LETTERS TO THE EDITOR Ethylene Glycol Poisoning To the E d i t o r : - - W e recently had a domestic tragedy, a fatal poisoning that could have been prevented. Our muchloved dog dashed ahead of us as we visited our beach house, which had been winterized by our pouring into the toilet bowls a special liquid containing ethylene glycol intended to protect plumbing against freezing. As she often did, she quenched her thirst by drinking from the toilet. We discovered her severely ill sometime later, but by the time we figured out what her illness might be, our veterinarian advised us it was too late for any treatment, including dialysis, to have been successful. Ethylene glycol, the active ingredient in antifreeze, is not uncommonly ingested by would-be suicides who develop severe metabolic acidosis, renal failure, and various neurologic symptoms.* The sweet taste of ethylene glycol makes it palatable in toxic quantities - - a s little as 100 mL may be fatal to humans. Its sweet taste, however, also makes it attractive to animals. Dogs are well-known to veterinarians to become frequently poisoned, often fatally, by lapping puddles of antifreeze left about on garage floors or driveways by the dogs' owners. Distraught humans may well phone human poison centers if they suspect a pet has been poisoned; antifreeze used to winterize plumbing is a distinct hazard to dogs. We have heard but been unable, despite several efforts, to confirm that in Great Britain poisonings, deliberate and accidental, by ethylene glycol are very much less frequent because by law a bitter substance is added to antifreeze. If this were true in the United States (and it sounds to us like a good idea), lives, both human and canine, might be saved.--ANTHONY CUCUZZEI,LA,MD, Medical Center of Delaware, Wilmington, DE 19807 Reference 1. Spillane t. Multiple cranial nerve deficits after ethylene glycol poisoning. Ann Emerg Med. 1991 ;20:208-20.
Stage ill Pressure Ulcers To the Editor:-- We read with interest the decision analysis by Drs. Siegler and Lavizzo-MoureyI on the management of stage III pressure ulcers. In the absence of data from randomized clinical trials, we agree that a decision analysis can provide useful information about whether surgical or conservative therapy is the optional approach. However, we take issue with their conclusion that under usual circumstances, myocutaneous flap surgery is preferable in the management of a moderately demented patient with a stage III pressure ulcer. Central to their conclusion is the assumption, based on data from Michocki and Lamy, z that only 10% of stage III pressure ulcers will heal with conservative therapies. We are perplexed, though, as to why these data were used in the present decision analysis. The results of Michocki and Lamy were based on only 22 patients. The stages of the pressure ulcers were not specified. Furthermore, these 22 patients, rather than being moderately demented but otherwise healthy, had severe underlying diseases as evidenced by the
deaths of 17 (77%) of these patients, the majority within two months of developing the ulcer. Recent articles have demonstrated that patients with stage III pressure ulcers can be successfully managed with conservative therapy. Our data with severely ill patients at a chronic care hospital demonstrated that even within six weeks of admission, 14% of stage III ulcers healed and 82% showed an improvement.3 With longer follow-up, many more of these pressure ulcers healed. Brandeis et al., in their study 4 of several hundred patients with stage III pressure ulcers, demonstrated a 75% one-year healing rate. While differences may exist between the patients in this study population and the decision analysis patients, the Brandeis results are likely to provide a more accurate estimate of the healing rate of stage III ulcers than are the results of the small, severely ill population studied by Michocki and Lamy. Whether a stage III pressure ulcer will heal with conservative therapy is dependent on the underlying condition of the patient. For those moderately demented patients whose mobility is not severely compromised, who maintain adequate nutritional intake, and who do not have severe coexisting illnesses, the rate of healing will be considerably higher than the 40% suggested in the sensitivity analysis. Only for the most severely ill nursing home patients, many of w h o m are likely to die in the near future, will the rate of healing be as low as 10%. These patients are not likely to be considered good surgical candidates.--DAN R. BERLOWITZ, MD, MPH,
Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA 01730; and SPENCERV. B. WILKING,MB, BS, MPH,Jewish Memorial Hospital, Boston University School o f Medicine, Boston, MA 02119 References 1. Siegler EL, Lavizzo-Mourey R. Management of stage III pressure ulcers in moderately demented nursing home residents. J Gen Intern Med. 1991;6:507-13. 2. Michocki RJ, Lamy PP. The problem of pressure sores in a nursing home population: statistical data. J Am Geriatr Soc. 1976; 24:323-8. 3. Berlowitz DR, Wilking SVB.The short-term outcome of pressure sores. J Am Geriatr Soc. 1991 ;38:748-52. 4. Brandeis GH, Morris JN, Nash DJ, Lipsitz LA. Epidemiology and natural history of pressure ulcers in elderly nursing home resident. JAMA. 1990;264:2905-9.
