New Requirements. —Congress recently passed The Copyright Revision Act of 1976, which affects JAMA's procedure for acceptance of submissions. Please refer to the "Instructions for Authors" page for details.
Letters will be published as space permits and at the discretion of the editor. They should be typewritten double-spaced, with five or fewer references, should not exceed 500 words in length, and will be subject to editing. Letters are not
acknowledged.
Neonatal Osteomyelitis Caused by Group B Streptococci To the Editor.\p=m-\McGuire and his
colleagues (238:2054, 1977) are indeed correct that osteomyelitis caused by group B \g=b\-hemolytic streptococci (GBS) is rare. However, their assertion that there are only five reported cases of osteomyelitis from GBS in neonates
is erroneous. There are three additional neonatal cases of osteomyelitis caused by GBS.1-3 In one of these three cases,1 GBS were also isolated from vaginal smears of the mother, whereas in the remaining two instances2-3 GBS were not found in vaginal-cervical smears or in breast milk from the mothers five to six weeks after
delivery.
Jata S. Ghosh
patient but also could be to the patient's detriment if the diagnosis is bronchial asthma. If the pulmonary edema is secondary to an acute asthmatic attack,2 then the diuretics will not be helpful in differentiating between the two conditions. We still believe that there does not exist a better instrument to distinguish be¬ tween the two conditions than a good bedside history, examination, and clinical judgment, even in the puz¬
zling cases.
Beni Habot, MD VALERY PORTNOI, MD Jewish Institute for Geriatric Care Long Island Jewish-Hillside Medical Center
1. VanArsdale PP Jr, Paul GH: Drug therapy in the management of asthma. Ann Intern Med 87:68-74,1977.
2. Stalcup SA, Mellins RB: Mechanical forces producing pulmonary edema in acute asthma. N Engl J Med 11:592-596,1977.
Ardmore, Pa 1. Kexel G: Occurrence of B
streptococci
in humans. Z
Hyg Infektionskr 151:336-348, 1965. 2. Ragnhildsveit E, Ose L: Neonatal osteomyelitis caused by group B streptococci. Scand J Infect Dis 8:219\x=req-\ 221,1976. 3. Henderson KC, Roberts RS, Dorsey SB: Group B \g=b\ x=req-\ hemolytic streptococcal osteomyelitis in a neonate. Pediatrics 59(suppl, pt 2):1053-1054, 1977.
Separating Cardiac From Pulmonary Dyspnea To the Editor.\p=m-\Inthe article "Separating Cardiac From Pulmonary Dyspnea" by Raffin and Theodore (238:2066-2067, 1977), it is recommended to give diuretics as a method
of differentiation between cardiac asthma and bronchial asthma. A rapid response to diuretics will support the diagnosis of cardiac asthma. We would like to call attention to the danger of this approach in the case of bronchial asthma. The current recommendation for the treatment of bronchial asthma universally includes the fluid administration to prevent dehydration and inspissation of bronchial
secretions,1 which could produce
a
mechanical obstruction of the bronchial tree and worsen the patient's status. Administering diuretics not only will not be helpful for the Edited
by John
D. Archer, MD, Senior Editor.
In Reply.\p=m-\We are anxious to reply to the complaint of Portnoi and Habot. In the interests of good patient care, they are apparently concerned with our recommendation to use an empiric diuretic trial to separate difficult cases of bronchial vs cardiac asthma. Essentially, they felt diuresis was too dangerous to try, even in problem cases, because of the risk of worsening a bronchial asthma attack by drying bronchial secretions. We could understand this concern if our article had called for a rigorous diuretic trial as an early routine diagnostic maneuver. However, our article was quite clear in advising a thoughtful diuretic trial after careful attempts to establish either a cardiac or pulmonary cause had failed. We do not understand their comment, "Administering diuretics not only will not be helpful. ." Did they mean to say that diuresis is not helpful in cardiac asthma? This is certainly incorrect. Also, they conclude by stating that puzzling cases of cardiac bronchial asthma could be distinguished using routine ap¬ proaches. This distorts the thrust of our article. By definition, the puzzling cases we all have confronted have not .
