Letters to the Editor - June 1998 - American Academy of Family Physicians


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Letters to the Editor

Drug-Induced Disorders

TO THE EDITOR: The article¹ and editorial² concerning adverse drug reactions highlight a major problem in medicine today. With the ever-enlarging body of drugs available and a population that is living longer and ingesting an increasing number of prescription and over-the-counter medications, the potential for harm grows.

The article by Drs. Holland and DeGruy suggests that as many as 10 percent of hospital admissions may be attributable to drug-induced disorders. Family physicians see a large proportion of patients and write many of the prescriptions that are ingested. They are thus apt to produce numerous unfavorable results.

I have been interested in this problem for over 15 years, writing and lecturing during this period.^3-5 Despite this focus, I have found myself guilty of failing to detect some important adverse events.

Because of the multiple and varying etiologies of some of these untoward reactions, we can never hope to fully eliminate all such accidents. Nevertheless, constant attention to this problem will help minimize much of the harm we are capable of inadvertently administering during therapy.

While we are all probably aware of the more frequent drug interactions, there are many less common interactions that are difficult for a physician to remember. We must depend on tools other than our memories. In this modern world, many of us are failing to enlist an obvious ally--the computer. Physicians, pharmacists and hospitals should all be required to check with existing computer programs when a patient receives a medication or prescription. Expecting a physician to devote the time necessary to search through the Physicians' Desk Reference or a similar volume is not realistic.

The possibility of your patient adversely reacting to a drug may be only 1 percent, but in that patient the adverse reaction would be 100 percent.

MARION FRIEDMAN, M.D.
7906 Terrapin Ct.
Baltimore, MD 21208-3126

REFERENCES

Holland EG, DeGruy FV. Drug-induced disorders. Am Fam Physician 1997;56:1781-8.

Kennedy DL, Goldman SA. Monitoring for adverse drug events [Editorial]. Am Fam Physician 1997;56: 1718-21.

Friedman M. Iatrogenic disease: addressing a growing epidemic. Postgrad Med 1982;71(6):123-9.

Friedman M. Iatrogenic disease in a general hospital. QRB 1983;9:346-7.

Friedman M. Iatrogenic disease: what the physician can do. Md Med J 1996;45:833-8.

IN REPLY: We appreciate the comments from Dr. Friedman. We agree that it is impossible for a prescribing physician to be aware of all potential problems of medications. The number of drugs available for use increases by one to two each month, and it is preposterous to expect one to memorize all of the potential problems inherent in using these agents.

Numerous computer programs and other resources that review medication lists for potential problems have been developed. Unfortunately, however, many programs are too sensitive and detect clinically irrelevant interactions, while significant interactions are often missed. Nonetheless, these resources can serve as valuable tools for prescribing medications appropriately.

To minimize drug-induced problems, physicians should create a systematic approach to prescribing, giving careful attention to all prescription and nonprescription medications, vitamins, herbs and "health food" products. This approach should include the development of active partnerships between the physician and the clinical pharmacist. Clinical pharmacists, who are trained drug experts, combine their expertise and the information provided from various resources to determine the drug-related issues that need to addressed and modified. Furthermore, clinical pharmacists who are provided with sufficient patient-specific data can identify additional drug-related problems, such as dosing concerns in patients with renal insufficiency and drug-disease interactions.

A deliberate and conscientious approach to prescribing medications, coupled with the full use of a clinical pharmacist's expertise, will enable physicians to use medications with maximum benefit and minimal harm. Providing safe and effective medications for patients is a shared responsibility between the prescribing physician and the clinical pharmacist.

EILEEN G. HOLLAND, PHARM. D.
Department of Clinical Pharmacy Practice
Auburn University School of Pharmacy
1504 Springhill Ave.
Mobile, AL 36604

FRANK V. DEGRUY, M.D.
University of South Alabama College of Medicine
Mobile, AL 36688

Bacterial Vaginosis: What's in a Name?

TO THE EDITOR: While I realize that there are more pressing issues in medicine than the one I am raising, I wish physicians could resolve to correct the anomalous terminology we use when discussing "a polymicrobial superficial vaginal infection involving a loss of the normal lactobacilli and an overgrowth of anaerobes."¹

The suffix -osis, most properly applied to Greek stems only, shouldn't be used with the Latin stem vagin- to begin with. If that were the only problem, I probably wouldn't lose any sleep over it. The deeper problem lies in the meaning of the suffix -osis, which is a "production or increase (of the stem) . . . an invasion and increase within the organism (of the stem)." Thus diverticulosis is excessive generation of diverticuli, and listeriosis is invasion by and multiplication of Listeria. However, I almost cannot stand the thought of bacteria sporting an excess number of vaginas, or worse yet, bacteria being invaded by proliferating vaginas, either of which could be suggested by the term, "bacterial vaginosis," and neither of which characterizes the entity itself.

