers, medical boards and health care companies, which is appropriate. However, in the United States, healthcare policies are dictated to physicians by administrators who know little about the practice of medicine.

Canada has been struggling with the concept of "care for all." More technology is needed (although there is a limit: at times, "high-tech" testing seems to make little difference in a patient's management and only generates profit for large private companies), and Canada is seeing more and more specialized health care personnel leave for the United States. Government money alone cannot solve these problems. But, in Canada, physicians still have a say in how health care is evolving, and we can maintain a substantial degree of independence.¹ In addition, burnout appears to be less of a problem for the frontline Canadian physicians than for their U.S. counterparts.

Maybe I returned to Canada because I missed my roots, but the above points do have merit. U.S. primary care physicians should realize that they can once again have a greater say in the health care mosaic if they support their local and regional organizations. They are knowledgeable, hard-working groups who shouldn't have to bend to every other part of the health care system. After all, they are the engine that keeps it going, and are indispensable.

GEORGE D. STRELIOFF, M.D.
84 Nightstar Dr.
Richmond Hill, Ontario L4C 8H4
CANADA

REFERENCE

1. Gutkin C. Change and progress: Part I. Are we responding to our members' needs? [Vital Signs]. Can Fam Physician 1997;43:580-77.

Preventing Falls in the Elderly

TO THE EDITOR: I am a family physician in West Point, Neb., a town of 4,000. Four other physicians and I cover the emergency department at night. I have often wondered how to prevent falls in the elderly, as we see a number of elderly patients come in during the night with injuries. After getting up during the night for whatever reason, these elderly patients have tripped and fallen because they had become disoriented.

I have an idea which may have some merit for individuals who are in a nursing home or assisted care environment. Installing motion detector lights inside the apartment would enable an individual who has risen from bed during the night to see, and would decrease his or her chances of becoming disoriented. For certain individuals, this would work very well. For others, it could possibly provide too much stimulus and add to insomnia. Certainly, for those individuals at risk of falling, the trade-off may be acceptable.

CHARLES E. SMITH, M.D.
West Point Medical Clinic
539 E. Decatur
West Point, NE 68788

Down Syndrome and Incidence of Alzheimer's Disease

TO THE EDITOR: I disagree with several of the comments regarding patients with Down syndrome in the article on adults with mental retardation.¹

First, although the Health Care Guidelines for Individuals with Down Syndrome² are referenced later in the article, they are not listed among the major health supervision guidelines for children and adults with Down syndrome. This publication is, in fact the original set of guidelines and is updated every few years. Although the guidelines are similar to those of the American Academy of Pediatrics, there are differences.

Second, in regard to hematologic disease, an annual complete blood count is no longer recommended by either of the guidelines.

Third, and most important, Table 1 states that early Alzheimer's disease occurs in "almost 100 percent" of Down syndrome patients over 40 years old. The literature states that although the neuropathology does develop in virtually all brains of people with Down syndrome over the age of 35, the clinical appearance of Alzheimer's disease is consideraly less than 100 percent.³ People with Down syndrome age more quickly and therefore develop Alzheimer's disease earlier, but not 100 percent of the time. A colleague of mine had taken care of a woman with Down syndrome who did not have Alzheimer's disease and who died at the age of 83.

The belief that all individuals with Down syndrome will develop dementia is unfortunate. As a result, adults with deteriorating skills are frequently labeled as having dementia when they actually have secondary causes. In one series,⁴ most such people did not have dementia but instead had depression or adjustment reactions; a smaller number had hypothyroidism. There have even been instances in which a person was believed to have Alzheimer's disease when he or she had conditions such as symptomatic atlantoaxial instability and alcoholism. The article correctly points out that other reversible causes should first be ruled out, including pseudodementia. I would also include abuse as an important consideration, given its high incidence in individuals with disabilities.

