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Letters to the Editor

Diagnosis of Acromioclavicular Joint Dislocations

TO THE EDITOR: I am writing in response to the article "Pitfalls in the Radiologic Evaluation of Extremity Trauma: Part I. The Upper Extremity," written by Drs. Shearman and El-Khoury.¹

The authors discussed the diagnosis of acromioclavicular joint dislocations and stated, "Stress views taken with weights suspended from each wrist will provide the diagnosis."¹ They offered no reference for their statement. The best evidence and current treatment preference for type III (complete) acromioclavicular joint dislocations support the abandonment of stress view radiographs.

While the comparison of weighted (stress) and unweighted (plain) radiographs is commonly mentioned in textbooks and articles, the results of the first and only prospective, randomized, blinded, controlled study comparing plain radiographs with stress views indicate that only a plain radiograph comparing injured and uninjured acromioclavicular joints is needed to grade a dislocation.² Stress views may mask the diagnosis of a type III injury.² Support for the use of stress views is lacking.

The importance of differentiating between a type I dislocation or a type II (partial) dislocation and a type III dislocation has changed because the preferred treatment of type III injuries is now conservative treatment rather than surgery. In 1974, 92 percent of the chairs of orthopedic residency programs recommended surgery for the treatment of type III dislocations.³ Results of two long-term, prospective, randomized, comparative studies^4,5 in the late 1980s showed that conservative treatment is as good as or better than surgery. In 1992, 72 percent of the chairs of orthopedic residency programs preferred conservative treatment of type III joint dislocations over surgery.⁶ Sixty-nine percent of Major League Baseball team orthopedists prefer conservative treatment, even for a type III dislocation of the throwing shoulder in their starting pitchers.⁷ If types I, II and III joint dislocations receive the same conservative treatment, radiographs for grading are unnecessary. Plain radiographs may be helpful, however, in ruling out other injuries that may need a different treatment approach.

Interestingly, an informal, nonscientific, unpublished survey among physicians at one hospital revealed that most orthopedists did not order any type of radiograph for the diagnosis of acromioclavicular joint dislocations and none ordered stress views. All of the radiologists surveyed recommended the comparison of plain radiographs and stress views. Family physicians were divided on the question, with the majority choosing to obtain stress views. Medical practice should not be changed on the basis of anecdotes or expert opinion. However, the fact that the majority of orthopedists have stopped ordering stress views should at least compel consideration of the existing evidence.

In summary, the preferred management of type III acromioclavicular joint dislocations has changed from surgery to conservative treatment. If the grading of an acromioclavicular joint dislocation is desired, plain radiographs that compare the injured and uninjured joint are adequate. Based on the best medical evidence, as well as the cost, the time involved and the exposure to radiation that patients receive, stress view radiographs should no longer be the standard method of evaluation of acromioclavicular joint dislocations.

STEVEN J. BLIVIN, LT, MC, USNR
ROBERT F. RASPA, CDR, MC, USN
Naval Hospital
2080 Child St.
Jacksonville, FL 32214

REFERENCES

1. Shearman CM, El-Khoury GY. Pitfalls in the radiologic evaluation of extremity trauma: part I. The upper extremity. Am Fam Physician 1998;57:995-1002.
2. Bossart PJ, Joyce SM, Manaster BJ, Packer SM. Lack of efficacy of 'weighted' radiographs in diagnosing acute acromioclavicular separation. Ann Emerg Med 1988;17:20-4.
3. Powers JA, Bach PJ. Acromioclavicular separations. Closed or open treatment? Clin Orthop 1974; 0:213-23.
4. Larsen E, Bjerg-Nielsen A, Christensen P. Conservative or surgical treatment of acromioclavicular dislocation. A prospective, controlled, randomized study. J Bone Joint Surg Am 1986;68:552-5.
5. Bannister GC, Wallace WA, Stableforth PG, Hutson MA. The management of acute acromioclavicular dislocation. A randomised prospective controlled trial. J Bone Joint Surg Br 1989;71:848-50.
6. Cox JS. Current method of treatment of acromioclavicular joint dislocations. Orthopedics 1992;15: 1041-4.
7. McFarland EG, Blivin SJ, Doehring CB, Curl LA, Silberstein C. Treatment of grade III acromioclavicular separations in professional throwing athletes: results of a survey. Am J Orthop 1997;26:771-4.

