had no information regarding either the Apgar scores or the birth weights of the children they were evaluating, overall bias was minimized. Third, the correspondents do not seem to be quarrelling with the data themselves, but rather with the pre¬ sentation of the data. Since the nonabused population was smaller than the abused population, we decided that the presentation of the absolute numbers without the percentages would have been misleading. For example, in Fig 3, 15 children in both groups had Apgar scores of 10. But, as is indicated, this represents 71.4% of the nonabused children and only 39.5% of the abused children. Thus, what are apparently equal numbers of children are not equal proportions of the
rately because many patients, although giving a history of fever, were afebrile in the office; of those with fever, 50% had a positive culture. Of interest to me was a finding of 75% positive cultures for yS-hemolytic streptococci whenever there was an association of tender lymph nodes and a pulse rate over 120 beats per minute
with the of Drs Pascoe and Davis regarding control of bias and presen¬ tation of data. However, we feel we have minimized bias and have pre¬ sented the data clearly and in a
/3-hemolytic streptococcal pharyngitis pending the culture results. RAFAEL LOPEZ, MD New York Medical College Flower and Fifth Avenue Hospitals
respective population. In conclusion, we agree concerns
nonmisleading
manner.
EDWARD GOLDSON, MD Department of Perinatology Family Care Center Children's Hospital 1056 E 19th Ave Denver, CO 80218
Diagnosing Streptococcal Pharyngitis Dear Sir.\p=m-\The article "A Simple Scorecard for the Tentative Diagnosis of Streptococcal Pharyngitis" by Breese that appeared in the Journal (131:514-517, 1977) pointed out that whenever a combination of factors, including clinical findings, are used a reasonably accurate prediction of streptococcal infection can be made. I carried out a small study among 109 patients previously known to this office who were seen during the months of September through April with acute onset of sore throat accompanied by enlarged anterior cervical lymph nodes. All patients were older than 5 years of age. The prevalence of \g=b\-hemolytic streptococci was 50%. Among those with tender nodes (69 patients) 58% had positive cultures for \g=b\-hemolyticstreptococci; and among those without tenderness (40 patients), 42% had positive cultures. The correlation of sore throat and elevated temperature with a positive culture could not be evaluated accu-
if febrile, and over 100 beats per minute if afebrile. Most of these 109 patients probably would have scored at or above 30 points on Breese's scorecard. With this score, more than 50% of his patients had positive cultures. It would appear that by following simple guidelines as those pointed out by Bréese and those suggested here, the physician in private practice may be able to make a tentative diagnosis of
Fifth Ave at 106th St New York, NY 10029
Reply.\p=m-\DrLopez' letter is of interus trying to increase the accuracy of a tentative diagnosis of streptococcal infection based on clinical criteria prior to the report of
In
est to those of
the culture. Using the information given on his patients and assuming fever to be present in those with swollen tender glands, each patient would score 31 points on the 9-point system as follows: Sore throat Season (September to
April) Age, 5 to
Points 4
3
(mean)
4 4 \s=deg\C 4 4 2 Headache (unknown)
10 years
glands Temperature, > 38 Cough (unknown)
Abnormal
Abnormal
known)
pharynx (un-
WBC count not done Total
3 3 31
Fifty-eight percent of such patients in his series were found to have positive cultures. This is almost identical to the 56.5% positive cultures found in our patients with the same score. Although such a score favors a streptococcal diagnosis it is in the questionable range, since approximately 40% would have negative cultures. Thus, the addition of one more item of considerable diagnostic value, such
the pulse rate, might increase the accuracy of the scoring system. This would add only slightly to the complexity of the scoring. I hope that Dr Lopez and others will pursue this as
intriguing lead.
BURTIS B. BREESE, MD Elmwood Pediatric Group 1580 Elmwood Ave Rochester, NY 14620
Anticonvulsant Medication
Sir.\p=m-\Iwas concerned by the statement made by Dr Smith in his article, "Teratogenicity of Anticonvulsive Medications," published in the December 1977 issue of the Journal (131:1337-1339, 1977), which suggested that women receiving anticonvulsant drugs, specifically phenytoin, should consider termination of a pregnancy if conception occurs while receiving this anticonvulsant agent. Results from my studies demonstrate a more optimistic outlook for infants exposed to phenytoin in utero, which would not indicate to me the medical need for a mother to consider elective abortion. I have now followed up 47 infants from birth until a maximum of 9 years of age who were born to mothers receiving anticonvulsant
agents.