Because expressive speech, in particular, is impaired in many people with Down syndrome, they frequently are not able to adequately express their fears or pain. Painful or frightening medical conditions such as gallbladder disease, seizures and arthritis can be associated with a significant amount of depression or an adjustment reaction that sometimes is confused with dementia. Diagnosis requires a careful history and suspicion for common illnesses as well as those more specific to individuals with Down syndrome. Although the signs and symptoms may be subtle, reversible causes of dementia should be ruled out.

DAVID S. SMITH, M.D.
Down Syndrome Clinic of Wisconsin
1000 N. 92nd St.
Milwaukee, WI 53226

REFERENCES

1. Martin BA. Primary care of adults with mental retardation living in the community. Am Fam Physician 1997;56:485-94.
2. Cohen WI, ed. Health care guidelines for individuals with Down syndrome (Down syndrome preventative medical check list). Down Synd Q 1996;1(2):1.
3. Zigman WB, Schupf N, Sersen E, Silverman W. Prevalence of dementia in adults with and without Down syndrome. Am J Ment Retard 1996;100: 403-12.
4. Chicoine B, McGuire D, Hebein S, Gilly D. Development of a clinic for adults with Down syndrome. Ment Retard 1994;32:100-6.

EDITOR'S NOTE: This letter was sent to the author of "Primary Care of Adults with Mental Retardation Living in the Community," who declined to reply.

Impact of Patient-Directed Pharmaceutical Advertising

TO THE EDITOR: I have become increasingly concerned about the newest type of pharmaceutical advertising that is targeted directly to the consumer, mostly through television commericals and advertisements in popular magazines. A new strategy of pharmaceutical companies is to encourage the general public to dial a toll-free number for information or to ask their doctor about a new prescription drug.

Usually, the specific drug is not even mentioned. The toll-free number may be listed as a source for more "information" on the disease in question, but the sponsor invariably markets a drug treatment for the condition. In one commercial, an advertiser tells people to phone a toll-free number if their blood sugar level is greater than 140.

Often, a slickly-produced "Madison Avenue" image is created, much in the way that other advertisers attempt to woo customers into trying a new soft drink or buying a new car. I have seen advertisements of this type for asthma, migraine, diabetes, allergies, herpes, acne, nail fungus, smoking cessation, depression and weight loss.

As with any advertiser, the drug companies' sole purpose is to sell the product. However, the pharmaceutical industry--by virtue of its regulation, patent protection, impact on individuals' health and the need for a doctor's prescription--does not respond to the same economic forces as do other companies that sell consumer perishables by mass marketing. The drug manufacturers are attempting to ignore the "therapeutic marketing equilibrium"¹ that drives the ultimate supply and demand for pharmaceutical products, which is based on efficacy and true value of a drug's overall benefit. Past evidence indicates that advertising expenditure has little or no long-term effect on the success or failure of a prescribed drug.²

The advertisements' effects during a patient visit can be cumbersome. The patient may ask, "What about that new drug for asthma?" If the physician responds in a way inconsistent with the image shown in the advertisement, then he or she may appear uninformed, rigid, uncooperative or unconcerned, even though the patient may already be on an ideal regimen.

I am completely in favor of informed and open dialogue between patients and their doctors, as well as patient education, but in the current managed care environment the efficient use of time during a patient visit is critical. What if the patient is being prescribed medicine from a preapproved formulary, and the advertised drug is not on the list? These newer drug advertisements do not represent the "tried and true" standbys, but are generally the newer "me too" drugs, vying for market share. This would also be a potential source of unnecessary frustration: telling patients that the product being promoted is not available under their managed care plan.

In my opinion, the benefit to the health of a patient population from this type of direct marketing will be neglible. If this were the only outcome, then I would simply gripe that the drug companies should put their money to better uses. Unfortunately, I do not believe their message to be this benign. In effect, the pharmaceutical manufacturers are saying, "If we cannot get the doctors to sell our drugs, we will sell them directly to the consumer."

The pharmaceutical industry should concentrate its efforts on educating physicians about its new products, not coercing patients to put pressure on physicians to make decisions that may not be necessary, beneficial or cost-effective.

