Comment.— Meralgia paresthetica has been reported immediately after in¬
guinal herniorrhapy.2 However, our pa¬ tient had had this operation 10 years earlier without any complications. In a review of 150 cases of meralgia pares¬ thetica from the Mayo Clinic, Roches¬ ter, Minn, Ecker and Woltman3 found two cases after injections into the thigh: one after tetanus antitoxin injection and one after quinine injection. However, our patient swore that the syringe he was carrying in his pocket was empty. We suggest that, in patients with meral¬ gia paresthetica, a history of accidental or intentional injections into the thigh be sought. Marc Auriacombe, MD Vasant Dhopesh, MD Pratap Yagnik, MD VA Medical Center Philadelphia, Pa 1. Williams PH, Trzil KP. Management of meralgia paresthetica. J Neurosurg. 1991;74:76-80. 2. Rao T, Kim H, Mathrubhutham M, Lee KN. Meralgia paresthetica: unusual complication of inguinal hemior-
rhaphy. JAMA. 1977;237:2525.
3. Ecker AD, Woltman HW. Meralgia paresthetica: a report of one hundred and fifty cases. JAMA. 1938;110:1650\x=req-\ 1652.
Prognostic
Indicators in Metastatic Prostate Cancer To the Editor. \p=m-\Inreading the article by Chodak et al,1I was surprised to find that neither the differentiation nor the Gleason score of the tumors was considered in the analysis. Many physicians have the impression from clinical experience that patients with a high Gleason score or a poorly differentiated adenocarcinoma will have a poorer response to hormone manipulation than patients with more well\x=req-\ differentiated tumors. Since I expect that the data are available for each patient, I wonder if such an analysis has been or could be performed by this group. William E. Powers, MD
Harper Hospital
Gershenson Radiation Oncology Center Detroit, Mich 1. Chodak GW, Vogelzang NJ, Caplan RJ, Soloway M, Smith JA. Independent prognostic factors in patients with metastatic (stage D2) prostate cancer. JAMA. 1991;265: 618-621.
In Reply. \p=m-\Thecomment by Dr Powers is most appropriate regarding the possible relationship between tumor grade and prognosis for patients with metastatic disease. Our initial analysis did not include tumor grade because there was no centralized pathology review and this raised the potential for significant variability. Nevertheless, we have now reviewed all of the data and found in a univariate
analysis that, indeed, tumor grade was prognostic. However, in the multivariate analysis, the addition of tumor grade did not add
any significant predictability for prognosis. The four parameters presented in our paper remain the most important within our own study population. Gerald W. Chodak, MD University of Chicago (III)
Urologic-Oncology Group
Malaria, Mefloquine, Madness,
and Mosquito Nets To the Editor.\p=m-\Lobel et al1 point out that mefloquine is the most effective drug for malaria prophylaxis in sub-Saharan Africa, South America, Asia (except the Middle East), and Oceania. As well, mefloquine is recommended by the Centers for Disease Control as the drug of choice for malaria prophylaxis in these regions.2 We would like to caution against indiscriminate use of this drug. Although we agree that travelers at high risk of developing malaria should receive mefloquine, it is not necessarily the drug of choice for all persons traveling to the aforementioned areas because of its neuropsychiatric side effects.3 These may be viewed as minor in the case of inpatient treatment but could prove more important for self-medicated patients in a foreign country, where psychiatric symptoms may not be recognized as such because of language or cultural differences, or may not be properly treated. In our opinion, the choice of prophylactic drug should be based on individual traveler risk-benefit evaluation. Thus, until the frequency of mefloquine neuro¬ psychiatrie side effects is better estab¬ lished, short-term travelers to South America or to Southeast Asia who re¬ ceive antimalarial drugs because of a remote possibility that they may stray away from an otherwise safe itinerary, and travelers to India, should receive chloroquine and should be counseled on antimosquito measures and on the im¬ portance of seeking prompt medical at¬ tention in case of symptoms. Guy Lonergan, MD, MSc H\l=o^\pitalCharles LeMoyne Greenfield Park, Quebec 1. Lobel HO, Bernard KW, Williams SL, Hightower AW, Patchen LC, Campbell CC. Effectiveness and tolerance of long-term malaria prophylaxis with mefloquine: need for a better dosing regimen. JAMA. 1991;265:361-364. 2. Centers for Disease Control. Health Information for International Travel. Washington, DC: US Dept of Health and Human Services; 1990. Publication CDC 90-8280. 3. Steffen R, Heusser R, Machler R, et al. Malaria chemoprophylaxis among European tourists in tropical Africa: use, adverse reactions and efficacy. Bull World Health Organ.
