hemorrhage occurring during intercourse, (3) emphysema, (4) coronary bypass surgery in September 1975, (5) degenerative disc
disease of C-4 to C-7, (6) cerebral vascular insufficiency with occasional transient ischemic attacks, (7) old right lower quadrant adhesions secondary to a perforated appendix, (8) Ascaris lumbricoides, and (9) polycythemia vera of more than 20 years' duration requiring 500-ml phlebotomies every two months until 1969. Following radiophosphorus 5MC administration on Feb 16, 1969, he required only three phlebotomies over the next 21 months. A second dose of radiophosphorus 5MC was given on Nov 11, 1970, and he required only one phlebotomy over the next 12 months. From Nov 29, 1971, to March 13, 1972, he was given busulfan, 4 to 8 mg daily. This therapy was discontinued on March 13 because of leucopenia, with the WBC count reaching a nadir of 2,300 on April 10. On May 12 and May 13 he required two units of packed cells. In 1973 and 1974 he required four phle¬ botomies per year, the last one being performed on Jan 30,1975. With hematocrit levels remaining in the range of 45% to 50%, no phlebotomies were necessary until March 30, 1977. Then he underwent a right hemicolectomy for acute small bowel ob¬ struction secondary to a large fungating adenocarcinoma of the cecum measuring 7x6x1.5 cm and involving mucosa, muscularis, and serosa.
Comment—In this case, the cessa¬ tion of clinical need for phlebotomies was attributed to the cumulative mar¬ row depressant effect of the radiophos¬ phorus and busulfan therapy. While this may have played a role, it is diffi¬ cult to conceive of a fungating carci¬ noma as large as this not having bled to a great degree and for a substantial period of time. The increased incidence of a second primary when one neoplasm exists is well known. Polycythemia vera is a neoplasm. When a long established polycythemia vera with a known behavior pattern suddenly changes that pattern, and apparently cures itself, without supervening myelofibrosis, one must consider hidden blood loss, from whatever cause. Given the neoplastic nature of polycythemia vera, a second neoplasm is high on the list of those causes. Daniel S. J. Choy, MD New York
Aeromonas
hydrophila Infection
To the Editor. \p=m-\Inthe article "Freshwater Wound Infection Due to Aeromonas
hydrophila" (238:1053, 1977),
Hanson et al comment that A hydrophila may be a more frequent human pathogen than the literature would suggest. The following two cases seen in August 1977 in Mercy Hospital, a 200-bed community hospital, support
suggestion and point out the need recognize A hydrophila as the cause of cellulitis in healthy immunocompethis
to
tent persons. Report of Cases.\p=m-\Case 1.\p=m-\A6-year-old boy was brought to the emergency room with an infected puncture wound on the right heel. His mother stated that the child had stepped on a rock while swimming a month earlier. Redness of adjacent soft tissues was noted and interpreted as cellulitis. The wound was debrided, and material was
submitted for culture and sensitivi-
ty testing. Cultures grew A hydrophila,
Staphylococcus aureus coagulase positive, and y streptococci. Case 2.\p=m-\A 16-year-old boy came to the
room with a laceration of the surface of the right foot. He indi¬ cated he had cut his foot by walking on a piece of broken glass. Two days later redness developed on the dorsal aspect of his foot, and purulent matter could be ex¬ pressed from the laceration. Culture and sensitivity testing were done. Culture grew abundant A hydrophila but no other orga¬ nism.
emergency
plantar
Comment—In one patient the in¬ jury occurred in a swimming pool, but in the other injury was produced by stepping on a piece of broken glass. This is explained by the fact that aeromonads are found not only in water but in soil, sewage, foodstuffs, and other environmental sources.1 In each case susceptibility testing by the stan¬ dardized Kirby-Bauer disk method showed the organism to be sensitive to gentamicin, tetracycline, and kanamycin and resistant to ampicillin and carbenicillin. A. E.
