Letters to R eferences 1. Geyman JP, Brown TC, Rivers K Referrals in fam ily practice: A Compaq five study by geographic region and the Editor practice setting. J Fam Pract 3:163,1975 2 . Slabaugh RC, Ringiewicz M, Babi- neau RA: The hospital work at a family practice group in a medium sized com­ munity in New England. J Fam Pract 1V 287, 1980 The Journal welcomes Letters to the Editor; if found suitable, they will be published as space allows. Letters should be typed double-spaced, should not exceed 400 words, and are subject to abridgment and other editorial changes in accordance with journal style. Use of the Family APGAR To the Editor: Over the past four years, Smilk- stein et al have published several articles13 in the Journal o f Family Practice concerning the validity and reliability of the Family The Consultation Note both the patient’s outpatient and APGAR questionnaire as a meas­ hospitalized care. A consultation ure of family function. The ques­ To the Editor: note should therefore be consid­ tionnaire was designed to measure Family physicians provide the ered one of the key elements in a a family member's satisfaction with major portion of the primary care successful consultation. five empirical components of fam­ for their patients. Studies have The consultation note should ily function. Since the publication shown that family physicians han­ include (1) a brief statement of the of their first paper in 1978, Smilk- dle 95 to 98 percent of the definitive problem and reason for the consul­ stein et al have attempted to vali­ care for their patients in the office.1 tation, (2) a master problem list to date the instrument by administer­ Similarly, family physicians main­ put the present illness into per­ ing it to married university stu­ tain a large portion of the direct spective for the consultation, (3) dents, adult community mental care for their hospitalized patients. history and physical findings that health patients, college students in In the hospital setting, however, pertain to the present consultation, an introductory psychology course, the consultation or referral rate is (4) laboratory and x-ray findings, adults in a university psychiatric much higher.2 The total care of the current and attempted therapies, clinic, Taiwanese students aged 10 family cannot be met by any single (5) specific questions the family to 13 years, and last, new patients physician. When more specialized physician wants answered, (6) a in a university family medical care is needed, the continuum of statement specifying the level of practice. care naturally extends into the care desired of the consultant, ie, I applaud the efforts of Dr. arena of consultation and referral. consultation vs referral, and (7) a Smilkstein and colleagues. The de­ The consultation process breaks statement requesting follow-up. velopment of an instrument for the down when open communication is The consultation note is not so rapid screening of family function not maintained. If this occurs, con­ radical an idea as it may first is beneficial to both practitioners tinuity of care is lost, and the appear. Although it requires more and researchers interested in family patient is the one who ultimately time on the part of the family phy­ epidemiology and health care utili­ suffers. sician to formulate and write, the zation. At the Duke University A written consultation note or benefits of providing optimal con­ Family Medicine Center, a similar form better defines the patient’s sultant care for the patient are sure­ instrument has been developed problems, workups done, reasons ly worth it. over the past two years. Different for consultation, and goals of the Joseph E. Ross, MD family characteristics have been consultation. This form should Office for Family Practice empirically chosen for our ques­ improve communication and better Rockford School of Medicine tionnaire based on our reading of delineate the consultant's role in Rockford, Illinois the social science and family therapy

882 THE JOURNAL OF FAMILY PRACTICE, VOL. 16, NO. 5, 1983 LETTERS TO THE EDITOR