1990;68:313-322.
To the Editor.\p=m-\For decades, the approach to malaria prophylaxis was to avoid getting bitten by mosquitoes, yet now in articles about malaria prophylaxis,1 advice on the prevention of mosquito bites is usually relegated to a short sentence or paragraph at the end, if that. It is long overdue that we should have re-
Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/07/2015
sumed expending our efforts on advising travelers to malarious areas and those who live there on the wisdom and methods of avoiding being bitten by ma-
laria-carrying mosquitoes. Simple expedients are available that will greatly reduce exposure to these dangerous conditions.
A. Holmes Pickering, MB, BS,
London, England
1. Lobel
FFOM, RCP
HO, Bernard KW, Williams SL, Hightower AW,
Patchen LC,
Campbell CC. Effectiveness and tolerance of long-term malaria prophylaxis with mefloquine: need for a
better dosing regimen. JAMA. 1991;265:361-364.
In Reply. \p=m-\Choosinga drug for prophylaxis against malaria requires weighing the risk of malaria infection against the effectiveness and tolerance of the drug. Mefloquine is the most effective drug available to prevent infections with chloroquine-resistant Plasmodium falciparum malaria, a potentially fatal infection. Available data indicate that the drug is well tolerated when used for prophylaxis at doses of 250 mg. The frequency and type of mild or moderate adverse events reported by users of mefloquine for prophylaxis do not differ from those reported by users of chloroquine for prophylaxis.1,2 Anecdotal case reports suggest that serious neurological and psychiatric events, such as convulsions or hallucinations, are possible with mefloquine for prophylaxis; however, such events have not been reported from prophylactic drug trials or from surveys of users of mefloquine for prophylaxis.1-4 These studies included a total of 18 591 persons.2 In contrast, therapeutic doses of mefloquine, 750 mg or higher, have been associated with neuropsychiatrie reac¬ tions.14 Mefloquine is, therefore, not recommended for self-treatment of sus¬ pected malaria." The Centers for Dis¬ ease Control recommend mefloquine as the drug of choice for malaria prophy¬ laxis for travelers to areas with chloroquine-resistant P falciparum. Alterna¬ tive drugs are available for persons who cannot tolerate mefloquine or for whom the drug is contraindicated.5 Hans O. Lobel, MD, MPH Eve M. Lackritz, MD Carlos C. Campbell, MD, MPH Centers for Disease Control Division of Parasitic Diseases Atlanta, Ga
1. Steffen R, Heusser R, Machler R, et al. Malaria chemoprophylaxis among European tourists in tropical Africa: use, adverse reactions and efficacy. Bull World Health Organ. 1990;68:313-322. 2. Lobel HO, Bernard KW, Williams SL, Hightower AW, Patchen LC, Campbell CC. Effectiveness and tolerance of long-term malaria prophylaxis with mefloquine: need for a better dosing regimen. JAMA. 1991;265:361-364. 3. World Health Organization. Practical Chemotherapy of Malaria. Geneva, Switzerland: World Health Organization; 1990. Technical Report Series 805. 4. World Health Organization. Central Nervous System Reactions Related to the Antimalarial Drug Mefloquine. Geneva, Switzerland: World Health Organization; 1989. WHO/MAL/89/1054 serial publication.