Fraire, MD
Mercy Hospital
Altoona, Pa
EH, Spaulding EH, Truant JP: Manual of Clinical Microbiology, ed 2. Washington, DC, American Society of Microbiology, 1974, pp 230-231. 1. Lennette
Surgical Nutrition: The Fourth Coming To the Editor.\p=m-\The advent of intensive nutritional support for nutritionally depleted preoperative and postoperative patients might well prove to be the "fourth coming" of a major advance in the care of surgical patients in the past 150 years. The "first coming" was the beginnings of surgical anesthesia exemplified by Crawford W. Long, MD, who in 1847 began using ether for obstetrical patients (including his wife). In 1867 Joseph Lister, MB, BS, recognized the importance of wound infection and proposed the antiseptic principle, thus providing a "second coming." The "third coming" was the antibiotic era, introduced by Sir Alexander Fleming in 1928 with the demonstration of the bactericidal effects of penicillin.
In 1968 Stanley Dudrick, MD, and others1 began to advocate total paren-
teral nutrition for patients with poorly functional gastrointestinal tracts and catabolic disease processes. He demonstrated accelerated healing in processes that had previously carried poor prognosis. Since that time we have come to appreciate the extreme usefulness of appropriate supplementation of vita¬ mins, carbohydrates, protein, and lip¬ ids by the intravenous or gastrointes¬ tinal route in surgical patients. We can aid in healing of wounds, closing of fistulas, clearing of infections, recovery of failing organs, and response to ther¬ apeutic agents. Nutrition is one of our
powerful therapeutic resources. implications of metabolic ma¬ nipulation are far-reaching. Investiga¬ tors are now exploring the metabolic changes accompanying shock and trau¬ more
The
and their reversal with nutritional therapy. We owe gratitude to Dr Dudrick and others who have made the ma
"fourth coming" possible. James C.
Stevens, MD Charlotte Memorial Hospital and Medical Center Charlotte, NC
SJ, Wilmore DW, Vars HM, et al: Long-term parenteral nutrition with growth, development and positive nitrogen balance. Surgery 64:134-142, 1968. 1. Dudrick
Antimicrobial
Prophylaxis
To the Editor.\p=m-\I believe a comment is necessary with respect to the letter from Chinh T. Le, MD, on antimicrobial prophylaxis (238:852, 1977). Dr Le's remarks re "detrimental omissions or inadequacies" as they relate to dentists could be misinterpreted to indicate a deficiency on the part of the dental profession. Despite reference to a random phone survey, it must be maintained that the dental profession has been keenly aware both educationally and clinically of the necessity for antimicrobial prophylaxis for many years, and some of the more important research papers on transient bacteremia are from the dental literature. The American Heart Association can attest to this by their continuous dialogue and well-received efforts to provide dental practitioners with current standards. What Dr Le is probably referring to is the result of the deference that dentists normally exhibit to the patient's personal physician who has failed to elaborate guidelines to the affected patient. In the absence of such reinforcement, many dentists are re¬ luctant to interfere in the physician-
patient relationship. It is common practice today to train
dental students to be aware of antimi¬ crobial prophylaxis in detail with
Downloaded From: http://jama.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/29/2015
respect
to
indications, drugs, dosages,
and regimen. Students are also taught to consult with the attending physician to confirm their treatment plans. Diffi¬ culty may arise from the large number of dental operations with which the physician may be unfamiliar and perhaps even uncertain as to whether prophylaxis is necessary. All of this reinforces dentistry's commitment to increase the opportunities for advanced education in hospital training pro¬ grams. From such interfaces physi¬ cians learn what dentists do, and dentists learn what physicians need to learn for better understanding of dental procedures. Eugene Friedman, DDS School of Dental Medicine Health Sciences Center State University of New York at Stony Brook
Stony
pyurias are associated with regular drinking of soda pop. Recently I saw a 10-year-old girl with gross hematuria; she admits to drinking two or three cans of soda pop daily. She will be rechecked in a few days for complete clearing after stop¬ ping consumption of pop. I fully expect to find no microscopic hematuria on
her return in about one week. This probably is due to metabolic acidosis; however, I would appreciate other comments as to the cause. Our heavy pop-drinking society of adults and children cannot eat because their stomachs hurt, cannot sleep because of the excessive caffeine, and cannot urinate because of the burning. A pop-drinking history should be included for every patient.
