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LETTERS TO THE ASYMPTOMATtC BACTERIURIA IN THE ELDERLY To the Editor: I have read with great interest the recent article by Nicolle et al (Am J Med 1987; 83: 27-33) on asymptomatic bacteri- uria in elderly women, as it is a problem frequently encoun- tered in the management of the elderly, both as outpatients and as inpatients. In an earlier study involving geriatric ward male patients with asymptomatic bacteriuria, Nicolle et al [l] concluded that the treatment of the bacteriuria was neither necessary nor effective. In their study of bacteriuria in the elderly, Boscia et al [2] suggested that the transient nature of the bacteriuria argued against active treatment. Nordenstam et al [3] have shown that when other diseases (i.e., cancers) were considered, the relation between bacte- riuria and mortality was not significant. However, what was disappointing in these earlier studies was the lack of data on the presence of pyuria in the urine samples of the patients. In the most recent study, however, Nicolle et al did include data on pyuria (Table I of the article). At my institu- tion, the presence of pyuria is used as a parameter of the extent of inflammation associated with the bacteriuria and often as an important determinant of whether an initial attempt is made to eradicate the bacteriuria. Although Ni- colle et al conclude that treatment for asymptomatic bacte- riuria in this population is not necessary, I would be curious to see if a comparison of the results on outcome of bacteri- uria, morbidity, and mortality in the patients with pyuria in the two treatment groups would yield significant differ- ences. DAVID BASKIN, M.D. St. Luke’sRoosevelt Medical Center New York, New York 10019 1. Nicolle L, Bjornson J, Harding G, Mactlonell J: Bacteriuria in elderly institutionalized men. N Engl J Med 1983; 309: 1420- 1425. 2. Boscia J, Kobasa W, Knight R, Abrutyn E, Levison M, Kaye D: Epidemiology of bacteriuria in an elderly ambulatory popula- tion. Am J Med 1986; 80: 208-214. 3. Nordenstam G, Brandberg C, Oden A. Svanborg C, Svanborg A: Bacteriuria and mortality in an elderly population. N Engl J Med 1986; 314: 1152-1156. Submitted August 11, 1987, and accepted August 26, 1987 TREATMENT OF CALCINOSIS UNIVERSALIS WITH LOW-DOSE WARFARIN To the Editor: I read with interest the study of Berger et al (Am J Med 1987; 83: 72-76) concerning treatment of calcinosis universalis with low-dose warfarin. Although data from the few patients presented would suggest that low-dose warfarin could inhibit the develop- ment of calcinosis in dermatomyositis or systemic sclero- sis, two major problems must temper the widespread clini- cal use of this treatment. The authors correctly pointed out that they studied a low number of patients, and the difficulty in making clinical decisions from such studies. Several previous studies have suggested the success of various treatments for calcinosis, but each has presented few num- ber of patients and has often not followed up with additional patients in double-blind controlled studies [ 1,2]. The authors neglected to point out that other reports have shown up to a 55 percent spontaneous resolution rate for calcinosis without treatment directed specifically at the calcific manifestations of the underlying muscle disease ]31* Although this study was theoretically interesting, further double-blind trials with large numbers of patients from sev- eral different centers would better define the treatment of calcinosis universalis. Such controlled studies will need to take into account the large percentage of patients with spontaneous resolution of calcinosis in childhood dermato- myositis before making recommendations for widespread clinical treatment. NICHOLAS A. PATRONE, M.D. East Carolina University School of Medicine Greenville, North Carolina 27858-4354 1. Tabron J, Bole G, Thompson G: Colchicine suppression of local and systemic inflammation due to calcinosis universalis in chronic dermatomyositis. Ann Intern Med 1978; 89: 648-649. 2. Steiner RM, Glassman L, Schwartz M, Vanace P: Radiological findings in dermatomyositis of children. Radiology 1974; ill: 385-393. 3. Fink CW, Cook JD: Spontaneous resolution of calcinosis in child- hood dermatomyositis. Arthritis Rheum 1986; 29(suppl): S91. Submitted August 10, 1987, and accepted August 26, 1987 DIAGNOSTIC VALUE OF ZINC LEVELS IN PLEURAL EFFUSIONS To the Editor: Pleural effusions that remain undiagnosed after initial thora- centesis and pleural needle biopsy are an important and relatively frequent clinical problem [I]. Because these effusions may be due to a wide variety of malignant and nonmalignant causes, numerous substances (e.g., carcin- oembryonic antigen and lysozyme) [z] have been assayed in pleural fluid in an attempt to make the distinction be- tween the possible causes. Unfortunately, due to poor sen- sitivity and/or specificity of these tests [2], clinicians are, at present, left without a relatively inexpensive, noninvasive diagnostic test to help with the decision concerning what course to follow (e.g., close observation or thoracotomy) when the results of initial thoracentesis and pleural needle biopsy are nondiagnostic. November 1987 The American Journal of Medicine Volume 83 1003