The incidence of major malformations was 19% (nine children) (Table 1). The mothers in seven cases received more than one anticonvulsant agent. The most prevalent anomaly was congenital heart disease (six children). Three infants died and three infants required no corrective treatment for their heart defect. Three of these infants had failure to thrive in the immediate newborn peri¬ od. In general, the infants who had major malformations had lower psy¬ chometric scores at a later age (IQ range, 72 to 92), with the exception of the infant with the epidural cyst, who had an IQ of 125 at 6 years of age. This infant was only exposed to phenytoin. All infants had varying degrees of minor physical abnormalities de¬ scribed in previous reports.1·2 We now have the results of serial psychometric testing on 31 infants born to mothers receiving anticonvul¬ sant drugs. Thirteen mothers received only phenytoin during their pregnan¬ cy, three received phénobarbital alone, 13 received a combination of phenyt¬ oin and phénobarbital, and two received a combination of phenytoin,
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rately because many patients, although giving a history of fever, were afebrile in the office; of those with fever, 50% had a positive culture. Of interest to me was a finding of 75% positive cultures for yS-hemolytic streptococci whenever there was an association of tender lymph nodes and a pulse rate over 120 beats per minute
with the of Drs Pascoe and Davis regarding control of bias and presen¬ tation of data. However, we feel we have minimized bias and have pre¬ sented the data clearly and in a
/3-hemolytic streptococcal pharyngitis pending the culture results. RAFAEL LOPEZ, MD New York Medical College Flower and Fifth Avenue Hospitals
respective population. In conclusion, we agree concerns
nonmisleading
manner.
EDWARD GOLDSON, MD Department of Perinatology Family Care Center Children's Hospital 1056 E 19th Ave Denver, CO 80218
Diagnosing Streptococcal Pharyngitis Dear Sir.\p=m-\The article "A Simple Scorecard for the Tentative Diagnosis of Streptococcal Pharyngitis" by Breese that appeared in the Journal (131:514-517, 1977) pointed out that whenever a combination of factors, including clinical findings, are used a reasonably accurate prediction of streptococcal infection can be made. I carried out a small study among 109 patients previously known to this office who were seen during the months of September through April with acute onset of sore throat accompanied by enlarged anterior cervical lymph nodes. All patients were older than 5 years of age. The prevalence of \g=b\-hemolytic streptococci was 50%. Among those with tender nodes (69 patients) 58% had positive cultures for \g=b\-hemolyticstreptococci; and among those without tenderness (40 patients), 42% had positive cultures. The correlation of sore throat and elevated temperature with a positive culture could not be evaluated accu-
if febrile, and over 100 beats per minute if afebrile. Most of these 109 patients probably would have scored at or above 30 points on Breese's scorecard. With this score, more than 50% of his patients had positive cultures. It would appear that by following simple guidelines as those pointed out by Bréese and those suggested here, the physician in private practice may be able to make a tentative diagnosis of
Fifth Ave at 106th St New York, NY 10029
Reply.\p=m-\DrLopez' letter is of interus trying to increase the accuracy of a tentative diagnosis of streptococcal infection based on clinical criteria prior to the report of
In
est to those of
the culture. Using the information given on his patients and assuming fever to be present in those with swollen tender glands, each patient would score 31 points on the 9-point system as follows: Sore throat Season (September to
April) Age, 5 to
Points 4
3
(mean)
4 4 \s=deg\C 4 4 2 Headache (unknown)
10 years
glands Temperature, > 38 Cough (unknown)
Abnormal
Abnormal
known)
pharynx (un-
WBC count not done Total
3 3 31
Fifty-eight percent of such patients in his series were found to have positive cultures. This is almost identical to the 56.5% positive cultures found in our patients with the same score. Although such a score favors a streptococcal diagnosis it is in the questionable range, since approximately 40% would have negative cultures. Thus, the addition of one more item of considerable diagnostic value, such
the pulse rate, might increase the accuracy of the scoring system. This would add only slightly to the complexity of the scoring. I hope that Dr Lopez and others will pursue this as
intriguing lead.
BURTIS B. BREESE, MD Elmwood Pediatric Group 1580 Elmwood Ave Rochester, NY 14620
Anticonvulsant Medication
Sir.\p=m-\Iwas concerned by the statement made by Dr Smith in his article, "Teratogenicity of Anticonvulsive Medications," published in the December 1977 issue of the Journal (131:1337-1339, 1977), which suggested that women receiving anticonvulsant drugs, specifically phenytoin, should consider termination of a pregnancy if conception occurs while receiving this anticonvulsant agent. Results from my studies demonstrate a more optimistic outlook for infants exposed to phenytoin in utero, which would not indicate to me the medical need for a mother to consider elective abortion. I have now followed up 47 infants from birth until a maximum of 9 years of age who were born to mothers receiving anticonvulsant
agents.
The incidence of major malformations was 19% (nine children) (Table 1). The mothers in seven cases received more than one anticonvulsant agent. The most prevalent anomaly was congenital heart disease (six children). Three infants died and three infants required no corrective treatment for their heart defect. Three of these infants had failure to thrive in the immediate newborn peri¬ od. In general, the infants who had major malformations had lower psy¬ chometric scores at a later age (IQ range, 72 to 92), with the exception of the infant with the epidural cyst, who had an IQ of 125 at 6 years of age. This infant was only exposed to phenytoin. All infants had varying degrees of minor physical abnormalities de¬ scribed in previous reports.1·2 We now have the results of serial psychometric testing on 31 infants born to mothers receiving anticonvul¬ sant drugs. Thirteen mothers received only phenytoin during their pregnan¬ cy, three received phénobarbital alone, 13 received a combination of phenyt¬ oin and phénobarbital, and two received a combination of phenytoin,
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