literature. I have administered the comparison is not valid because respond to Dr. Hoffman’s letter in questionnaire to 154 individuals different facets of a patient’s well­ which he questioned the efficacy of from 128 separate families. I have being are measured in each study the Family APGAR in identifying not used the same criteria as and that the study populations are psychosocial problems. In this Smilkstein to validate this instru­ not comparable. connection I would like to make the ment, but a comparison of my initial I am concerned, however, that following comments: findings with those of Smilkstein the Family APGAR questionnaire 1. The Family APGAR is a serves to highlight problems facing may be relatively insensitive, lead­ screening instrument for family investigators of family function. ing to falsely labeling sick families function. The questionnaire consists of 13 as well families. This is important 2. One cannot always equate the questions with the total score rang­ because physicians who are sensi­ level of family function with the ing from 0 to 100. Equal to or below tive to family problems may easily psychosocial status of the patient. 62 was empirically defined as a identify patients with highly dys­ A patient with family dysfunction sick or poorly functioning family. functional families. But a family will almost invariably manifest Twenty-four percent of the inter­ function questionnaire, if it is to be psychosocial problems; however, viewees in my study scored in the valuable, must entice patients who patients with psychosocial prob­ poorly functioning category. In two otherwise would discuss with their lems may not have family dysfunc­ articles recently published in the physician only somatic complaints tion. Psychosocial problems result Journal,4-5 the percentage of pa­ to reveal dissatisfaction with their from stressful life events that are tients with psychosocial diagnoses family and its functioning. By ask­ not buffered or modified by a pa­ in family practices in Sacramento ing only five broad questions, the tient’s resources (primarily family, and Canada ranged from 30.5 to Family APGAR may too easily friends, and groups). Thus one or 33.3 percent. By comparison, the permit a patient to deny family more overwhelming stressful life distribution of Family APGAR problems. events may cause psychosocial problems even with satisfactory scores achieved by patients in the Richard E. Hoffman, MD university family practice showed School of Hygiene and family function. 15.3 percent scored less than 7 out Public Health 3. The goal of the Family APGAR questionnaire is to help of a total possible score of 10; these Johns Hopkins University respondents were considered to Baltimore, Maryland the physician in assessing whether have moderately to highly dysfunc­ the family is the source of the pa­ References tient’s psychosocial problem or a tional families. The authors3 noted 1. Smilkstein G: The Family APGAR: resource in time of trouble. the bunching of responders at high A proposal for a family function test and Gabriel Smilkstein, MD scores and stated that this ampli­ its use by physicians. J Fam Pract 6:1231, 1978 Department of Family Medicine fied the worth of the Family 2. DelVecchio Good MJ, Smilkstein G, University of Washington APGAR as a screen for patients Good BJ, et al: The Family APGAR index: Seattle, Washington who perceive their family to be A study of construct validity. J Fam Pract 8:577, 1979 dysfunctional. 3. Smilkstein G, Ashworth C, Mon­ At Duke, we have noted that in­ tano D: Validity and reliability of the Fam­ Alcoholism in Family Practice terviewees not uncommonly deny ily APGAR as a test of family function. J Fam Pract 15:303, 1982 family problems and give socially To the Editor: 4. Brennan M, Noce A: A study of pa­ The September 1982 article by desirable responses to our family tients with psychosocial problems in a C. Richard Kirkwood et al on the function questionnaire, thereby fam ily practice. J Fam Pract 13:837, 1981 5. Stumbo D, DelVecchio Good MJ, 50 most common diagnoses in Pa­ falsely elevating their scores. It is Good BJ: Diagnostic profile of a family cific Northwest family practices not clear why the Family APGAR practice clinic: Patients with psychosocial provides a ranked list of these 50 appears to identify a smaller per­ diagnoses. J Fam Pract 14:281, 1982 diagnoses (The diagnostic content centage of poorly functioning fami­ of family practice: 50 most com­ lies in a family practice than in my The preceding letter was referred mon diagnoses recorded in the study or the percentage of persons to Dr. Smilkstein, who responds as WAMI community practices. J with psychosocial diagnoses in the follows: Fam Pract 15:485, 1982). I find it Sacramento and Canadian prac­ distressing, although predictable, tices. Two explanations are that the I appreciate the opportunity to