Treatment of calcinosis universals with low-dose warfarin

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LETTERS TO THE

ASYMPTOMATtC BACTERIURIA IN THE ELDERLY

To the Editor: I have read with great interest the recent article by Nicolle et al (Am J Med 1987; 83: 27-33) on asymptomatic bacteri- uria in elderly women, as it is a problem frequently encoun- tered in the management of the elderly, both as outpatients and as inpatients. In an earlier study involving geriatric ward male patients with asymptomatic bacteriuria, Nicolle et al [l] concluded that the treatment of the bacteriuria was neither necessary nor effective. In their study of bacteriuria in the elderly, Boscia et al [2] suggested that the transient nature of the bacteriuria argued against active treatment. Nordenstam et al [3] have shown that when other diseases (i.e., cancers) were considered, the relation between bacte- riuria and mortality was not significant. However, what was disappointing in these earlier studies was the lack of data on the presence of pyuria in the urine samples of the patients. In the most recent study, however, Nicolle et al did include data on pyuria (Table I of the article). At my institu- tion, the presence of pyuria is used as a parameter of the extent of inflammation associated with the bacteriuria and often as an important determinant of whether an initial attempt is made to eradicate the bacteriuria. Although Ni- colle et al conclude that treatment for asymptomatic bacte- riuria in this population is not necessary, I would be curious to see if a comparison of the results on outcome of bacteri- uria, morbidity, and mortality in the patients with pyuria in the two treatment groups would yield significant differ- ences.

DAVID BASKIN, M.D. St. Luke’sRoosevelt Medical Center

New York, New York 10019

1. Nicolle L, Bjornson J, Harding G, Mactlonell J: Bacteriuria in elderly institutionalized men. N Engl J Med 1983; 309: 1420- 1425.

2. Boscia J, Kobasa W, Knight R, Abrutyn E, Levison M, Kaye D: Epidemiology of bacteriuria in an elderly ambulatory popula- tion. Am J Med 1986; 80: 208-214.

3. Nordenstam G, Brandberg C, Oden A. Svanborg C, Svanborg A: Bacteriuria and mortality in an elderly population. N Engl J Med 1986; 314: 1152-1156.

Submitted August 11, 1987, and accepted August 26, 1987

TREATMENT OF CALCINOSIS UNIVERSALIS WITH LOW-DOSE WARFARIN

To the Editor: I read with interest the study of Berger et al (Am J Med 1987; 83: 72-76) concerning treatment of calcinosis universalis with low-dose warfarin.

Although data from the few patients presented would suggest that low-dose warfarin could inhibit the develop- ment of calcinosis in dermatomyositis or systemic sclero-

sis, two major problems must temper the widespread clini- cal use of this treatment. The authors correctly pointed out that they studied a low number of patients, and the difficulty in making clinical decisions from such studies. Several previous studies have suggested the success of various treatments for calcinosis, but each has presented few num- ber of patients and has often not followed up with additional patients in double-blind controlled studies [ 1,2].

The authors neglected to point out that other reports have shown up to a 55 percent spontaneous resolution rate for calcinosis without treatment directed specifically at the calcific manifestations of the underlying muscle disease ]31*

Although this study was theoretically interesting, further double-blind trials with large numbers of patients from sev- eral different centers would better define the treatment of calcinosis universalis. Such controlled studies will need to take into account the large percentage of patients with spontaneous resolution of calcinosis in childhood dermato- myositis before making recommendations for widespread clinical treatment.

NICHOLAS A. PATRONE, M.D. East Carolina University School of Medicine

Greenville, North Carolina 27858-4354

1. Tabron J, Bole G, Thompson G: Colchicine suppression of local and systemic inflammation due to calcinosis universalis in chronic dermatomyositis. Ann Intern Med 1978; 89: 648-649.

2. Steiner RM, Glassman L, Schwartz M, Vanace P: Radiological findings in dermatomyositis of children. Radiology 1974; ill: 385-393.

3. Fink CW, Cook JD: Spontaneous resolution of calcinosis in child- hood dermatomyositis. Arthritis Rheum 1986; 29(suppl): S91.

Submitted August 10, 1987, and accepted August 26, 1987

DIAGNOSTIC VALUE OF ZINC LEVELS IN PLEURAL EFFUSIONS

To the Editor: Pleural effusions that remain undiagnosed after initial thora- centesis and pleural needle biopsy are an important and relatively frequent clinical problem [I]. Because these effusions may be due to a wide variety of malignant and nonmalignant causes, numerous substances (e.g., carcin- oembryonic antigen and lysozyme) [z] have been assayed in pleural fluid in an attempt to make the distinction be- tween the possible causes. Unfortunately, due to poor sen- sitivity and/or specificity of these tests [2], clinicians are, at present, left without a relatively inexpensive, noninvasive diagnostic test to help with the decision concerning what course to follow (e.g., close observation or thoracotomy) when the results of initial thoracentesis and pleural needle biopsy are nondiagnostic.

November 1987 The American Journal of Medicine Volume 83 1003