ROBERT S. THOMPSON, D.O., M.S.
PinnacleHealth System
101 S. Second St., Suite 1219
Harrisburg, PA 17101-2516

REFERENCES

1. Thompson RS. Pharmaceutical marketing [Letter]. Arch Fam Med 1994;3:1031-2.
2. Feldstein PJ. Healthcare economics. 3d ed. Albany, N.Y.: Delmar Publishers, 1988;447-58.

Hepatitis A Vaccination

TO THE EDITOR: After reviewing the article on immunizations,¹ we agree that updating family physicians about the changes in the recommended schedule for vaccine administration is vitally important. Although the article extensively covers the need for hepatitis B vaccines, it makes only brief mention of hepatitis A vaccines. We believe that hepatitis A vaccination warrants more attention than it received in this article.

Everyone is at risk for hepatitis A, especially international travelers and people living in areas with an outbreak. In fact, the U.S. Centers for Disease Control and Prevention (CDC) recommends hepatitis A vaccination for international travelers, since more than one half of Americans who travel outside the United States visit hepatitis A endemic regions (e.g., Mexico, parts of the Caribbean and Asia, South and Central America).² Additionally, the CDC recommends that patients with chronic liver disease be vaccinated for hepatitis A and hepatitis B.

Every year, approximately 10 million persons worldwide are infected with the hepatitis A virus. Hepatitis A is the only foodborne illness preventable by vaccination. The need for hepatitis A vaccination has been underscored further by the rash of outbreaks that have occurred across the country in the past year. One of the most serious outbreaks ocurred in Michigan in April 1997, when 260 persons contracted hepatitis A after eating contaminated strawberries. Even more recently, in September of 1997, also in Michigan, 46 more persons were infected with the virus through a local deli's coleslaw. A 67-year-old man who was infected died as a result.

More than 100 Americans die of hepatitis A each year, yet nearly one quarter of them have never even heard of the disease.³ Not only is it vital for physicians to seriously consider vaccinating patients who are at risk for hepatitis A infection, it is also important for them to discuss this option with all of their patients. For more information on hepatitis, call the Hepatitis Foundation International, toll-free, at 800-891-0707.

THELMA KING THIEL
Chairman and Chief Executive Officer
The Hepatitis Foundation International
30 Sunrise Terr.
Cedar Grove, NJ 07009-1423

REFERENCE

1. Adkins SB. Immunizations: current recommendations. Am Fam Physician 1997;56:865-74.
2. Abstract of international travel to and from the United States 1995. Department of Commerce, U.S. Travel and Tourism Administration, Office of Research. November 1996:21-3.
3. Hepatitis A (Chapter 11). Epidemiology and prevention of vaccine-preventable diseases. The Pink Book. 4th ed. Atlanta, Ga.: Centers for Disease Control and Prevention, 1997:184.

Correction

Question 26 of the February 15, 1998, "Clinical Quiz" (page 626), pertaining to the item in "Tips from Other Journals" titled "Diagnosis, Treatment and Prevention of Giardiasis," was written incorrectly. The question should have asked which one of the five listed agents is commonly used in the United States as a single course of treatment for giardiasis in an adult patient who is not pregnant. The correct answer remains D. In the same issue, question 29, which refers to the item in "Tips from Other Journals" titled "Antibiotic Utilization in Hospitalized Elderly Patients," was misleading because a key sentence was left out of the Tip (page 844). The missing sentence, which should have opened the fourth paragraph, reads as follows: "[The] ability to diminish antibiotic expenditures was in large part related to aggressive conversion of parenteral to oral formulations." The correct answer remains A.

---

"Tips from Other Journals" are written by the medical editors of American Family Physician.

Copyright 1998 by the American Academy of Family Physicians.
This file may be downloaded (1) solely for the personal, non-commercial reference of individuals and (2) for use by members of the AAFP. It may not be copied, printed, or reproduced in any other medium, whether now known or hereafter invented, for the use of others or for commercial use.

The 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.