883 the j o u r n a l o f f a m il y PRACTICE, VOL. 16, NO. 5, 1983 Mazanor® (mazindol) e Wyeth LETTERS TO THE EDITOR

Actions— Average magnitude of increased weight loss »fdnn placebo-treated patients in studies of anorectics in genera v narily only a fraction of a pound a week Rate of weight to,, , that alcohol (3031) is not even in ber 1982, present to its parent or­ est in first weeks for both drug and placebo and tends to Z * the top 50, much less in the top five succeeding weeks. Total impact of drug-induced weight i n a Z i’ ganizations a core curriculum on of diet alone must be considered clinically limited * or ten, where it belongs. It is naive occupational medicine for family Indication— Management of exogenous obesity as short termn weeks) adjunct in regimen of weight reduction based on cata to hope that alcoholism is being practice residency programs. It is stnction. Limited usefulness of agents ol this class (see should be measured against possible inherent risk factor? ,7. treated, but not recorded “to pro­ also working with the Arizona Cen­ scribed below. tect the patient.” ter for Occupational Safety and Contraindications— Glaucoma; hypersensitivity or idiosyncimi mazindol; agitated states; history of drug abuse; during o’ . i S It is equally unfortunate that the Health in the preparation of mod­ days following the administration of MAO inhibitors (hvoerh . crises may result). authors do not comment on this ules on occupational health topics, W arnings— Tolerance to many anorectics may develop within ft> omission, especially since an weeks; if it occurs, recommended dose should not be exceed a Primer on Occupational Health attempt to increase effect; rather, drug should be disconlij American Indian population is in­ for the Family Physician, a work­ Mazindol may impair ability of patient lo engage in potentially haz ardous activities, as operating machinery or driving motor ve ltt cluded in the survey, a group in shop on teaching how to take an patient should be cautioned accordingly which alcoholism rates among men Drug Interactions— Mazindol may decrease hypotensive effect ol adequate occupational history, and guanelhidine; patients should be monitored accordingly MaziiM routinely exceed 50 percent. is preparing for a national meeting may markedly polentiate pressor elfect of exogenous catecholamines If il is necessary to give pressor amine (e g levarterenol or isoptcr In our residency training, we in September 1983 on occupational terenol) to a patient in shock (e g Irom a myocardial infarction) who has recently been taking mazindol, extreme care should be taken ii stress early assessment and appro­ health for the family physician. monitoring blood pressure at frequent intervals and initialing press® priate treatment of alcohol abuse or therapy with low inilial dose and careful titration The committee, among its many Drug Dependence— Mazindol shares important pharmacologk dependence. We also help physi­ other charges, will be more than properties with amphetamines. Amphetamines and related stimulants have been extensively abused and can produce tolerance and strait cians, a high-risk population, focus happy to help set up educational psychologic dependence In this regard, manifestations ol chronic on their own attitudes and drinking. overdosage or withdrawal of mazindol have not been determinedin lectures and suggest speakers for humans. Abstinence effects have been observed in dogs afterabrupi Frederick B. Cooley, PhD the purpose of making family phy­ cessation lor prolonged periods. There was some sell-adminislialioi ol the drug in monkeys. EEG studies and "liking" scores in human Senior Alcohol Educator sicians more aware of their active subjects yielded equivocal results. While abuse potential of mazindol has not been further defined, possibility ol dependence should lx Deaconess Family Medicine Center, role in occupational medicine and kept in mind when evaluating desirability of including mazindol a: and providing them with the informa­ part of weight-reduction program. Usage in Pregnancy— An increase in neonatal modality and possible Department of Family Medicine tion necessary to remain updated in increased incidence of rib anomalies in rats were observed al rela­ tively high doses. Although these studies have nol indicated impor­ State University of New York this rapidly changing field. The tant adverse effects, use of mazindol by women who are or may become pregnant requires that potential benefit be weighed againsl at Buffalo committee can be reached for fur­ possible hazard to mother and infant. Buffalo, New York ther information or making sugges­ Usage in Children— Mazindol is .not recommended lor use in chil­ dren under 12 years. tions by contacting its chairman. Precautions— Insulin requirements in diabetes mellitus may be al­ tered in association with mazindol and concomitant dietary regimen. Eugene S. Welter, MD Least amount of mazindol feasible should be prescribed lo minimize Teaching Occupational Chairman, overdosage. Use only wilh caution in hypertension with monitoring Medicine of blood pressure. Mazindol is not recommended in severely hyper­ Joint Liaison Committee tensive patients nor in patients with symptomatic cardiovascular dis­ To the Editor: ease including arrhythmias. International Harvester Co. Adverse Reactions— Most common are. dry moulh, tachycardia, It was a pleasure to read of the constipation, nervousness, and insomnia. Cardiovascular: Palpita­ Melrose Park, Illinois tion, tachycardia. CNS: Overstimulation, restlessness, dizziness, in­ efforts of the Department of Family somnia, dysphoria, Iremor, headache, depression, drowsiness, weakness Gl: Dry mouth, unpleasant taste, diarrhea, constipation, Medicine at the Medical University nausea, other Gl disturbances. Skin: Rash, excessive sweating, clam­ of South Carolina to introduce oc­ miness Endocrine: Impotence, rare changes in libido. Eye: Treatmenl Inappropriate Drug of dogs with high doses of mazindol for long periods resulted in some cupational medicine to the family Prescribing corneal opacities, reversible on cessation ol drug; no such elfect ob­ served in humans. physician (Hainer BE, Dannenberg To the Editor: Dosage and Adm inistration— Lowest effective dose should be AL, Schuman SH: Teaching occu­ used. To determine this, therapy may be initiated at 1 mg once a day. In a recent editorial (Geyman and adjusted to the response. If Gl discomforl occurs, give mazindol pational medicine in a family med­ with meals. JF- Inappropriate drug prescrib­ Overdosage— There are no human data as yet on acute overdosage icine residency program. J Fam ing: A soluble problem? J Fam Manifestations of acute overdosage with amphetamines and related Pract 14:1150, 1982). The Ameri­ substances include restlessness, tremor, rapid respiration, dizziness Pract 15:15, 1982), it was correctly Fatigue and depression may follow stimulatory phase. Cardiovascu­ can Academy of Family Physicians lar effects include tachycardia, hypertension, and circulatory col­ noted that inappropriate drug pre­ lapse. Gl symptoms include nausea, vomiting, and abdominal and American Occupational Medi­ scribing, particularly of antibiotic cramps While similar manifestations ol overdosage may be seen wilh cal Association have also realized mazindol, their exact nature is nol yel determined. Management of and psychotropic agents, is a con­ acute intoxication is largely symptomatic. Data are nol available on this necessity and established a treatment of acute intoxication with mazindol by hemodialysis or per­ tinuing problem. This situation has itoneal dialysis, bul Ihedrug is poorly soluble except al very acid pH joint liaison committee in 1979, been remarkably persistent through How Supplied— in bottles of 30 tablets: 1 mg, NDC 0 008-00(1, white, round, scored tablet marked "WYETH" and “ 71". which has since been joined by the the years despite major educational References— 1, Bierman EL: Obesity, in Beeson PB, McDermott W, Society of Teachers of Family Wyngaarden JB (eds): Cecil Textbook ol Medicine, ed 15. Philadel­ efforts and repeated verbal and phia, W.8. Saunders Company, 1979, p 1692. Medicine. published admonitions. 