Downloaded From: http://jama.jamanetwork.com/ by a Carleton University User on 06/18/2015
been resolved by routine approaches. It is in this context that a careful, empiric diuretic trial may be useful. Finally, although many clinicians recommend rigorous intravenous or oral fluid administration for an acute asthmatic attack, scientific validation is lacking. In a patient with cardiac asthma, such treatment would be dangerous. Local airway hydration is the therapeutic goal. Only in the systemically dehydrated bronchial asthmatic patient does vigorous fluid administration make sense beyond airway hydration. Thus, if Drs Habot and Portnoi are concerned with diur¬ esis with occult bronchial asthma, they should be equally concerned about vigorous fluid administration with occult cardiac asthma. Thomas A. Raffin, MD James Theodore, MD Stanford
University Medical Center Stanford, Calif
Treatment of Intracranial
Aneurysms To the Editor.\p=m-\The5% mortality for patients with intracranial aneurysms reported by Ballenger et al (237:1845, 1977) is a tribute to the care their patients receive. I would question, however, whether this low rate can be
attributed to surgery. Ballenger et al state that of patients who have survived the first subarachnoid hemorrhage (SAH), "more than 40% will suffer a recurrence within the first eight weeks, and 60% of these second hemorrhages will prove to be fatal. The overwhelming majority of such instances will occur in the first two weeks after the initial hemorrhage. One day after the initial SAH, a conservatively treated patient in good condition has only a 50% chance of surviving one year. The chief advantage of intracranial surgery over alternative forms of treatment is that it offers the patient definitive protection from recurrent hemorrhage with its attendant mortality." Or does it? The average time to surgery in this study was 17.8 days, too late to avoid the "overwhelming majority" of re¬ current hemorrhages. The one-year survival rate of 50% applies, as noted, to a patient one day after initial SAH. A patient who already has survived 17.8 days has a much higher proba¬ bility of survival. Alvord et al' have devised a table of probabilities of survival at two months and two years for medically treated patients based on the clinical grade of the patient and the number of days after subarachnoid hemorrhage to initiation of
treatment. The patients of Ballenger et al were in fairly good condition, with an average clinical grade of 2.2. Using these two measurements and
Alvord's table, the predicted survival rate at six months would be at least 90%, very close to the actual survival rate of 95% in this study. In other words, we are dealing with a difference in survival rates of approximately 5%, not 20% to 45%, as implied by this article. Is 5% (or even 10% substantial? I think not when the controls are from other hospitals and had been treated five to ten years earlier. Small differences in clinical grading alone could account for this variation. Use of clinical grade and time from SAH to treat¬ ment leaves out many other impor¬ tant measurements such as age (the average age in this study is 42 years, which is relatively young) and asso¬ ciated medical conditions, ie, severe diabetes or hypertension. The results of microsurgery are encouraging, but the definitive, randomized, controlled study still needs to be done. Robert Karis, MD
St Louis University School of Medicine St Louis
1. Alvord EC
et al: Sub-
Bailey WL, ruptured aneurysms: A simple method of estimating prognosis. Arch Neurol Jr, Loeser JD, arachnoid hemorrhage due to
27:273-284, 1972.