guinal herniorrhapy.2 However, our pa¬ tient had had this operation 10 years earlier without any complications. In a review of 150 cases of meralgia pares¬ thetica from the Mayo Clinic, Roches¬ ter, Minn, Ecker and Woltman3 found two cases after injections into the thigh: one after tetanus antitoxin injection and one after quinine injection. However, our patient swore that the syringe he was carrying in his pocket was empty. We suggest that, in patients with meral¬ gia paresthetica, a history of accidental or intentional injections into the thigh be sought. Marc Auriacombe, MD Vasant Dhopesh, MD Pratap Yagnik, MD VA Medical Center Philadelphia, Pa 1. Williams PH, Trzil KP. Management of meralgia paresthetica. J Neurosurg. 1991;74:76-80. 2. Rao T, Kim H, Mathrubhutham M, Lee KN. Meralgia paresthetica: unusual complication of inguinal hemior-
rhaphy. JAMA. 1977;237:2525.
3. Ecker AD, Woltman HW. Meralgia paresthetica: a report of one hundred and fifty cases. JAMA. 1938;110:1650\x=req-\ 1652.
Prognostic
Indicators in Metastatic Prostate Cancer To the Editor. \p=m-\Inreading the article by Chodak et al,1I was surprised to find that neither the differentiation nor the Gleason score of the tumors was considered in the analysis. Many physicians have the impression from clinical experience that patients with a high Gleason score or a poorly differentiated adenocarcinoma will have a poorer response to hormone manipulation than patients with more well\x=req-\ differentiated tumors. Since I expect that the data are available for each patient, I wonder if such an analysis has been or could be performed by this group. William E. Powers, MD
Harper Hospital
Gershenson Radiation Oncology Center Detroit, Mich 1. Chodak GW, Vogelzang NJ, Caplan RJ, Soloway M, Smith JA. Independent prognostic factors in patients with metastatic (stage D2) prostate cancer. JAMA. 1991;265: 618-621.
In Reply. \p=m-\Thecomment by Dr Powers is most appropriate regarding the possible relationship between tumor grade and prognosis for patients with metastatic disease. Our initial analysis did not include tumor grade because there was no centralized pathology review and this raised the potential for significant variability. Nevertheless, we have now reviewed all of the data and found in a univariate
analysis that, indeed, tumor grade was prognostic. However, in the multivariate analysis, the addition of tumor grade did not add
any significant predictability for prognosis. The four parameters presented in our paper remain the most important within our own study population. Gerald W. Chodak, MD University of Chicago (III)
Urologic-Oncology Group
Malaria, Mefloquine, Madness,
and Mosquito Nets To the Editor.\p=m-\Lobel et al1 point out that mefloquine is the most effective drug for malaria prophylaxis in sub-Saharan Africa, South America, Asia (except the Middle East), and Oceania. As well, mefloquine is recommended by the Centers for Disease Control as the drug of choice for malaria prophylaxis in these regions.2 We would like to caution against indiscriminate use of this drug. Although we agree that travelers at high risk of developing malaria should receive mefloquine, it is not necessarily the drug of choice for all persons traveling to the aforementioned areas because of its neuropsychiatric side effects.3 These may be viewed as minor in the case of inpatient treatment but could prove more important for self-medicated patients in a foreign country, where psychiatric symptoms may not be recognized as such because of language or cultural differences, or may not be properly treated. In our opinion, the choice of prophylactic drug should be based on individual traveler risk-benefit evaluation. Thus, until the frequency of mefloquine neuro¬ psychiatrie side effects is better estab¬ lished, short-term travelers to South America or to Southeast Asia who re¬ ceive antimalarial drugs because of a remote possibility that they may stray away from an otherwise safe itinerary, and travelers to India, should receive chloroquine and should be counseled on antimosquito measures and on the im¬ portance of seeking prompt medical at¬ tention in case of symptoms. Guy Lonergan, MD, MSc H\l=o^\pitalCharles LeMoyne Greenfield Park, Quebec 1. Lobel HO, Bernard KW, Williams SL, Hightower AW, Patchen LC, Campbell CC. Effectiveness and tolerance of long-term malaria prophylaxis with mefloquine: need for a better dosing regimen. JAMA. 1991;265:361-364. 2. Centers for Disease Control. Health Information for International Travel. Washington, DC: US Dept of Health and Human Services; 1990. Publication CDC 90-8280. 3. Steffen R, Heusser R, Machler R, et al. Malaria chemoprophylaxis among European tourists in tropical Africa: use, adverse reactions and efficacy. Bull World Health Organ.