Neither Dr Fellner nor Dr Culp includes in his published correspondence any thought of the patient's obligation to follow up his own disease. It may be that the unknown urologist who cared for him so inadequately instructed the patient firmly that he must return for follow up, and the patient did not do so. The experience of 30 years with patients' failure to participate in their own care has taught me that one can never jump to the conclusion that the previous physician was always a careless dummy. Perhaps our biggest mistake in caring for patients is not emphasizing the importance of their own obligations to their health. C. Balcom Moore, MD Walla Walla, Wash
Daniel M. Thompson, MD Wichita, Kan
Brook
Treatment of Hematuria Associated With Soda Pop Drinking
Synovial
To the Editor.\p=m-\The summer of 1963 was hot in Kansas and everyone was thirsty. In July 1963 a 63-year-old man was seen with hematuria. Initially, no cultures were taken, and he was treated with a sulfa preparation. He made no improvement, and gross hematuria continued for the next ten
days. He was hospitalized, and a complete urological workup was done, including urine culture, cystoscopy with retrograde pyelogram, and individual cultures from each ureter. Workup results were completely normal. On the third day of his hospitalization, the hematuria stopped, and there was no further hematuria for the next several days. A few days later an 18-year-old was seen with gross hematuria. He was not treated but was immediately hospitalized for the
complete urological workup, the results were also within normal limits. Hematuria stopped on the third day of hospitalization. Both of these patients were released to return to work on the same day. They both returned within the week with gross hematuria. They both had identical jobs at soft-drink bottling plants checking bottles for foreign material. When they were thirsty, they
would take a bottle of carbonated beverage off the line and drink it. They rarely drank water. They were both advised to drink no more soda pop, and neither had hematuria again that summer.
Since these two episodes, I have seen many cases of hematuria in those people who are heavy drinkers of soda pop. In my practice a considerable
number of recurrent
urinary
tract
Fluid Glucose
To the Editor.\p=m-\Iread with interest the article "Leukocytosis and Artifactual Hypoglycemia" (237:1961-1962, 1977). An analogous situation occurs in synovial fluid and needs to be emphasized. For example, on occasion synovial fluids from patients with rheumatoid arthritis and gout have leukocyte counts greater than 50,000 cells/cu mm. If the glucose determination is not done within an hour, the glycolytic action of the leukocytes can produce a value of 30 mg/dl or less, and the inexperienced clinician may make an erroneous diagnosis of septic arthritis. To avoid confusion and errors, we recommend that the synovial fluids to be used for glucose determinations be placed in a tube containing sodium fluoride.1,2 Tubes containing sodium fluoride are commercially available. Duncan S. Owen, Jr, MD
Neuralgia
Postherpetic
To the Editor.\p=m-\This letter is written in response to the treatment that was recommended for postherpetic neuralgia in a recent issue of The Journal. Ervin Epstein, MD, suggested repeated injections of triamcinolone acetonide into the symptomatic areas (238:517\x=req-\
518, 1977).
Two alternative methods that I have used successfully in treating postherpetic neuralgia are intercostal nerve block and sympathetic ganglion block. The blocks may be repeated daily until the symptoms subside. The reader is referred to Moore's textbook on Regional Block1 for descriptions of the
techniques.
Robert H. Libman, MD Illinois Masonic Medical Center University of Illinois Abraham Lincoln School of Medicine
Chicago Regional Block. Springfield, Ill, Charles C Thomas Publisher, 1975. 1. Moore DC:
Medical College of Virginia Virginia Commonwealth University Richmond
Jr, Cooke CL, Toone E: Practical synovial fluid examination. Va Med Mon 97:88-94, 1972. 2. Owen DS Jr: Recent advances in synovial fluid analysis. MCV Q 10:13-17, 1974. 1. Owen DS
Patients'
Responsibility
To the Editor.\p=m-\In regard to the discussion of management of prostatic carcinoma in QUESTIONS AND ANSWERS (238:254, 1977), I would like to compliment David A. Culp, MD, on his restraint in saying that "the postoperative management of the patient was rather inadequate." It was completely inadequate, and Donald W. Fellner, MD, is certainly very correct in his implication that this was the case.
Restraints in Use of Statistics To the Editor.\p=m-\The BRIEF REPORT, "Amebiasis: An Increasing Problem Among Homosexuals in New York
City" (238:1386, 1977), was a shrewd piece of research that will undoubtedly be of value to many physicians. In an era in which research physicians use statistically significant associations
as
conclusive evidence of
etiologic relations, it is gratifying that the authors did not conclude, as they had every right to do, that overseas travel to areas in which amebiasis is endemic is less frequently undertaken by homosexual men than by heterosexual men.