In Reply.\p=m-\We appreciate the comments of Dr Karis on our article. Certainly, we would have to agree with his conclusions based on the statistics that he uses to support them. On the other hand, we believe that the statistics that we have presented from the literature do demonstrate the superior results of microsurgery in centers where many of these patients are treated. Consequently, we would be uncomfortable
participating in a "definitive, randomized, controlled study." Cerin
tainly, there are issues here that can only be resolved by such a study, but
do not believe that these would alter the fundamental conclusion that direct microsurgical intervention is superior to conservative treatment or we
carotid ligation. Once again, we are grateful for his kind comments, especially in regard to the level of care our patients have received. Michael Salcman, MD Thomas B. Ducker, MD
University
of
Maryland
Baltimore
Nontreatment of Hip Fractures To the Editor.\p=m-\Lyon and Nevins advocate persuasively the "nontreatment" of hip fractures in senile
patients (238:1175,1977). They realize clearly (as shown by the opening sentence of their withhold surgery
discussion) that to deliberately in the
management of fractured femoral
necks in elderly patients is to fly in the face of the orthodox opinions of many specialists in orthopedics and in geriatric medicine, but they emphasize that their policy is based on an assessment of the severity of brain failure in their patients, relating this to the likelihood of successful mobilization of the patients. They point out the merits of their conservative approach\p=m-\partlyhumanitarian,
partly pragmatic, ic.
and
partly econom-
Such a policy calls for certain essential conditions: (1) the prognosis of the patients' chances of mobilization must be made with great care and be based on sufficient hard data; (2) good nursing care, of the standard described by the authors, is a sine qua non.
regard to the first condition, ready a diagnosis of senility of a degree sufficient to prevent rehabili¬ With
too
tation will lead to unwarranted num¬ bers of patients being left as chairbound or bed-bound invalids; this would negate the humanitarian and economic benefits of the conservative approach. The stereotyped responses of many people (including physicians) to old age and its problems could lead to an excess of such overly-pessi¬ mistic prognostications. Careful as¬ sessment of the prefracture mental state is essential. With regard to the second condi¬ tion, great tribute should be paid to the nursing staff who cared for the nonsurgical patients of Lyon and Nevins. Home nursing and nursing in other hospitals and nursing homes must be as good if the noninterven¬ tion policy is to be adopted in selected
patients.
It also should be borne in mind that may be wrong and that even the most unlikely patient may walk again, possibly needing help; even a limited degree of mobility (short of walking) ultimately attained may assist in the ease of nursing the patient thereafter. Lyon and Nevins have written a bold report and have justified their approach by their own results, but less discriminating physicians could in fact, do more harm than good by adopting the "no-operating" policy too often. This could result in an unnecessary increase in invalidism and the need for institutionalized extended care, and it would be a
prognosis
Downloaded From: http://jama.jamanetwork.com/ by a Carleton University User on 06/18/2015
disservice to the elderly in the community. In view of the wellknown frequency of this injury in old age and the growing numbers of the elderly in the United States, such small seeds can rapidly grow into influences for good or otherwise. As a physician who has, until recently, spent 16 years specializing in the medical care of the elderly in England, I urge caution in adopting
conservative or inactive methods of treatment in elderly patients. Experi¬ ence teaches that a dynamic and opti¬ mistic approach usually gives the best results in the aged; any decision to act otherwise must be based on as thor¬ ough an assessment and diagnosis of the patient's condition as would be made in those with well-preserved mental function or at younger ages. In conclusion, I would deplore the use of the word "senility" to mean brain failure. It implies an advanced and irreversible situation without hope and without everything, and it encourages woolly thinking and a pessimistic attitude. The latter may sometimes be justified; the former, never. Dennis E. Hyams, MB, FRCP Westfield, NJ
In Reply.\p=m-\We thank Dr Hyams for his thoughtful comments about our article. He raises an important question: will we (or other physicians) unnecessarily confine some patients to bed and chair for the remainder of their lives by not treating their hip fractures? The patients who were the subject of our report all had severe organic mental syndromes prior to their fractures. (Although our methods of evaluation of mental status were not discussed in the report, we always make every effort to exclude severe depression, thyroid diseases, intercurrent infection, anemia, and other treatable causes of organic mental syndrome before labeling a patient as senile.) The five conservatively treated patients, as well as three more that we have treated similarly since the report was submitted for
publication,
from
were one or more
already suffering chronic illnesses
requiring prolonged or permanent nursing home care. Only one was independently ambulatory before the hip fracture. Our prior experience, typified by but by no means limited to the four surgically treated patients, indicated that these severely impaired patients had virtually no chance of regaining good function. We believe that for many patients suffering from | chronic, progressive illness, there
Letters will be published as space permits and at the discretion of the editor. They should be typewritten double-spaced, with five or fewer references, should not exceed 500 words in length, and will be subject to editing. Letters are not
acknowledged.