2. West JB: Disorders ol regulation of respiration, in Winlrobe MM el al. (eds): Harrison's Principles ol Internal Medicine, ed 7 New York, The committee will, in Novem- Continued on page 888 McGraw-Hill, 1974, p 1298. 3. Thorn GW, Cahill GF Jr: Gain in weight Obesity. Ibid, p 232 4 Walker BR, Ballard IM, Gold JA: A multicenlre study comparing mazindol and placebo in obese patients. J Inti Med Res b ib. 1977 5. Rothwell NJ, Stock MJ, Wyllie MG: Sympathetic mechanisms in 884 diet-induced Ihermogenesis: modification by ciclazindol and anorec­ tic drugs. BrJ Pharmacol 74:539,1981 11/17*1 Wyeth Laboratories Diet& D iabinese LETTERS TO THE EDITOR [chlorpropamide] Tablets 100 mg and 250 mg Continued from page 884 laxis against hepatitis A is m A proven regimen... Since efforts in the cognitive mL/kg of immune globulin, rather area have not eliminated the prob­ than the .06 mL/kg quoted in the continue it with lem, perhaps it is time to consider article.1 confidence. the affective concomitants of medi­ BRIEF SUMMARY Pre-exposure prophylaxis for up DIABINESE" (chlorpropamide) Tablets cal practice. What does it feel like to two or three months is also at the Contraindications: Diabinese is not indicated in to be in an examining room with a patients having juvenile or growth-onset diabetes melli- lower dosage level, while the higher tus, severe or unstable “brittle” diabetes, and diabetes complicated by ketosis and acidosis, diabetic coma, patient who pleads for medication dosage level is utilized every fiVe major surgery, severe infection, or severe trauma. Diabinese is contraindicated during pregnancy. Serious to relieve mental discomfort in a months for prolonged exposure. consideration should be given to the potential hazard of setting in which patient loads and its use in women of childbearing age who may become J e ff Altman, MD pregnant. economic realities militate against Diabinese is contraindicated in patients with serious Student Health Center impairment of hepatic, renal, or thyroid function. prolonged counseling? What emo­ Precautions: Use chlorpropamide with caution with bar­ University o f Washington biturates, in patients with Addison’s disease or in those tions does a physician experience ingesting: alcohol, antibacterial sulfonamides, thiazides, Seattle, Washington phenylbutazone, salicylates, probenecid, dicoumarol or MAO inhibitors. Adequate dietary intake should be upon learning that a patient diag­ assured in all patients using Diabinese. W arnings: DIABINESE (CHLORPROPAMIDE) nosed as having viral bronchitis SHOULD NOT BE USED IN JUVENILE DIABETES OR R eference IN DIABETES COMPLICATED BY ACIDOSIS, COMA, and treated without antibiotics two SEVERE INFECTION, MAJOR SURGICAL PROCE­ days ago has now been admitted to 1. Immunization Practices Advisory DURES, SEVERE TRAUMA, SEVERE DIARRHEA, Committee: Immune globulins for pro­ NAUSEA AND VOMITING, ETC. HERE, INSULIN IS a hospital with a diagnosis of INDISPENSABLE. tection against viral hepatitis. MMWR 34 HYPOGLYCEMIA, IF IT OCCURS, MAY BE PRO­ 426, 1981 LONGED. (SEE ADVERSE REACTIONS.) IN pneumonia by another physician? INSTANCES OF CONCOMITANT USE WITH INSULIN, PATIENTS SHOULD BE CAREFULLY MONITORED. In an age in which knowledge and Adverse Reactions: Usually dose-related and generally respond to reduction or withdrawal of therapy. Generally certainty are valued highly, how transient and not of a serious nature and include ano­ rexia, nausea, vomiting and gastrointestinal intolerance; does the physician cope with ambi­ To the Editor: weakness and paresthesias. Certain untoward reactions associated with idiosyncrasy guity and the necessity of “playing Dr. Alcoff s article on viral or hypersensitivity have occasionally occurred, including jaundice, skin eruptions rarely progressing to erythema the odds” in the ambulatory