EDITOR'S NOTE: This letter was sent to the authors of "Pitfalls in the Radiologic Evaluation of Extremity Trauma: Part I. The Upper Extremity," who declined to reply.

Use of Antibiotics in Patients with Acute Bronchitis

TO THE EDITOR: After reading the article "Acute Bronchitis" by Drs. Hueston and Mainous,¹ I have as many new questions as questions that were answered by the article. I think the authors wrote an informative review of the pathophysiology, epidemiology and etiologic agents of bronchitis. However, I wonder how a practicing family physician might approach the disease given this information.

The authors state that only about 5 percent of cases of bronchitis are bacterial in origin. They also point out that production of sputum is a poor diagnostic clue and that physical examination is unreliable in diagnosing the disease. They cite numerous studies showing that the use of antibiotics has no increased benefit over the use of placebo. Finally, they quote studies that demonstrate benefit from the use of bronchodilators in adults with bronchitis.

I would be interested to know how, in the authors' opinion, a physician might approach a patient who falls into the general category of "acute bronchitis." Do the authors feel that antibiotics should never be used, or do they think they should only be used in certain groups of patients? If patients with bronchitis caused by Chlamydia infection are at increased risk of developing asthma, wouldn't it be important to treat those patients? Is it possible (and cost effective) to stratify a patient's risk for bronchitis caused by Chlamydia? If antibiotics are to be used selectively, what criteria should one use to identify patients who would benefit? Last, do the authors recommend a trial use of bronchodilators in every patient with bronchitis or only in those who have clinical signs and symptoms of bronchial obstruction?

As a family physician caring for patients on a daily basis, I want to treat disease in a reasonable, safe, effective and cost-efficient manner. I would appreciate the authors' advice on how best to do that when faced with the very common clinical picture of acute bronchitis.

DEAN A. SEEHUSEN, M.D.
Department of Family Medicine
Tripler Army Medical Center
1 Jarrett White Rd.
Tripler AMC, Hawaii 96859-5000

REFERENCE

1. Hueston WJ, Mainous AG III. Acute bronchitis. Am Fam Physician 1998;57:1270-6.

Bronchodilator Therapy in Patients with Acute Bronchitis

TO THE EDITOR: I read with interest the article "Acute Bronchitis" by Drs. Hueston and Mainous¹ in the March 15 issue of American Family Physician. I agree with the authors regarding the limited value of antibiotics in the treatment of this common condition. However, recommendations for the appropriate use of bronchodilator therapy were not clearly stated. Should one base treatment on history alone or on physical examination findings alone? Should peak flow measurements be less than 80 percent of the predicted measurement before treatment is started? How long should bronchodilator therapy be used to treat this condition? Clarification of these issues will help physicians to better care for their patients who have this common condition.

CATHERINE M. SHARKNESS, M.D.
Department of Family Medicine
University of Medicine and Dentistry of New Jersey
Robert Wood Johnson Medical School
One Robert Wood Johnson Pl.
New Brunswick, N.J. 08903-0019

REFERENCE

1. Hueston WJ, Mainous AG III. Acute bronchitis. Am Fam Physician 1998;57:1270-6.

IN REPLY: As Dr. Seehusen points out, antibiotics have not been shown to be beneficial in the treatment of acute bronchitis. Therefore, we do not recommend routine use of antibiotics in patients with acute bronchitis. While it would be convenient to have a "high-risk" profile for patients who are more likely to have a bacterial infection, as we pointed out in our article, there is no way to predict the rare patient who has a bacterial etiology for his or her bronchitis.

As far as treatment to prevent adult-onset asthma is concerned, antibiotics are not justified at this time. Currently, there is no good estimate of how often Chlamydia pneumoniae is the etiologic agent for acute bronchitis, nor is there conclusive proof that Chlamydia infection causes asthma or that early treatment of Chlamydia prevents the development of asthma. For patients with prolonged cough lasting a month or longer, treatment with antibiotics may be cost effective, especially when compared with an expensive evaluation for chronic cough.¹ Otherwise, antibiotics should be avoided since they are an unnecessary expense, can cause side effects and may increase resistance to antibiotics.