Neonatal Osteomyelitis Caused by Group B Streptococci To the Editor.\p=m-\McGuire and his
colleagues (238:2054, 1977) are indeed correct that osteomyelitis caused by group B \g=b\-hemolytic streptococci (GBS) is rare. However, their assertion that there are only five reported cases of osteomyelitis from GBS in neonates
is erroneous. There are three additional neonatal cases of osteomyelitis caused by GBS.1-3 In one of these three cases,1 GBS were also isolated from vaginal smears of the mother, whereas in the remaining two instances2-3 GBS were not found in vaginal-cervical smears or in breast milk from the mothers five to six weeks after
delivery.
Jata S. Ghosh
patient but also could be to the patient's detriment if the diagnosis is bronchial asthma. If the pulmonary edema is secondary to an acute asthmatic attack,2 then the diuretics will not be helpful in differentiating between the two conditions. We still believe that there does not exist a better instrument to distinguish be¬ tween the two conditions than a good bedside history, examination, and clinical judgment, even in the puz¬
zling cases.
Beni Habot, MD VALERY PORTNOI, MD Jewish Institute for Geriatric Care Long Island Jewish-Hillside Medical Center
1. VanArsdale PP Jr, Paul GH: Drug therapy in the management of asthma. Ann Intern Med 87:68-74,1977.
2. Stalcup SA, Mellins RB: Mechanical forces producing pulmonary edema in acute asthma. N Engl J Med 11:592-596,1977.
Ardmore, Pa 1. Kexel G: Occurrence of B
streptococci
in humans. Z
Hyg Infektionskr 151:336-348, 1965. 2. Ragnhildsveit E, Ose L: Neonatal osteomyelitis caused by group B streptococci. Scand J Infect Dis 8:219\x=req-\ 221,1976. 3. Henderson KC, Roberts RS, Dorsey SB: Group B \g=b\ x=req-\ hemolytic streptococcal osteomyelitis in a neonate. Pediatrics 59(suppl, pt 2):1053-1054, 1977.
Separating Cardiac From Pulmonary Dyspnea To the Editor.\p=m-\Inthe article "Separating Cardiac From Pulmonary Dyspnea" by Raffin and Theodore (238:2066-2067, 1977), it is recommended to give diuretics as a method
of differentiation between cardiac asthma and bronchial asthma. A rapid response to diuretics will support the diagnosis of cardiac asthma. We would like to call attention to the danger of this approach in the case of bronchial asthma. The current recommendation for the treatment of bronchial asthma universally includes the fluid administration to prevent dehydration and inspissation of bronchial
secretions,1 which could produce
a
mechanical obstruction of the bronchial tree and worsen the patient's status. Administering diuretics not only will not be helpful for the Edited
by John
D. Archer, MD, Senior Editor.
In Reply.\p=m-\We are anxious to reply to the complaint of Portnoi and Habot. In the interests of good patient care, they are apparently concerned with our recommendation to use an empiric diuretic trial to separate difficult cases of bronchial vs cardiac asthma. Essentially, they felt diuresis was too dangerous to try, even in problem cases, because of the risk of worsening a bronchial asthma attack by drying bronchial secretions. We could understand this concern if our article had called for a rigorous diuretic trial as an early routine diagnostic maneuver. However, our article was quite clear in advising a thoughtful diuretic trial after careful attempts to establish either a cardiac or pulmonary cause had failed. We do not understand their comment, "Administering diuretics not only will not be helpful. ." Did they mean to say that diuresis is not helpful in cardiac asthma? This is certainly incorrect. Also, they conclude by stating that puzzling cases of cardiac bronchial asthma could be distinguished using routine ap¬ proaches. This distorts the thrust of our article. By definition, the puzzling cases we all have confronted have not .