Downloaded From: http://jama.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/29/2015
Jack R.
Harnes, MD
New York
disease of C-4 to C-7, (6) cerebral vascular insufficiency with occasional transient ischemic attacks, (7) old right lower quadrant adhesions secondary to a perforated appendix, (8) Ascaris lumbricoides, and (9) polycythemia vera of more than 20 years' duration requiring 500-ml phlebotomies every two months until 1969. Following radiophosphorus 5MC administration on Feb 16, 1969, he required only three phlebotomies over the next 21 months. A second dose of radiophosphorus 5MC was given on Nov 11, 1970, and he required only one phlebotomy over the next 12 months. From Nov 29, 1971, to March 13, 1972, he was given busulfan, 4 to 8 mg daily. This therapy was discontinued on March 13 because of leucopenia, with the WBC count reaching a nadir of 2,300 on April 10. On May 12 and May 13 he required two units of packed cells. In 1973 and 1974 he required four phle¬ botomies per year, the last one being performed on Jan 30,1975. With hematocrit levels remaining in the range of 45% to 50%, no phlebotomies were necessary until March 30, 1977. Then he underwent a right hemicolectomy for acute small bowel ob¬ struction secondary to a large fungating adenocarcinoma of the cecum measuring 7x6x1.5 cm and involving mucosa, muscularis, and serosa.
Comment—In this case, the cessa¬ tion of clinical need for phlebotomies was attributed to the cumulative mar¬ row depressant effect of the radiophos¬ phorus and busulfan therapy. While this may have played a role, it is diffi¬ cult to conceive of a fungating carci¬ noma as large as this not having bled to a great degree and for a substantial period of time. The increased incidence of a second primary when one neoplasm exists is well known. Polycythemia vera is a neoplasm. When a long established polycythemia vera with a known behavior pattern suddenly changes that pattern, and apparently cures itself, without supervening myelofibrosis, one must consider hidden blood loss, from whatever cause. Given the neoplastic nature of polycythemia vera, a second neoplasm is high on the list of those causes. Daniel S. J. Choy, MD New York
Aeromonas
hydrophila Infection
To the Editor. \p=m-\Inthe article "Freshwater Wound Infection Due to Aeromonas
hydrophila" (238:1053, 1977),
Hanson et al comment that A hydrophila may be a more frequent human pathogen than the literature would suggest. The following two cases seen in August 1977 in Mercy Hospital, a 200-bed community hospital, support
suggestion and point out the need recognize A hydrophila as the cause of cellulitis in healthy immunocompethis
to
tent persons. Report of Cases.\p=m-\Case 1.\p=m-\A6-year-old boy was brought to the emergency room with an infected puncture wound on the right heel. His mother stated that the child had stepped on a rock while swimming a month earlier. Redness of adjacent soft tissues was noted and interpreted as cellulitis. The wound was debrided, and material was
submitted for culture and sensitivi-
ty testing. Cultures grew A hydrophila,
Staphylococcus aureus coagulase positive, and y streptococci. Case 2.\p=m-\A 16-year-old boy came to the
room with a laceration of the surface of the right foot. He indi¬ cated he had cut his foot by walking on a piece of broken glass. Two days later redness developed on the dorsal aspect of his foot, and purulent matter could be ex¬ pressed from the laceration. Culture and sensitivity testing were done. Culture grew abundant A hydrophila but no other orga¬ nism.
emergency
plantar
Comment—In one patient the in¬ jury occurred in a swimming pool, but in the other injury was produced by stepping on a piece of broken glass. This is explained by the fact that aeromonads are found not only in water but in soil, sewage, foodstuffs, and other environmental sources.1 In each case susceptibility testing by the stan¬ dardized Kirby-Bauer disk method showed the organism to be sensitive to gentamicin, tetracycline, and kanamycin and resistant to ampicillin and carbenicillin. A. E.
Fraire, MD
Mercy Hospital
Altoona, Pa
EH, Spaulding EH, Truant JP: Manual of Clinical Microbiology, ed 2. Washington, DC, American Society of Microbiology, 1974, pp 230-231. 1. Lennette
Surgical Nutrition: The Fourth Coming To the Editor.\p=m-\The advent of intensive nutritional support for nutritionally depleted preoperative and postoperative patients might well prove to be the "fourth coming" of a major advance in the care of surgical patients in the past 150 years. The "first coming" was the beginnings of surgical anesthesia exemplified by Crawford W. Long, MD, who in 1847 began using ether for obstetrical patients (including his wife). In 1867 Joseph Lister, MB, BS, recognized the importance of wound infection and proposed the antiseptic principle, thus providing a "second coming." The "third coming" was the antibiotic era, introduced by Sir Alexander Fleming in 1928 with the demonstration of the bactericidal effects of penicillin.