In response to Dr. Sharkness's questions, the use of bronchodilators, more specifically albuterol, is based on clinical suspicion of acute bronchitis. No aspect of the patient's history or physical findings (including wheezing) or findings on peak flow measurement indicates when albuterol will be most effective. Albuterol can be continued until symptoms are cleared; it should be noted, though, that in the two studies that examined the use of albuterol, 90 percent of patients had resolution of their cough after one week.^2,3

WILLIAM J. HUESTON, M.D.
ARCH G. MAINOUS III, PH.D.
Department of Family Medicine
Medical University of South Carolina
171 Ashley Ave.
Charleston, S.C. 29425-5820

REFERENCES

1. Hueston WJ. Antibiotics: neither cost effective nor 'cough' effective. J Fam Pract 1997;44:261-5.
2. Hueston WJ. Albuterol delivered by metered-dose inhaler to treat acute bronchitis. J Fam Pract 1994;39:437-40.
3. Hueston WJ. A comparison of albuterol and erythromycin for the treatment of acute bronchitis. J Fam Pract 1991;33:476-80.

Smoking Cessation in Recovering Alcoholics

TO THE EDITOR: Bravo! I was greatly heartened to see the no-nonsense article and patient education handout on smoking cessation in patients with a history of alcohol abuse, written by Dr. McIlvain and colleagues.¹ I have preached for nearly 15 years now that most patients addicted to both nicotine and alcohol would probably be better off if they quit using both substances at the same time. During my work in the field of recovery from addictions, I caught quite a bit of grief for taking such a radical stance, especially from the recovering community. Thank you.

ROBERT J. BOLSTER, M.D.
The Corpus Christi Better Health Institute
Spohn Health Plaza #425
5920 Saratoga Blvd.
Corpus Christi, TX 78413

REFERENCE

1. McIlvain HE, Bobo JK, Leed-Kelly A, Sitorius MA. Practical steps to smoking cessation for recovering alcoholics. Am Fam Physician 1998;57:1869-76.

Relationship Between the Patient and the Medical Student

TO THE EDITOR: I would like to comment on "The Patient/Medical Student Relationship" written by Angelo Volandes for "Resident and Student Voice."¹ The author says that he is afraid that when he becomes a "doctor," his patients will no longer confide in him in the same way they did while he was a student, and that he will not know his patients as well as he does now. I would like to reassure him that his patients will continue to share the most intimate details of their lives with him if he remains open and approachable. I do not think that age, gender or any external circumstances will affect his ability to know his patients. Some of us have it and some of us don't, although the cultivation of such an attitude is possible.

It is also possible that his mentor had indeed heard the racial slurs of the professor patient, and that may have been part of what he was referring to when he called the patient "priceless." We don't know whether his mentor shared those views or if he simply realized that this was part of the patient's perspective and knew that he was unlikely to change.

SUSAN STANGL, M.D.
UCLA School of Medicine
200 UCLA Medical Plaza
Suite 220, Box 95-1628
Los Angeles, CA 90095-1628

REFERENCE

1. Volandes A. The patient/medical student relationship. Am Fam Physician 1998;57:1693-4.

The Role of the Family Physician in Hospice Care

TO THE EDITOR: I laud the editorial by Dr. Whitten that proposes "Ten Commandments for the Care of Terminally Ill Patients."¹ Addressing the emotional climate that surrounds terminal illness is an appropriate exercise in primary medical care. However, I would like to suggest a preamble to his commandments--an early hospital referral. Hospice care is provided through a team approach. It includes the skills of nurse aids, social workers, chaplains, nurses and physicians. Each program has a hospice physician on hand for consultation, but the physician who refers the patient usually remains the primary physician and is an integral part of the team. The remainder of Dr. Whitten's commandments can be more easily carried out through this team concept.

For diagnosis or acute treatment, the commandment to "ask about consultations" should not be followed unless its purpose is to aid in the management of the patient's symptoms in a palliative manner. Good communication often starts with finding out what the patient, the family or both desire or expect of the physician. Such knowledge will greatly aid the consultative process. Consulted physicians, who are usually acute care specialists, may confuse the patient and family by making recommendations that are not consistent with the concept of palliative symptom management. The primary physician should remain in charge of the patient's overall care regardless of the process of consultation.