Now some will protest that this poor clinical entity has already suffered too many name changes as it is, from "nonspecific vaginitis" to "Gardnerella vaginitis" to "bacterial vaginosis," and should be allowed to rest in peace. But I suggest that the entity could, in the interest of consistent nomenclature, and in the interest of shutting down the fantastic images conjured by the present terminology, tolerate one more change, to "vaginal bacteriosis," which means "overgrowth of bacteria in the vagina," and accurately describes the entity. Or, if we must retain the abbreviation "BV," then we could change the term to "bacterial vaginopathy."

RICHARD L. GARRISON, M.D.
Department of Family Practice and Community Medicine
University of Texas-Houston Medical School
6431 Fannin, 2.112 M.S.B.
Houston, TX 77030

REFERENCES

Majeroni BA. Bacterial vaginosis: an update. Am Fam Physician 1998;57:1285-9.

Stedman TL. Stedman's Medical Dictionary. 25th ed. New York: Macmillan, 1990:105.

Accidental Coin Swallowing and Sublingual Nitroglycerin

TO THE EDITOR: A teenager presented to the emergency department with sudden onset of lower chest pain after she had flipped a quarter into the air and caught it in her mouth. The coin was accidentally swallowed, and pain occurred momentarily thereafter. The patient had a completely normal physical examination, other than some evidence of embarrassment and anxiety.

Chest radiograph revealed that the coin was just above the gastroesophageal junction. After discussing the management options, we elected to administer 0.4 mg of nitroglycerin sublingually.

The pain completely disappeared in less than five minutes. The follow-up radiograph indicated that the coin had dropped well below the gastroesophageal junction. The patient was instructed to call if pain recurred or if she experienced any difficulty passing the coin. A follow-up contact with the patient indicated that the coin had passed without any difficulty.

The case described here occurred years ago when I was a young physician. I applied basic medical school knowledge and reasoned that nitroglycerin would cause smooth muscle relaxation. I also knew that an incredible array of objects could pass through the gastrointestinal tract without difficulty once they reached the stomach. It worked!

In recent years, I have seen numerous articles about retrieving swallowed coins endoscopically, with a Foley catheter, or with a bouginage. Each of these methods has associated problems and may be expensive. However, sublingual nitroglycerin costs only pennies. The risks of administering nitroglycerin are quite minimal, even in children. This may prove to be a safe and inexpensive way of getting past a sticky problem and should be studied.

DOUGLAS H. GRANT, M.D.
401 N. Oneida St.
Appleton, WI 54911

Screening for Prostate Cancer

TO THE EDITOR: I first want to compliment Dr. Spann on a well-written editorial¹ regarding prostate cancer, a topic that is rife with controversy, subspecialist and specialty society (e.g., American Cancer Society) bias, and incomplete information. I recommend that family physicians read this editorial, along with the companion "Special Medical Report."²

My only point of disagreement is with the author's last paragraph and particularly the last sentence, where it is advised that prostate cancer screening is the patient's choice after being "carefully informed" by the physician. My concern is that this editorial takes three pages to explore the controversies regarding screening, and the companion piece (Special Medical Report) is a two-page summary of a three-article guideline--and all of this information is supposed to be "carefully" explained so that the patient can make an informed choice.

It would appear that physicians are having a hard time understanding and making a decision on this topic; is it fair or realistic to expect the patient to be able to make a truly informed choice? Physicians have a hard enough time analyzing statistics, let alone the layman! How many physicians know that it will take a 10- to 15-year study involving several hundred thousand men to demonstrate prospectively that screening actually reduces mortality, weeding out the various biases that Dr. Spann nicely discusses?³ How often are physicians misled by either the "snails" or the "evangelists," who come to opposite conclusions on studying the same data?⁴

I think this is an issue in which the family physician needs to draw the line, saying, "This is what I do, based on my study of the currently available literature. To do more (or less) is just not something I can currently defend." Or, as I tell my patients, "This is what I would do for my dad/granddad." Patients seem to listen to and respect this approach. Often, the patient has a strong preconception and won't listen or is dazed when I have attempted to carefully explain the more than myriad hypotheses, interpretations and facts.

DAVID L. SMITH, M.D.
Central Maine Medical Center-FPR
76 High Street
Lewiston, ME 04240

REFERENCES

Spann SJ. Prostate cancer screening--what's a physician to do? [Editorial]. Am Fam Physician 1997;56:1563-8.

Special Medical Report. ACP issues guidelines on the early detection of prostate cancer and screening for prostate cancer. Am Fam Physician 1997; 56:1674-5.

Gerber GS, Chodak GW. Value of prostate cancer screening. Eur Urol 1993;24:161-5.