Downloaded From: http://jama.jamanetwork.com/ by a Carleton University User on 06/18/2015
been resolved by routine approaches. It is in this context that a careful, empiric diuretic trial may be useful. Finally, although many clinicians recommend rigorous intravenous or oral fluid administration for an acute asthmatic attack, scientific validation is lacking. In a patient with cardiac asthma, such treatment would be dangerous. Local airway hydration is the therapeutic goal. Only in the systemically dehydrated bronchial asthmatic patient does vigorous fluid administration make sense beyond airway hydration. Thus, if Drs Habot and Portnoi are concerned with diur¬ esis with occult bronchial asthma, they should be equally concerned about vigorous fluid administration with occult cardiac asthma. Thomas A. Raffin, MD James Theodore, MD Stanford
University Medical Center Stanford, Calif
Treatment of Intracranial
Aneurysms To the Editor.\p=m-\The5% mortality for patients with intracranial aneurysms reported by Ballenger et al (237:1845, 1977) is a tribute to the care their patients receive. I would question, however, whether this low rate can be
attributed to surgery. Ballenger et al state that of patients who have survived the first subarachnoid hemorrhage (SAH), "more than 40% will suffer a recurrence within the first eight weeks, and 60% of these second hemorrhages will prove to be fatal. The overwhelming majority of such instances will occur in the first two weeks after the initial hemorrhage. One day after the initial SAH, a conservatively treated patient in good condition has only a 50% chance of surviving one year. The chief advantage of intracranial surgery over alternative forms of treatment is that it offers the patient definitive protection from recurrent hemorrhage with its attendant mortality." Or does it? The average time to surgery in this study was 17.8 days, too late to avoid the "overwhelming majority" of re¬ current hemorrhages. The one-year survival rate of 50% applies, as noted, to a patient one day after initial SAH. A patient who already has survived 17.8 days has a much higher proba¬ bility of survival. Alvord et al' have devised a table of probabilities of survival at two months and two years for medically treated patients based on the clinical grade of the patient and the number of days after subarachnoid hemorrhage to initiation of
treatment. The patients of Ballenger et al were in fairly good condition, with an average clinical grade of 2.2. Using these two measurements and
Alvord's table, the predicted survival rate at six months would be at least 90%, very close to the actual survival rate of 95% in this study. In other words, we are dealing with a difference in survival rates of approximately 5%, not 20% to 45%, as implied by this article. Is 5% (or even 10% substantial? I think not when the controls are from other hospitals and had been treated five to ten years earlier. Small differences in clinical grading alone could account for this variation. Use of clinical grade and time from SAH to treat¬ ment leaves out many other impor¬ tant measurements such as age (the average age in this study is 42 years, which is relatively young) and asso¬ ciated medical conditions, ie, severe diabetes or hypertension. The results of microsurgery are encouraging, but the definitive, randomized, controlled study still needs to be done. Robert Karis, MD
St Louis University School of Medicine St Louis
1. Alvord EC
et al: Sub-
Bailey WL, ruptured aneurysms: A simple method of estimating prognosis. Arch Neurol Jr, Loeser JD, arachnoid hemorrhage due to
27:273-284, 1972.
In Reply.\p=m-\We appreciate the comments of Dr Karis on our article. Certainly, we would have to agree with his conclusions based on the statistics that he uses to support them. On the other hand, we believe that the statistics that we have presented from the literature do demonstrate the superior results of microsurgery in centers where many of these patients are treated. Consequently, we would be uncomfortable
participating in a "definitive, randomized, controlled study." Cerin
tainly, there are issues here that can only be resolved by such a study, but
do not believe that these would alter the fundamental conclusion that direct microsurgical intervention is superior to conservative treatment or we
carotid ligation. Once again, we are grateful for his kind comments, especially in regard to the level of care our patients have received. Michael Salcman, MD Thomas B. Ducker, MD
University
of
Maryland
Baltimore
Nontreatment of Hip Fractures To the Editor.\p=m-\Lyon and Nevins advocate persuasively the "nontreatment" of hip fractures in senile
patients (238:1175,1977). They realize clearly (as shown by the opening sentence of their withhold surgery
discussion) that to deliberately in the
management of fractured femoral
necks in elderly patients is to fly in the face of the orthodox opinions of many specialists in orthopedics and in geriatric medicine, but they emphasize that their policy is based on an assessment of the severity of brain failure in their patients, relating this to the likelihood of successful mobilization of the patients. They point out the merits of their conservative approach\p=m-\partlyhumanitarian,
partly pragmatic, ic.
