over 90% of menstrually related TSS, it is found in only 50% of nonmenstrually related TSS. Recently other toxins (staphylococcal enterotoxins and Cl and streptococcal pyrogenic exotoxin A) have been implicated in TSS besides TSS toxin-1.8 Toxin assays can be useful in circumstances where the presenta¬ tion of TSS is atypical.12,13 In summary, this patient exhibited life-threatening third-degree heart block that occurred unexpectedly after apparent stabilization of her circulatory status with intravenous fluids and catecholamines. Both noninvasive transthoracic and temporary transvenous pac¬ ing were successful in maintaining the patient's circulatory stability. We be¬ lieve that clinicians should be aware of the rare occurrence of complete heart block in patients with TSS since successful management may require prompt recognition and intervention. WILLIAM S. MCMAHON, MD M. ELIZABETH PATRENOS, MD Division of Critical Care MICHAEL E. MCCONNELL, MD Department of Cardiology SAMUEL J. TILDEN, MD Division of Critical Care Department of Pediatrics University of Alabama at Birmingham 1600 7th Ave S Birmingham, AL 35233

Reprint requests to The Children's Hospital of Alabama, 1600 7th Ave S, Birmingham, AL 35233

Albert JD, Shires GT. Cachectin/tumor necrosis factor mediates changes of skeletal muscle plasma membrane potential. J Exp Med. 1986;164:1368\x=req-\ 1373. 11. Immerman RP, Greenman RL. Toxic shock syndrome associated with pyomyositis caused by a strain of Staphylococcus aureus that does not produce toxic shock syndrome toxin\p=n-\1. Infect Dis.

1989;57:291-294. 10. Tracey KJ, Lowry SF, Beutler B, Cerami A,

Medical University of South Carolina Children's Hospital Department of Pediatrics 171 Ashley Ave Charleston, SC 29425-3313

J

1987;156:505-507.

12. Olson RD, Stevens DL, Melish ME. Direct effects of purified staphyloccal toxic shock syndrome toxin\p=n-\1on myocardial function of isolated rabbit atria. Rev Infect Dis. 1989;11(suppl):313-314. 13. Tyson W, Wensley DF, Anderson JD, Fraser GC, Wilson EM. Atypical staphylococcal toxic shock syndrome: two fatal pediatric cases. Pediatr Infect Dis J. 1989;8:642-645.

Syndrome?

me.

ROBERT J.

GORLIN, MD Department of Oral Science University of Minnesota

515 Delaware St SE Minneapolis, MN 55455 1. Levkoff AH, Maize JC. Picture of the Month. AJDC. 1989;143:963-964.

Sir.\p=m-\Inthe Picture of the Month in the August 1989 issue of AJDC, the infant appears to have oculocerebrocutaneous

drome).

syndrome (Delleman's

syn-

CAROL CLERICUZIO, MD Division of Dysmorphology University of New Mexico Albuquerque, NM 87131

In Reply. \p=m-\Theskin appendages seen in our infant do seem to resemble those seen in oculocerebrocutaneous syndrome. The striking difference, however, was the contractile movement of these appendages and the histologic appearance of striated muscle bundles. Furthermore, with a normal brain computed tomographic scan, there was no diagnosable central nervous

in Bone Size and Cortical Area

a distinct pleasure to disthat Li et al1 have been able to confirm our earlier findings on black\x=req-\ white differences in skeletal mass and volume even in the preschool years. Despite differences in technology (direct photon absorptiometry vs radio\x=req-\ grammetry), in anatomical site (forearm vs hand), and in the samples considered, we are in agreement that black children (like black adolescents and adults) have larger skeletal dimensions once birth differences are erased, and they have larger bone masses as well.2-4 Since our sample of 1163 white children and 675 black children is considerable, it is possible to show how the relative magnitude of the differences increases from the first through the sixth year. Arranging our single-year data to agree with the 2-year age groupings used by Li et al, black-white differences in total bone width increased from 1% to more than 7% (Table). Differences in cortical area also increased, to more than 12% in the fifth to sixth years. Black boys and girls attain greater bone lengths and greater bone widths and have a much larger area of compact (ie, cortical) bone in the bone cross section than their white age-matched peers. To be sure, black boys and girls are also more advanced than white boys and girls in ossification timing and bone age, as we have shown for the same population samples,5 and some of the dimensional differences and dif¬ ferences in bone "quality" merely re¬ flect that fact. However, black adoles¬ cents and black adults also evidence larger bone widths and greater bone masses. Even in advanced adulthood these differences persist, despite much lower calcium intake and a greater prevalence of lactose intoler¬ ance in blacks.6 Although the direct-photon method does not separately meter medullary cavity expansion, the radiogramcover

Sir.\p=m-\Inthe Picture of the Month in the August 1989 issue of AJDC, Levkoff and Maize1 have described an infant with oculocerebrocutaneous syndrome, or at least it looks like that to

Lifelong Black-White Differences Sir.\p=m-\It is

Oculocerebrocutaneous

(Dr Tilden).