Collins MM, Barry MJ. Controversies in prostate cancer screening. Analogies to the early lung cancer screening debate. JAMA 1996;276:1976-9.

IN REPLY: Dr. Smith raises a very important issue regarding the implementation of evidence-based clinical practice guidelines that incorporate the patient's values or preferences into the decision process: How does a busy physician discuss all of the benefits, risks and costs of a given medical intervention with the patient during a brief clinical encounter in enough detail to allow that patient to make a truly informed decision?

This dilemma is not unique to the issue of prostate cancer screening; it is common to many of the preventive and therapeutic interventions that we offer to our patients on a daily basis. Eddy¹ asserts that clinical practice guidelines should incorporate the patient's preferences or values in the decision-making process. Lee² states that patients must give informed consent before participating in a screening program, insisting that physicians should "match the appropriate level of screening with each patient's unique attitude toward the risks of disease and the risks associated with the screening procedure." He goes on to state that, as physicians, "our duty is to give these patients the best data available, untainted by our personal feelings or symbolism, and let them plug these numbers into their own value systems."

The physician must, in my opinion, be careful not to interject his or her own biases or values into the patient's decision-making process. To do so risks interfering with the patient's autonomy and verges on paternalism. The real challenge, though, is to communicate to the patient all of the information he needs to make a truly informed choice. Physicians need practical tools to be able to do this in a busy practice setting. One approach is to develop a brief, written "balance sheet," which lists in simple language the risks, benefits and costs of the intervention. Hahn and Roberts³ have developed such a balance sheet for prostate cancer screening.

Another approach is to develop a videotape that educates the patient about the different choices. Such an educational videotape was used by Flood and colleagues⁴ in a study that evaluated the impact of viewing a videotape about prostate-specific antigen (PSA) testing on patients' knowledge about prostate cancer screening and treatment, and their decision to undergo PSA testing. Men who reviewed the videotape were found to better informed about PSA tests and were less likely to undergo screening for prostate cancer.⁴

Volk and colleagues conducted a similar study using the videotape "The PSA Decision: What YOU Should Know," produced by the Foundation for Informed Medical Decision Making, of Hanover, N.H. Results of the study showed that men who reviewed the videotape were more knowledgeable about prostate cancer screening and less likely to choose to be screened for prostate cancer than men who did not watch the videotape (unpublished data).

Another option is for the physician to become very familiar with all of the issues important to the decision, and to present these issues to patients in a conversational fashion, as suggested by Marshall.⁵ This approach requires that the physician memorize the facts and practice communicating them verbally in an understandable and efficient manner.

The difficulty of the task should not dissuade us from carefully educating our patients about their choices so that they can make truly informed decisions. The development of simple and practical tools to communicate benefits, risks and costs to patients and elicit their preferences or values for incorporation into medical decisions in an efficient manner remains an important research challenge for family medicine.

STEPHEN J. SPANN, M.D.
Department of Family and Community Medicine
Baylor College of Medicine
5510 Greenbriar
Houston, TX 77005

REFERENCES

Eddy DM. Clinical decision making: from theory to practice: a collection of essays from the Journal of the American Medical Association. Boston: Jones and Bartlett, 1996.

Lee JM. Screening and informed consent. N Engl J Med 1993;328:438-40.

Hahn DL, Roberts RG. PSA screening for asymptomatic prostate cancer: truth in advertising [Editorial]. J Fam Pract 1993;37:432-6.

Flood AB, Wennberg JE, Nease RF Jr, Fowler FJ Jr, Ding J, Hynes LM. The importance of patient preference in the decision to screen for prostate cancer. Prostate Patient Outcomes Research Team. J Gen Intern Med 1996;11:342-9.

Marshall KG. Screening for prostate cancer. How can patients give informed consent? Can Fam Physician 1993;39:2385-90.

Air Bag Deployment and Hearing Loss

TO THE EDITOR: Exposure to high noise levels associated with air bag deployment during an automobile accident may result in irreversible hearing loss. Laboratory studies have established that peak acoustic pressure of 170 dB produced during air bag deployment can induce harmful inner ear effects.¹ In these air bag studies, the greatest hearing loss has occurred at 4,000 Hz.

In my practice, I have seen this pattern of hearing loss in patients exposed to air bag deployment. These patients showed the greatest hearing loss in the range of 3,000 to 6,000 Hz. Since the loss occurs above the speech frequency range of 500 to 2,000 Hz, it may not be immediately apparent to the patient; audiologic testing is required to detect hearing loss in this range.

However, the injury to the ear may manifest as tinnitus, which some of my patients have reported. Tinnitus is commonly caused by damage to the inner ear and is usually associated with hearing loss in frequencies above the speech frequency range. Thus, air bag deployment may not only cause hearing deficits but may also result in the onset of tinnitus. Other presenting complaints include loudness intolerance, dizziness or a sensation of stuffiness in the ear.