In 1968 Stanley Dudrick, MD, and others1 began to advocate total paren-
teral nutrition for patients with poorly functional gastrointestinal tracts and catabolic disease processes. He demonstrated accelerated healing in processes that had previously carried poor prognosis. Since that time we have come to appreciate the extreme usefulness of appropriate supplementation of vita¬ mins, carbohydrates, protein, and lip¬ ids by the intravenous or gastrointes¬ tinal route in surgical patients. We can aid in healing of wounds, closing of fistulas, clearing of infections, recovery of failing organs, and response to ther¬ apeutic agents. Nutrition is one of our
powerful therapeutic resources. implications of metabolic ma¬ nipulation are far-reaching. Investiga¬ tors are now exploring the metabolic changes accompanying shock and trau¬ more
The
and their reversal with nutritional therapy. We owe gratitude to Dr Dudrick and others who have made the ma
"fourth coming" possible. James C.
Stevens, MD Charlotte Memorial Hospital and Medical Center Charlotte, NC
SJ, Wilmore DW, Vars HM, et al: Long-term parenteral nutrition with growth, development and positive nitrogen balance. Surgery 64:134-142, 1968. 1. Dudrick
Antimicrobial
Prophylaxis
To the Editor.\p=m-\I believe a comment is necessary with respect to the letter from Chinh T. Le, MD, on antimicrobial prophylaxis (238:852, 1977). Dr Le's remarks re "detrimental omissions or inadequacies" as they relate to dentists could be misinterpreted to indicate a deficiency on the part of the dental profession. Despite reference to a random phone survey, it must be maintained that the dental profession has been keenly aware both educationally and clinically of the necessity for antimicrobial prophylaxis for many years, and some of the more important research papers on transient bacteremia are from the dental literature. The American Heart Association can attest to this by their continuous dialogue and well-received efforts to provide dental practitioners with current standards. What Dr Le is probably referring to is the result of the deference that dentists normally exhibit to the patient's personal physician who has failed to elaborate guidelines to the affected patient. In the absence of such reinforcement, many dentists are re¬ luctant to interfere in the physician-
patient relationship. It is common practice today to train
dental students to be aware of antimi¬ crobial prophylaxis in detail with
Downloaded From: http://jama.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/29/2015
respect
to
indications, drugs, dosages,
and regimen. Students are also taught to consult with the attending physician to confirm their treatment plans. Diffi¬ culty may arise from the large number of dental operations with which the physician may be unfamiliar and perhaps even uncertain as to whether prophylaxis is necessary. All of this reinforces dentistry's commitment to increase the opportunities for advanced education in hospital training pro¬ grams. From such interfaces physi¬ cians learn what dentists do, and dentists learn what physicians need to learn for better understanding of dental procedures. Eugene Friedman, DDS School of Dental Medicine Health Sciences Center State University of New York at Stony Brook
Stony
pyurias are associated with regular drinking of soda pop. Recently I saw a 10-year-old girl with gross hematuria; she admits to drinking two or three cans of soda pop daily. She will be rechecked in a few days for complete clearing after stop¬ ping consumption of pop. I fully expect to find no microscopic hematuria on
her return in about one week. This probably is due to metabolic acidosis; however, I would appreciate other comments as to the cause. Our heavy pop-drinking society of adults and children cannot eat because their stomachs hurt, cannot sleep because of the excessive caffeine, and cannot urinate because of the burning. A pop-drinking history should be included for every patient.