1. Todd J, Fishaut M, Kapral F, Welch T. Toxic shock syndrome associated with phage-group I staphylococci. Lancet. 1978;2:1116-1118. 2. Chesney PJ, Davis JP, Purdy WK, Wand PJ, Chesney RW. Clinical manifestations of toxic shock syndrome. JAMA. 1981;246:741-748. 3. Fisher CJ Jr, Horowitz BZ, Albertson TE. Cardiorespiratory failure in toxic shock syndrome: effect of dobutamine. Crit Care Med. 1985;13:160\x=req-\ 165. 4. Burns RJ, Menapace FJ. Acute reversible cardiomyopathy complicating toxic shock syndrome. Arch Intern Med. 1982;142:1032-1034. 5. Chesney PJ. Clinical aspects and spectrum of illness of toxic shock syndrome: overview. Rev Infect Dis. 1989;11(suppl):S1-S6. 6. Beland MJ, Hesslein PS, Findlay CD, Faerron-Angel JE, Williams WG, Rowe RD. Non-invasive transcutaneous cardiac pacing in children. PACE. 1987;10:1262-1270. 7. Nadas AS, Fyler DC. Pediatric Cardiology. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1972:210. 8. Tofte RW, Williams DN. Toxic shock syndrome: clinical and laboratory features in 15 patients. Ann Intern Med. 1981;94:149-156. 9. Fast DJ, Schlievert PM, Nelson RD. Toxic shock syndrome\p=n-\associatedstaphylococcal and streptococcal pyrogenic toxins are potent inducers of tumor necrosis factor production. Infect Immun.

1 year of age with normal motor milestones and verbalization. He has not had any seizure activity. ABNER H. LEVKOFF, MD

imately

system abnormality present. was no orbital cyst for-

Lastly, there

mation. Given all that, we believe the case did not warrant the diagnosis of oculocerebrocutaneous syndrome. Instead, we chose to describe what we saw as congenital rhabdomyomatous mesenchymal hamartoma. Recently, a corneal transplant was performed on the left eye; the retina appeared normal. An ultrasound examination of the right eye revealed

mild to moderate retinal detachment. At this writing, the infant is approx-

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Black-White Differences in Metacarpal Lengths, Breadths, and Cortical Areas of Preschool Children*

Bone

Cortical

Age, y

Black

White

Bone Width

Length

Area

1-2

81

120

1.25

3.68

-1.09

3-4

190

403

5.91

6.75

9.96

5-6

404

640

7.23

6.63

12.46

*Bone widths, bone lengths, and cortical area were measured or calculated as described by Garn,3 using age-specific data from Garn et al." Percent differences are simply (black values/white values) 100.

metric approach does allow us to con¬ sider the remodeling rates at both of the bone surfaces. Black boys and girls clearly have a higher rate of subperiosteal apposition combined with a higher rate of endosteal résorption; yet the rate of subperiosteal apposi¬ tion exceeds the rate of endosteal surface résorption such that cortical bone is also larger in amount. Though there is no direct evidence that direct-photon absorptiometry is than radiogrammore "accurate" metry for infants or small children, in the absence of destructive analyses of such tiny hands, the trends evidenced by the two methods are much the same. For the early ages considered, there is very little calcified spongy bone in either of the two bone sites (forearm or hand) to complicate the comparisons. What emerges from our separate studies is of considerable di¬ agnostic importance when the osteopenias, osteoporoses, and their causes are considered. Also, with the growing number of biracial progeny, there is further interest in how these early differences in bone size and tissue bone mass are inherited and main¬ tained, from infancy through the ninth decade and beyond.4 STANLEY M. GARN, PHD Center for Human Growth and