treat­ hepatitis in the July 1982 issue of multiforme and exfoliative dermatitis, and probably depression of formed elements of the blood. They occur ment of infections, where decisions The Journal of Family Practice characteristically during the first six weeks of therapy. With a few exceptions, these manifestations have been must often be made on the basis of provided a good review of the mild and readily reversible on the withdrawal of the drug. incomplete information? The more severe manifestations may require other ther­ topic.1 One statement in the article apeutic measures, including corticosteroid therapy. Diabinese should be discontinued promptly when the There seems to be no reasonable could be somewhat misleading and development of sensitivity is suspected. Jaundice has been reported, and is usually promptly prospect that human emotions, ei­ probably deserves some clarifica­ reversible on discontinuance of therapy. THE OCCUR­ RENCE OF PROGRESSIVE ALKALINE PHOSPHA­ ther in patients or physicians, will tion. When referring to the person TASE ELEVATION SHOULD SUGGEST THE POSSI­ BILITY OF INCIPIENT JAUNDICE AND CONSTITUTES be completely replaced by rational who is a chronic carrier of HBsAg, AN INDICATION FOR WITHDRAWAL OF THE DRUG. Leukopenia, thrombocytopenia and mild anemia, which thinking in the foreseeable future. the author states that the prognosis occur occasionally, are generally benign and revert to normal, following cessation of the drug. A program to change physician be­ for this condition is excellent. Cases of aplastic anemia and agranulocytosis, generally similar to blood dyscrasias associated with other sulfo- havior can succeed only if it is Several recent reports have indi­ nylureas, have been reported. BECAUSE OF THE PROLONGED HYPOGLYCEMIC constructed in accordance with this cated a markedly increased risk of ACTION OF DIABINESE, PATIENTS WHO BECOME obvious fact. HYPOGLYCEMIC DURING THERAPY WITH THIS primary hepatocellular carcinoma DRUG REQUIRE CLOSE SUPERVISION FOR A MINI­ MUM PERIOD OF 3 TO 5 DAYS, during which time fre- Robert D. Gillette, MD in chronic carriers.2,3 This tumor uent feedings or glucose administration are essential, he anorectic patient or the profoundly hypoglycemic and is a common tumor in Southeast patient should be hospitalized. Rare cases of phototoxic reactions have been reported. Jay Gibson, PhD Asians (who also have high rates of Edema associated with hyponatremia has been infre­ quently reported. It is usually readily reversible when Department of Family Medicine the carrier state). Although it is not medication is discontinued. Dosage: The total daily dosage is generally taken at a University of Cincinnati yet clear if any preventive steps single time each morning with breakfast. Occasionally, cases of gastrointestinal intolerance may be relieved by Cincinnati, Ohio can be taken, a preliminary report dividing the daily dosage. A LOADING OR PRIMING DOSE IS NOT NECESSARY AND SHOULD NOT BE from China of an HBsAg immune USED. The mild to moderately severe, middle-aged, stable diabetic should be started on 250 mg daily. RNA showed some promise.4 Because the geriatric diabetic patient appears to be Viral Hepatitis more sensitive to the hypoglycemic effect of sulfonyl­ In the meantime, clinicians who urea drugs, older patients should be started on smaller To the Editor: amounts of Diabinese, in the range of 100 to 125 mq see HBsAg carriers, especially daily. After five to seven days following initiation of therapy, The otherwise excellent article Southeast Asians, should be aware dosage may be adjusted upward or downward in incre­ ments of 50 to 125 mg at intervals of three to five days by Joel Alcoff titled “Viral Hepati­ of this potential complication. PATIENTS WHO DO NOT RESPOND COMPLETELY tis’ in the July 1982 issue contains a TO 500 MG DAILY WILL USUALLY NOT RESPOND TO Bery Engebretsen, MD HIGHER DOSES. Maintenance doses above 750 mg daily should be avoided. substantive error (J Fam Pract 15: Broadlawns Medical Center S upply: 100 mg and 250 mg, blue, D'-shaped, scored tablets. 141, 1982). Postexposure prophy­ Des Moines, Iowa More detailed professional information available on request.