1990;68:313-322.
To the Editor.\p=m-\For decades, the approach to malaria prophylaxis was to avoid getting bitten by mosquitoes, yet now in articles about malaria prophylaxis,1 advice on the prevention of mosquito bites is usually relegated to a short sentence or paragraph at the end, if that. It is long overdue that we should have re-
Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/07/2015
sumed expending our efforts on advising travelers to malarious areas and those who live there on the wisdom and methods of avoiding being bitten by ma-
laria-carrying mosquitoes. Simple expedients are available that will greatly reduce exposure to these dangerous conditions.
A. Holmes Pickering, MB, BS,
London, England
1. Lobel
FFOM, RCP
HO, Bernard KW, Williams SL, Hightower AW,
Patchen LC,
Campbell CC. Effectiveness and tolerance of long-term malaria prophylaxis with mefloquine: need for a
better dosing regimen. JAMA. 1991;265:361-364.
In Reply. \p=m-\Choosinga drug for prophylaxis against malaria requires weighing the risk of malaria infection against the effectiveness and tolerance of the drug. Mefloquine is the most effective drug available to prevent infections with chloroquine-resistant Plasmodium falciparum malaria, a potentially fatal infection. Available data indicate that the drug is well tolerated when used for prophylaxis at doses of 250 mg. The frequency and type of mild or moderate adverse events reported by users of mefloquine for prophylaxis do not differ from those reported by users of chloroquine for prophylaxis.1,2 Anecdotal case reports suggest that serious neurological and psychiatric events, such as convulsions or hallucinations, are possible with mefloquine for prophylaxis; however, such events have not been reported from prophylactic drug trials or from surveys of users of mefloquine for prophylaxis.1-4 These studies included a total of 18 591 persons.2 In contrast, therapeutic doses of mefloquine, 750 mg or higher, have been associated with neuropsychiatrie reac¬ tions.14 Mefloquine is, therefore, not recommended for self-treatment of sus¬ pected malaria." The Centers for Dis¬ ease Control recommend mefloquine as the drug of choice for malaria prophy¬ laxis for travelers to areas with chloroquine-resistant P falciparum. Alterna¬ tive drugs are available for persons who cannot tolerate mefloquine or for whom the drug is contraindicated.5 Hans O. Lobel, MD, MPH Eve M. Lackritz, MD Carlos C. Campbell, MD, MPH Centers for Disease Control Division of Parasitic Diseases Atlanta, Ga
1. Steffen R, Heusser R, Machler R, et al. Malaria chemoprophylaxis among European tourists in tropical Africa: use, adverse reactions and efficacy. Bull World Health Organ. 1990;68:313-322. 2. Lobel HO, Bernard KW, Williams SL, Hightower AW, Patchen LC, Campbell CC. Effectiveness and tolerance of long-term malaria prophylaxis with mefloquine: need for a better dosing regimen. JAMA. 1991;265:361-364. 3. World Health Organization. Practical Chemotherapy of Malaria. Geneva, Switzerland: World Health Organization; 1990. Technical Report Series 805. 4. World Health Organization. Central Nervous System Reactions Related to the Antimalarial Drug Mefloquine. Geneva, Switzerland: World Health Organization; 1989. WHO/MAL/89/1054 serial publication.