Development University of Michigan 300 N Ingalls, 10th Level Ann Arbor, MI 48109 1. Li J-Y, Specker BL, Ho ML, Tsang RC. Bone mineral content in black and white children 1 to 6 years of age. AJDC. 1989;143:1346-1349. 2. Garn SM, Poznanski AK. Early attainment of sex and race differences in skeletal mass. AJDC. 1987;141:1251-1252. 3. Garn SM. The Earlier Gain and the Later Loss of Cortical Bone. Springfield, Ill: Charles C Thomas Publisher, 1970:58,68,135. 4. Garn SM, Poznanski AK, Larson KC. Metacarpal lengths, cortical diameters and areas from the Ten-State Nutrition Survey including: estimated skeletal weights, weight, and stature for whites, blacks, and Mexican-Americans. In: Jaworski FG, ed. Proceedings of the First Work-

physicians reconsider the impor¬

tant role this time-honored practice serves.810 In most cases, only a small

percentage of

(%) Differences

No. of Children

that

shop on Bone Morphometry. Ottawa, Canada: University of Ottawa Press; 1976:367-391. 5. Garn SM, Sandusky ST, Nagy JM, McCann MB. Advanced skeletal development in low income Negro children. J Pediatr. 1972;80:965\x=req-\ 969. 6. Garn SM, Solomon MA, Friedl J. Calcium intake and bone quality in the elderly. Ecology Food Nutr. 1981;10:131-133.

House Calls Are Here to Stay Sir.\p=m-\Inhis essay on house calls, editorial board member Richard Blumberg reminisces about the good old days when doctors still made them.1 After discussing their advantages and disadvantages, he concludes that house calls will probably remain archaic. Like much of the public, however, Dr Blumberg mistakenly believes that house calls are a thing of the past. Family physicians and general practitioners continue to spend a small, but important, part of their time visiting patients in their homes. In a survey conducted by the American Academy of Family Physicians, half of the family physicians spent between 0 and 6 hours a weeks making house calls.2 A more recent national survey showed that almost two thirds (62%) of recent graduates of a family practice residency program made house calls: about half made them more often than once a month, and half less often. Eleven percent made between one and five home visits per week.3 Home visits are routinely per¬ formed in family practice residency programs. They have also been en¬ couraged in pediatrie residency train¬ ing programs.4 With the growing pop¬ ulation of frail and homebound elderly, home visits and home care are becom¬

ing an increasingly important aspect of geriatric medicine.6"7 Before accepting the myth that doc¬ tors don't make house calls anymore

(and thus letting those of us who don't make them off the hook), I suggest

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a

primary

care

physi¬

cian's practice is best served by a home visit. But for those few patients need¬ ing one, a home visit will usually end with an enlightened doctor and a very

grateful patient. JAY SIWEK, MD Department of Community and Family Medicine Georgetown University

School of Medicine 3001 Bladensburg Rd NE Washington, DC 20018 1. Blumberg RW. The house call: is it an anachronism that has seen its day? AJDC. 1989;143:

1281. 2. Profile of office-based practice of active Academy members. Kansas City, Mo: Division of Research and Information Services, American Academy of Family Physicians; 1980:31-32. 3. Knight AL, Adelman AM, Sobal JS. House call practices among young family physicians. J Fam Pract. 1989;29:638-642. 4. Berger LR, Samet KP. Home visits: extending the boundaries of comprehensive pediatric care. AJDC. 1981;135:812-814. 5. Burton JR. The house call: an important service for the frail elderly. J Am Geriatr Soc.

1985;33:291-293.

6. Rossman I. The geriatrician and the homebound patient. J Am Geriatr Soc. 1988;36:348\x=req-\ 354. 7. Ramsdell JW, Swart JA, Jackson JE, Renvall M. The yield of a home visit in the assessment of geriatric patients. J Am Geriatr Soc. 1989;37: 17-24. 8. Siwek J. House calls: current status and rationale. Am Fam Physician. 1985;31:169-174. 9. Loudon MF. Visiting patients in their

homes. JAMA. 1988;260:501-502. 10. McClintic WR. A piece of my mind: medicine. JAMA. 1989;262:1381.

family

Statistical Interpretation of Multiple Comparisons and Sample Size Sir.\p=m-\Cautionmust be exercised in interpreting the results of the study by Miller and Strunk1 regarding the deaths of children that were due to asthma. Even if the control group was perfectly matched with the study group, statistical analysis of the results should take at least two factors into account: (1) The greater the number of comparisons undertaken, the more likely it is that a "significant" low P value will be found on the basis of chance alone.2 In the study by Miller and Strunk, at least 30 comparisons were made between the control and study groups. Six variables were noted to be different between the two groups at P