LABORATORIES DIVISION PFIZER INC THE JOURNAL OF FAMILY PRACTICE, VOL. 16, NO. 5, 1983 Leaders in Oral Diabetic Therapy LETTERS TO THE EDITOR

References of documented evidence of effi­ nothing about the patient or his 1 Alcoff J : Viral hepatitis. J Fam Pract cacy. I believe my position would lifestyle. 15-141, 1982 be supported by most people work­ The unique perspective offered 2 Beasley RP, Hwang L, Lin C, et al: ing in the field of aging, and also by by family medicine is gradually Hepatocellular carcinoma and hepatitis B virus. Lancet 2:1129, 1981 most individuals in the area of in­ contributing to the “rehumaniza­ 3. Viola LA, Coleman JC, Fluken JL, et fectious disease. tion” of medicine in America. The a|. Natural history of liver disease in William J. Kane, MD Journal of Family Practice can chronic hepatitis B surface antigen car­ riers. Lancet 2:1156, 1981 Vice President for Medical Affairs continue to lead in presenting that 4. Shi-Shan L, Fu-Ying H, Chang-Fu L, Burlington County Memorial perspective if it does not begin to etal: Preparation and clinical use of HBhA* Hospital sound like “those other journals.” immune RNA. Lancet 1:197, 1982 Mount Holly, New Jersey Robert Drickey, MD, MPH Department of Health Services and Use of Pneumococcal Vaccine Department of Family Medicine To the Editor: A Reader's Comment University o f Washington I am writing in regard to an arti­ To the Editor: Seattle, Washington cle that appeared in the December The Family Practice Grand 1982 issue of the Journal of Family Rounds, “ Unstable Angina and the Practice by H. James Brownlee et Intermediate Syndrome” by Rich­ Family Practice at UCLA al, entitled, “The Utilization of ard L. Holve et al (J Fam Pract 15: To the Editor: Pneumococcal Vaccine in a Family 861, 1982), was a good discussion I would like to comment on the Practice Residency” (J Fam Pract of a subject area in which medical article by Ivan N. Mensh entitled 15:1111, 1982). knowledge is rapidly evolving. “Selection and Recruitment of 1 must strongly disagree with the However, in The Journal of Family Medical Students for Family Prac­ content of the article, particularly Practice I have come to expect tice” (J Fam Pract 15:805, 1982). in regard to recommendations for more than a good discussion of clin­ The UCLA Family Medicine the use of pneumococcal vaccine in ical and technical details. Such dis­ Group appreciates the compilation elderly patients. Although the man­ cussions can be found in abun­ of statistics regarding UCLA vs ufacturers advocate the use of the dance in the Annals of Internal University of Washington medical vaccine for all elderly, the litera­ Medicine, the American Heart graduates during the decade 1972 to ture does not support this position. Journal, or The New England 1981. It was nice to see that the In the discussion, the authors do Journal of Medicine. The Journal number of UCLA graduates enter­ mention a review done by Hirsch- o f Family Practice usually offers a ing family practice approximately man and Lipsky, which finds little discussion of broader biopsycho- tripled during the second half of the evidence to support widespread social issues in the care of patients. decade. During much of this time use of the pneumococcal vaccine. In the case in question, the inclu­ we were a beleaguered division The review also shows that there is sion of personal and family consid­ with only three or four full-time practically no evidence to support erations in the decision to proceed faculty members. Whether you its routine use in an elderly popula­ with surgery would have been more choose to give credit to those fac­ tion, since it has never been tested characteristic of your fine journal. ulty for their impact, or cite the on ambulatory or institutionalized From the case report we learned strength of family practice as an elderly. nothing about the patient except “idea whose time has come,” it The authors draw the conclusion that he “ was a 64-year-old Mexican- would be charitable and accurate to that “until further evidence ap­ American man with a history of mention that this is a fifth signifi­ pears, it seems reasonable to con­ adult-onset diabetes mellitus, hyper­ cant variation among the frequen­ tinue to give pneumococcal vaccine tension, osteoarthritis, peptic ulcer cies that were measured. to those over 60 years of age.” It disease, multiple abdominal and Given the grand total figures would be more reasonable to con­ spinal surgeries, and depression.” cited in Table 1, it would appear clude that until further evidence is The final paragraph in the article that UCLA graduated an additional available, the vaccine should not be reminds us that “treatment must be 360 medical students during this used routinely in the elderly be­ selective with regard to the patient decade. Thus the UCLA total cause of cost, morbidity, and lack and his lifestyle.” But we are told would represent an approximate 29