Establishing the cause-and-effect relationship between air bag noise exposure and hearing loss is facilitated when preaccident audiology results are available.

Physicians, other health care professionals and emergency department staffs should be cognizant of the possibility of yet another morbidity associated with air bag deployment. Patients who have been in a motor vehicle accident should be queried about air bag exposure and any noticeable change in hearing or onset of tinnitus.

MICHAEL S. MORRIS, M.D.
LETICIA P. BORJA
Department of Otolaryngology-1/Gorman
Georgetown University Medical Center
3800 Reservoir Rd., NW
Washington, DC 20007

REFERENCE

Price GR. Hearing hazard from the noise of air bag deployment. Abstract, Acoustical Society of America 131st meeting. Indianapolis, Ind., May 13-17, 1996. J Acoust Soc Am 1996;99(4 Pt 2):2462.

Novel Treatment for Leg Ulcers

TO THE EDITOR: I would like to share a tried, inexpensive and effective method of treating leg ulcers. I have used this procedure in many patients over the course of 20 years, and it has been favorably adopted by my fellow physicians. Although it is not a controlled or scientifically proven treatment, it has worked for me.

While in Australia, with the help of physical therapists, my colleagues and I developed this simple technique of healing leg ulcers. These indolent infected craters are often associated with local leg ischemia and are the result of arteriosclerosis, diabetes, minor trauma and pressure.

In contrast to the wet dressings, pressure bandages and grafting methods used in current treatments, our approach relies on the restoration of an active blood supply to the open ulcer base. If an "ulcer" is surveyed closely, a red granulomatous center is found, often with superficial purulent matter, and an encircling firm, bandlike rim of edematous tissues is present that blends into the surrounding normal skin.

Figure
Circular daily massage with the thumb, using a solution of 2 percent lidocaine and polymyxin-bacitracin ointment, will eventually remove the compressing rim of the leg ulcer.

Our approach restores a healthy pink center to the ulcer by removing the compressing rim. The procedure is simple: the physician gently massages the center of the ulcer with the thumb in a circular manner using a mix of 2 percent lidocaine (Xylocaine Viscous) and polymyxin-bacitracin ointment as a lubricant (see figure). This circular massage, performed daily, is later carried more firmly to the rim around the edge of the ulcer. This therapy alleviates ulcer pain in the early days of treatment, helps to remove the surface infection and begins the slow destruction of the rim, which is the key to the process.

After a few days, the ulcer is usually painless and lidocaine is no longer needed. Shortly thereafter, the superficial infection will clear and use of the antibiotic ointment can be discontinued. Continue daily massaging using vegetable oil (maize, peanut, soya or safflower) as a lubricant. This firm massaging will remove the constricting rim in a few days and allows blood to reach the base of the ulcer. In a remarkably short time (one to two weeks), even a fairly large ulcer (3 cm) can be persuaded to heal. During the periods between massaging, a simple nonadherent dressing can be used to protect the ulcer if circumstances dictate, but the better approach is to leave the ulcer exposed to the air with a thin covering of lubricant.

Once the physician demonstrates the proper technique, the daily massage can be continued at a clinic or by a visiting nurse. As soon as progress is evident, the family or even the patient can take over. When the ulcer appears to be healed, a visit to the physician for a final check and instructions for prophylactic care (regular light oiling of the legs, early treatment of minor trauma and smoking cessation) should prevent a recurrence. This technique is simple, effective and offers a rapid healing of the leg ulcer.

JOHN B. DAWSON, M.D., F.R.C.P.
Department of Internal Medicine
Eastern Virginia Medical School
46 Hardwick Rd.
Newport News, VA 23602

REFERENCES

Fletcher A, Cullum N, Sheldon TA. A systematic review of compression treatment for venous leg ulcers. BMJ 1997;315:576-80.

Treatment of Pressure Ulcers Guideline Panel. Treatment of pressure ulcers. Clinical practice guideline no. 15. Rockville, Md.: Dept. of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1994; AHCPR publication no. 95-0652.

Corrections

Question 17 in the October 1, 1997, "Clinical Quiz" (page 1270), based on an item from "Tips from Other Journals" titled "Congestive Heart Failure in Elderly Patients," contained an error. The question incorrectly refers to diastolic congestive heart failure; it should instead refer to systolic congestive heart failure. The correct answer remains D.

The text and Table 1 of the article "Understanding the Guidelines for Treating HIV Disease" (January 15, 1998, p. 315) contained a recurring typographical error. In each case that the CD4⁺ count was given--for example, 500 per mm³ (500 3 10⁶ per L)--the multiplication sign that should have been part of the SI unit was inadvertently printed as a numeral 3.

Copyright 1998 by the American Academy of Family Physicians.
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