and
partly econom-
Such a policy calls for certain essential conditions: (1) the prognosis of the patients' chances of mobilization must be made with great care and be based on sufficient hard data; (2) good nursing care, of the standard described by the authors, is a sine qua non.
regard to the first condition, ready a diagnosis of senility of a degree sufficient to prevent rehabili¬ With
too
tation will lead to unwarranted num¬ bers of patients being left as chairbound or bed-bound invalids; this would negate the humanitarian and economic benefits of the conservative approach. The stereotyped responses of many people (including physicians) to old age and its problems could lead to an excess of such overly-pessi¬ mistic prognostications. Careful as¬ sessment of the prefracture mental state is essential. With regard to the second condi¬ tion, great tribute should be paid to the nursing staff who cared for the nonsurgical patients of Lyon and Nevins. Home nursing and nursing in other hospitals and nursing homes must be as good if the noninterven¬ tion policy is to be adopted in selected
patients.
It also should be borne in mind that may be wrong and that even the most unlikely patient may walk again, possibly needing help; even a limited degree of mobility (short of walking) ultimately attained may assist in the ease of nursing the patient thereafter. Lyon and Nevins have written a bold report and have justified their approach by their own results, but less discriminating physicians could in fact, do more harm than good by adopting the "no-operating" policy too often. This could result in an unnecessary increase in invalidism and the need for institutionalized extended care, and it would be a
prognosis
Downloaded From: http://jama.jamanetwork.com/ by a Carleton University User on 06/18/2015
disservice to the elderly in the community. In view of the wellknown frequency of this injury in old age and the growing numbers of the elderly in the United States, such small seeds can rapidly grow into influences for good or otherwise. As a physician who has, until recently, spent 16 years specializing in the medical care of the elderly in England, I urge caution in adopting
conservative or inactive methods of treatment in elderly patients. Experi¬ ence teaches that a dynamic and opti¬ mistic approach usually gives the best results in the aged; any decision to act otherwise must be based on as thor¬ ough an assessment and diagnosis of the patient's condition as would be made in those with well-preserved mental function or at younger ages. In conclusion, I would deplore the use of the word "senility" to mean brain failure. It implies an advanced and irreversible situation without hope and without everything, and it encourages woolly thinking and a pessimistic attitude. The latter may sometimes be justified; the former, never. Dennis E. Hyams, MB, FRCP Westfield, NJ
In Reply.\p=m-\We thank Dr Hyams for his thoughtful comments about our article. He raises an important question: will we (or other physicians) unnecessarily confine some patients to bed and chair for the remainder of their lives by not treating their hip fractures? The patients who were the subject of our report all had severe organic mental syndromes prior to their fractures. (Although our methods of evaluation of mental status were not discussed in the report, we always make every effort to exclude severe depression, thyroid diseases, intercurrent infection, anemia, and other treatable causes of organic mental syndrome before labeling a patient as senile.) The five conservatively treated patients, as well as three more that we have treated similarly since the report was submitted for
publication,
from
were one or more
already suffering chronic illnesses
requiring prolonged or permanent nursing home care. Only one was independently ambulatory before the hip fracture. Our prior experience, typified by but by no means limited to the four surgically treated patients, indicated that these severely impaired patients had virtually no chance of regaining good function. We believe that for many patients suffering from | chronic, progressive illness, there