In r e p l y : - - W e appreciate the comments of Berlowitz and Wilking. We w o u l d like to make four points in response to their concerns. First, the decision analysis was constructed and tested before the publication of the two articles he cites. The data presented by Michocki and Lamy were all that were available at the time, and they were not far offfrom our clinical experience in a predominantly Medicaid nursing home. Second, major differences in healing rates within the nursing home may be due not just to patient comorbidities (after all, in their letter, the authors describe their population as "severely ill," too) but to differences in staffing, which are often tied to payer mix. The Brandeis et al. study cited by the authors (and, one can infer, the Berlowitz study) had a rate of self-pay patients much higher than those of most nursing homes, and, therefore, may have had higher staffing ratios, as 467
Stage ill Pressure Ulcers To the Editor:-- We read with interest the decision analysis by Drs. Siegler and Lavizzo-MoureyI on the management of stage III pressure ulcers. In the absence of data from randomized clinical trials, we agree that a decision analysis can provide useful information about whether surgical or conservative therapy is the optional approach. However, we take issue with their conclusion that under usual circumstances, myocutaneous flap surgery is preferable in the management of a moderately demented patient with a stage III pressure ulcer. Central to their conclusion is the assumption, based on data from Michocki and Lamy, z that only 10% of stage III pressure ulcers will heal with conservative therapies. We are perplexed, though, as to why these data were used in the present decision analysis. The results of Michocki and Lamy were based on only 22 patients. The stages of the pressure ulcers were not specified. Furthermore, these 22 patients, rather than being moderately demented but otherwise healthy, had severe underlying diseases as evidenced by the
deaths of 17 (77%) of these patients, the majority within two months of developing the ulcer. Recent articles have demonstrated that patients with stage III pressure ulcers can be successfully managed with conservative therapy. Our data with severely ill patients at a chronic care hospital demonstrated that even within six weeks of admission, 14% of stage III ulcers healed and 82% showed an improvement.3 With longer follow-up, many more of these pressure ulcers healed. Brandeis et al., in their study 4 of several hundred patients with stage III pressure ulcers, demonstrated a 75% one-year healing rate. While differences may exist between the patients in this study population and the decision analysis patients, the Brandeis results are likely to provide a more accurate estimate of the healing rate of stage III ulcers than are the results of the small, severely ill population studied by Michocki and Lamy. Whether a stage III pressure ulcer will heal with conservative therapy is dependent on the underlying condition of the patient. For those moderately demented patients whose mobility is not severely compromised, who maintain adequate nutritional intake, and who do not have severe coexisting illnesses, the rate of healing will be considerably higher than the 40% suggested in the sensitivity analysis. Only for the most severely ill nursing home patients, many of w h o m are likely to die in the near future, will the rate of healing be as low as 10%. These patients are not likely to be considered good surgical candidates.--DAN R. BERLOWITZ, MD, MPH,
Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA 01730; and SPENCERV. B. WILKING,MB, BS, MPH,Jewish Memorial Hospital, Boston University School o f Medicine, Boston, MA 02119 References 1. Siegler EL, Lavizzo-Mourey R. Management of stage III pressure ulcers in moderately demented nursing home residents. J Gen Intern Med. 1991;6:507-13. 2. Michocki RJ, Lamy PP. The problem of pressure sores in a nursing home population: statistical data. J Am Geriatr Soc. 1976; 24:323-8. 3. Berlowitz DR, Wilking SVB.The short-term outcome of pressure sores. J Am Geriatr Soc. 1991 ;38:748-52. 4. Brandeis GH, Morris JN, Nash DJ, Lipsitz LA. Epidemiology and natural history of pressure ulcers in elderly nursing home resident. JAMA. 1990;264:2905-9.
In r e p l y : - - W e appreciate the comments of Berlowitz and Wilking. We w o u l d like to make four points in response to their concerns. First, the decision analysis was constructed and tested before the publication of the two articles he cites. The data presented by Michocki and Lamy were all that were available at the time, and they were not far offfrom our clinical experience in a predominantly Medicaid nursing home. Second, major differences in healing rates within the nursing home may be due not just to patient comorbidities (after all, in their letter, the authors describe their population as "severely ill," too) but to differences in staffing, which are often tied to payer mix. The Brandeis et al. study cited by the authors (and, one can infer, the Berlowitz study) had a rate of self-pay patients much higher than those of most nursing homes, and, therefore, may have had higher staffing ratios, as 467