the JOURNAL OF FAMILY PRACTICE, VOL. 16, NO. 5, 1983 889 LETTERS TO THE EDITOR

percent increase over the number substitutes an unobtrusive gauze insulated from the unwarranted of UW medical students (in con­ pad for a bag filled with liquid in­ conclusions third-party payers may trast to the 44 percent stated in the testinal contents. The advantages derive from such statements, but article). Again, my thanks for pro­ are obvious. There are few opera­ the patients and the majority of the viding the tabulation, which dem­ tions that contribute so dramatical­ family physicians in this country onstrates increasing viability of ly to an improved quality of life as a certainly are not. family medicine at UCLA. Koch ileostomy. Second, any economic benefit Win. MacMillan Rodney, MD Martin I. Laichtman, MD truly generated must be balanced Director, UCLA Residency Clinical Instructor in against the cost of the additional Program in Family Practice Family Practice screening, not against a vacuum. University o f California, Los Angeles Department of Medicine What are the anticipated costs of Los Angeles, California UCLA School of Medicine three complete thyroid panels per Santa Monica, California patient plus professional time devoted to analysis of symptom Ileostomy for Ulcerative scores and physical findings? Colitis Prevalence of Hypothyroidism Again, in my own practice, these To the Editor: To the Editor: figures would be $48 x 3 + $18 x 3, It was with great interest that I Regarding the article by Peter J. or $198 per patient, which would read the article on ulcerative colitis Rizzolo and Paul M. Rischer in the buy a lot of replacement thyroid by Dr. Weigert et al (J Fam Pract June issue of the Journal, entitled medication. I am not suggesting 15:621, 1982). With regard to the “Re-evaluation of Thyroid Hor­ that persons be treated on shaky continent ileostomy (Koch pouch), mone Status After Long-Term Hor­ diagnostic grounds; I am merely I think I speak from a great deal of mone Therapy” (J Fam Pract 14: suggesting that this paper offers no experience. I myself have had this 1017, 1982), I would offer the fol­ useful information, medical or eco­ procedure, have had ulcerative lowing comments: nomic, on rescreening the bulk of colitis, and feel that this procedure Based on my own private prac­ patients carrying a diagnosis of is superior to the conventional ile­ tice experience over the last five hypothyroidism in a general family ostomy, which I have also had. and a half years, the quoted preva­ practice setting. It could be con­ Certainly, both are an improve­ lence in the index population is strued to offer such guidelines to ment over the symptoms so debili­ hopelessly low. Postulating a total the reimburser, Physicians Desk tating to the patient with ulcerative practice population of perhaps 30 Reference in hand, who sees such colitis. percent of the 6,000 cited by the au­ conclusions as presented combined I must take issue with Dr. Ram thors, I can come up with more with such statements as (replace­ when he states that there is a higher than their two dozen cases of hypo­ ment thyroid medication) “is not degree of complications with the thyroidism off the top of my head without side effects.” Whoever Koch pouch, and therefore, a (certainly a thorough record search implied that it was! standard ileostomy had been rec­ on my part would reveal even Finally, the well-recognized con­ ommended to the patient in the ar­ more) that are, most emphatically, nection between recurrent bouts of ticle. I lecture to many patients re­ patients diagnosed as hypothyroid thyroiditis and ultimate develop­ garding the continent ileostomy, by documented increases in thyroid ment of permanent hypothyroidism since I serve as a medical advisor stimulating hormone (TSH). I can leaves me wondering for what we to the Los Angeles Chapter of the only assume that the authors are are sparing these “ unnecessarily United Ostomy Association. A dealing with a fragmentary and medicated” people: a future truly conventional ileostomy is no longer self-selected population, and gen­ free of hypothyroidism off treat­ the last-resort, unsatisfactory op­ eralizing from such should be done ment, or an eventual recurrence of eration of the past because of ad­ with extreme caution, not the near that thyroid failure for which they vances in surgical techniques and bombast that projects such a series were once perhaps quite appropri­ in preoperative and postoperative into a “ $40 million per year sav­ ately treated? care, as well as improvements in ing" on unnecessary medication Harry E. Salyards, MD modern external appliances. A alone. Perhaps in the university Hastings Family Practice, PC continent ileostomy, however, setting the authors are sufficiently Hastings, Nebraska

890 THE JOURNAL OF FAMILY PRACTICE, VOL. 16, NO. 5, 1983