Finally, I would like to suggest that physicians give their dying patients the hope that they will be free of symptoms at the time of death. It is the most powerful and kindest service we can provide.

JAMES B. WRIGHT, D.O.
Vitas Hospice Medical Director
2501 Parkview Dr.
Suite 600
Fort Worth, TX 76102

REFERENCE

1. Whitten JR. Ten commandments for the care of terminally ill patients [Editorial]. Am Fam Physician 1998;57:935-40.

IN REPLY: Reading the letter from Dr. Wright made me aware that we both are concerned with the care of the dying patient and that many ways are available to provide excellent care. A team approach, as he recommends, is most appropriate and was suggested in Commandments III and IV described in my editorial. However, many patients either do not want a hospice or find a hospice to be impractical because of distance or availability. Cost is another factor. I am sure that in some large cities, the availability of hospices is good. However, in the West and Southwest, areas with which I am most familiar, hospices are not always available and many patients prefer to "be at home when their time comes." Dr. Wright implies that the terminally ill patient should be in the hospice of a hospital or other hospice. This may be seen as distancing the traditional physician from the patient and family.

With regard to his point about consultations, I feel I made it clear that all that can be done should be done for the patient and that what I suggest is that the patient's family be offered additional consultations in the management and care of a terminally ill family member. Death is a family affair and this suggestion is more often for the benefit of the family members and not directly for the patient.

Finally, I appeal to the family physician to use the most powerful of all medicines--a human relationship in which there is trust, empathy, understanding and the willingness to see the dying patient through not only the good times but also the final time.

JAMES R. WHITTEN, M.D.
Department of Psychiatry
University of Missouri­Kansas City
600 E. 22nd St.
Kansas City, MO 64108

Use of Systemic Tetracyclines in Women Who Are Lactating

TO THE EDITOR: I enjoyed the excellent article on conjunctivitis written by Drs. Morrow and Abbott.¹ I found it to be practical and useful. I do feel, however, that one point in the article is in error.

They write that systemic tetracyclines are contraindicated in women who are nursing. Tetracycline is excreted into breast milk in low concentrations. It binds to calcium in breast milk and is absorbed poorly by the infant. A study of lactating women who were taking 500 mg of tetracycline four times a day found that levels of tetracycline in the infants were below the level of detection (0.05 µg per mL).^2,3 Theoretic concerns about the possibility of dental staining or delayed bone growth in the infants seems unlikely at these serum concentrations.³

In their publication "Transfer of Drugs and Other Chemicals into Human Milk," the American Academy of Pediatrics places tetracycline under the label "Usually Compatible with Breast-Feeding," the classification used for those medications that are safest in lactation.⁴

Better choices may be available for the treatment of meibomianitis or acne rosacea in lactating women, especially since these conditions often require prolonged treatment, but I feel it is unwise to perpetuate the misconception that tetracyclines are always contraindicated during lactation.

JEANNE SPENCER, M.D.
Conemaugh Valley Memorial Hospital
1086 Franklin St.
Johnstown, PA 15905-4398

REFERENCES

1. Morrow GL, Abbott RL. Conjunctivitis. Am Fam Physician 1998;57:735-46.
2. Hale TW. Medications and mothers' milk. 6th ed. Amarillo, Tex.: Pharmasoft Medical Publishing, 1997:558-9.
3. Briggs GG, Freeman RK, Yaffe SJ. Drugs in pregnancy and lactation: a reference guide to fetal and neonatal risk. 4th ed. Baltimore: Williams & Wilkins, 1994:808-13.
4. American Academy of Pediatrics Committee on Drugs: The transfer of drugs and other chemicals into human milk. Pediatrics 1994;93:137-50.

EDITOR'S NOTE: This letter was sent to the authors of "Conjunctivitis," who declined to reply.

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Correction

The article "Drugs for Conversion of Atrial Fibrillation" (August 1998, page 471) contained an error. On page 474, the fourth sentence in the first paragraph should read as follows: "In patients with atrial fibrillation refractory to external direct current cardioversion, internal transvenous cardioversion is an alternative means of restoring sinus rhythm."

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Copyright 1998 by the American Academy of Family Physicians.
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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.