Neither Dr Fellner nor Dr Culp includes in his published correspondence any thought of the patient's obligation to follow up his own disease. It may be that the unknown urologist who cared for him so inadequately instructed the patient firmly that he must return for follow up, and the patient did not do so. The experience of 30 years with patients' failure to participate in their own care has taught me that one can never jump to the conclusion that the previous physician was always a careless dummy. Perhaps our biggest mistake in caring for patients is not emphasizing the importance of their own obligations to their health. C. Balcom Moore, MD Walla Walla, Wash
Daniel M. Thompson, MD Wichita, Kan
Brook
Treatment of Hematuria Associated With Soda Pop Drinking
Synovial
To the Editor.\p=m-\The summer of 1963 was hot in Kansas and everyone was thirsty. In July 1963 a 63-year-old man was seen with hematuria. Initially, no cultures were taken, and he was treated with a sulfa preparation. He made no improvement, and gross hematuria continued for the next ten
days. He was hospitalized, and a complete urological workup was done, including urine culture, cystoscopy with retrograde pyelogram, and individual cultures from each ureter. Workup results were completely normal. On the third day of his hospitalization, the hematuria stopped, and there was no further hematuria for the next several days. A few days later an 18-year-old was seen with gross hematuria. He was not treated but was immediately hospitalized for the
complete urological workup, the results were also within normal limits. Hematuria stopped on the third day of hospitalization. Both of these patients were released to return to work on the same day. They both returned within the week with gross hematuria. They both had identical jobs at soft-drink bottling plants checking bottles for foreign material. When they were thirsty, they
would take a bottle of carbonated beverage off the line and drink it. They rarely drank water. They were both advised to drink no more soda pop, and neither had hematuria again that summer.
Since these two episodes, I have seen many cases of hematuria in those people who are heavy drinkers of soda pop. In my practice a considerable
number of recurrent
urinary
tract
Fluid Glucose
To the Editor.\p=m-\Iread with interest the article "Leukocytosis and Artifactual Hypoglycemia" (237:1961-1962, 1977). An analogous situation occurs in synovial fluid and needs to be emphasized. For example, on occasion synovial fluids from patients with rheumatoid arthritis and gout have leukocyte counts greater than 50,000 cells/cu mm. If the glucose determination is not done within an hour, the glycolytic action of the leukocytes can produce a value of 30 mg/dl or less, and the inexperienced clinician may make an erroneous diagnosis of septic arthritis. To avoid confusion and errors, we recommend that the synovial fluids to be used for glucose determinations be placed in a tube containing sodium fluoride.1,2 Tubes containing sodium fluoride are commercially available. Duncan S. Owen, Jr, MD
Neuralgia
Postherpetic
To the Editor.\p=m-\This letter is written in response to the treatment that was recommended for postherpetic neuralgia in a recent issue of The Journal. Ervin Epstein, MD, suggested repeated injections of triamcinolone acetonide into the symptomatic areas (238:517\x=req-\
518, 1977).
Two alternative methods that I have used successfully in treating postherpetic neuralgia are intercostal nerve block and sympathetic ganglion block. The blocks may be repeated daily until the symptoms subside. The reader is referred to Moore's textbook on Regional Block1 for descriptions of the
techniques.
Robert H. Libman, MD Illinois Masonic Medical Center University of Illinois Abraham Lincoln School of Medicine
Chicago Regional Block. Springfield, Ill, Charles C Thomas Publisher, 1975. 1. Moore DC:
Medical College of Virginia Virginia Commonwealth University Richmond
Jr, Cooke CL, Toone E: Practical synovial fluid examination. Va Med Mon 97:88-94, 1972. 2. Owen DS Jr: Recent advances in synovial fluid analysis. MCV Q 10:13-17, 1974. 1. Owen DS
Patients'
Responsibility
To the Editor.\p=m-\In regard to the discussion of management of prostatic carcinoma in QUESTIONS AND ANSWERS (238:254, 1977), I would like to compliment David A. Culp, MD, on his restraint in saying that "the postoperative management of the patient was rather inadequate." It was completely inadequate, and Donald W. Fellner, MD, is certainly very correct in his implication that this was the case.
Restraints in Use of Statistics To the Editor.\p=m-\The BRIEF REPORT, "Amebiasis: An Increasing Problem Among Homosexuals in New York
City" (238:1386, 1977), was a shrewd piece of research that will undoubtedly be of value to many physicians. In an era in which research physicians use statistically significant associations
as
conclusive evidence of
etiologic relations, it is gratifying that the authors did not conclude, as they had every right to do, that overseas travel to areas in which amebiasis is endemic is less frequently undertaken by homosexual men than by heterosexual men.
Downloaded From: http://jama.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/29/2015
Jack R.
Harnes, MD
New York
