500
CIRCULATION
the chronicity of severe heart disease. There was therefore a very definite correlation between the preoperative history and the histologic observations. On the other hand Aschoff bodies did not have a prognostic significance because acute rheumatic fever is a self-limiting disorder of months' duration and operation was performed at variable times during the acute rheumatic episode. Murphy's patients were all operated upon before 1957. Up until at least 1950, acute rheumatic fever was the commonest cause of death in childhood, adolescence and young adulthood.2 Today acute rheumatic fever is very rare, is much milder when it does occur, and deaths from it are almost unknown. It is therefore to be expected that Aschoff bodies will rarely be seen at a time when rheumatic valvular subjects have clinical disability sufficient to justify operation. It is to be anticipated that the Aschoff body will soon be of historical interest only, but we should not mimic our political associates who continuously rewrite history. Louis A. SOLOFF, M.D. Division of Cardiology
Temple University Philadelphia, Pennsylvania 19140
References 1. Virmani R, Roberts WC: Aschoff bodies in operatively excised atrial appendages and in papillary muscle. Circulation 55: 559, 1977 2. Connor CAR: The diagnosis and management of rheumatic fever. Am J Med 1:376, 1946
The authors reply: To the Editor: Doctor Soloff's experience with patients with acute rheumatic fever is extensive and therefore we read carefully his letter commenting on our report. In our report we avoided making or commenting on possible implications of our study but simply described the frequency of Aschoff bodies in operatively excised atrial appendages and papillary muscles, and also described certain clinical features present in our patients who had Aschoff bodies. For omissions we had, if any, we are sorry. We welcome others to report objectively their experiences with Aschoff bodies. RENU VIRMANI, M.D. WILLIAM C. ROBERTS, M.D. Pathology Branch National Heart, Lung, and Blood Institute Bethesda, Maryland 20014
Athletic Echoes To the Editor: The paper by Allen and his colleagues entitled "Quantitative echocardiographic study of champion childhood swimmers" has been based on very carefully collected data and raises some interesting questions. We wish to take issue with the conclusion that the echocardiograms are quantitatively different from normal. It seems that there are three possible explanations for these findings. First, that the confidence limits (or percentile values) drawn during the original study of normal children1 2 are too narrow; second, that the data come from the same population but with the sample populations coming from opposite ends of the normal Gaussian distribution curve; and third, that the data come from two different populations. We regard the first possibility, that the confidence limits of the original study are too narrow, as the most likely explanation for the disparate findings between these two studies. There are several reasons for our opinion. First, in the original study of two hundred normal patients by the authors the correlation coefficients quoted for the thickness of the right ventricular anterior wall, ventricular septum and left ventricular posterior wall are r = 0.21, r = 0.32
VOL 56, No 3, SEPTEMBER 1977
and r = 0.74, respectively. These seem incongruous with such narrow confidence limits of fraction of a millimeter which are beyond the limits of resolution and measurement by echocardiography. These narrow confidence lines might well have been valid for the line but could they be the wrong confidence lines for the data points? We consider that the findings of the left ventricular wall thickness, left ventricular cavity dimensions, left atrial dimensions and aorta below as well as above the 95 percent confidence limits in their childhood athlete population would support our supposition. Second, in a study of some 80 normal children (in whom we have not elicited a history of physical activity) we found that our data points also exceed the 95 percent confidence limits in a similar manner to that shown in their study of athletic children. Our measurements were obtained using the same method described in the text.' 2 These authors might have allayed our concern by publishing the data points and the confidence lines of their original study together with the data from the present study. With regard to the second possibility the authors point out that athletic children who swim were compared to a group of nonathletic children whom they have defined as normal. We are not informed whether the group of children from Indiana was equally unathletic. If this was so, are the confidence limits established for these children valid for children of normal activity? One must propose that a normal population should consist of children with a Gaussian distribution of levels of activity as well. The authors have adopted the third possibility, namely that the data from this study and the normal data are from two different population groups. To explain the differences they have compared the findings of increased cardiac wall thickness to data from two groups who have examined adult champion athletes.2 The study by Morganroth et al.2 showed that world class swimmers have normal left ventricular wall thickness and increased cavity size which is the opposite of that found in the childhood athletes; the authors have offered no explanation for this difference. The study by Roeske et al.4 is more in keeping with that of the current study but Roeske's study was one of professional basketball players who had both left ventricular wall hypertrophy and increase in left ventricular cavity size. Whatever the outcome of this study may prove to be, we consider the need to establish normal data in children important because measurements of chamber and wall dimensions in health and disease can only be compared to normal. To date Dr. Allen and his colleagues are the only group to have attempted this task. NORMAN H. SILVERMAN, M.D. CLAUDE L. L. ROGi, M.D. Department of Pediatrics University of California San Francisco, California 94143
References 1. Goldberg SJ, Allen HD, Sahn DJ: Pediatric and Adolescent Echocardiography: A Handbook. Chicago, Year Book Medical Publishers, 1975 2. Epstein M, Goldberg SJ, Allen HD, Konecke L, Wood J: Great vessels, cardiac chamber and wall growth patterns in normal children. Circulation 51: 1124, 1975 3. Morganroth J, Maron B, Henry WL, Epstein SE: Comparative left ventricular dimensions in trained athletes. Ann Intern Med 82:521, 1975 4. Roeske WR, O'Rourke RA, Klein A, Leopold G, Karliner JS: Noninvasive evaluation of ventricular hypertrophy in professional athletes. Circulation 53: 286, 1976
The authors reply: To the Editor: We would like to thank Drs. Silverman and Roge for their comments about our paper.1 They raised some interesting questions. They questioned the confidence limits of our original study of normal children,2' wondering whether these confidence limits might be too narrow and perhaps explain the differences between
Downloaded from http://circ.ahajournals.org/ by guest on April 28, 2015
Athletic echoes. N H Silverman and C L Roge Circulation. 1977;56:500-501 doi: 10.1161/01.CIR.56.3.500 Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 1977 American Heart Association, Inc. All rights reserved. Print ISSN: 0009-7322. Online ISSN: 1524-4539
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://circ.ahajournals.org/content/56/3/500.citation
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Circulation can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: http://www.lww.com/reprints Subscriptions: Information about subscribing to Circulation is online at: http://circ.ahajournals.org//subscriptions/
Downloaded from http://circ.ahajournals.org/ by guest on April 28, 2015
CIRCULATION
the chronicity of severe heart disease. There was therefore a very definite correlation between the preoperative history and the histologic observations. On the other hand Aschoff bodies did not have a prognostic significance because acute rheumatic fever is a self-limiting disorder of months' duration and operation was performed at variable times during the acute rheumatic episode. Murphy's patients were all operated upon before 1957. Up until at least 1950, acute rheumatic fever was the commonest cause of death in childhood, adolescence and young adulthood.2 Today acute rheumatic fever is very rare, is much milder when it does occur, and deaths from it are almost unknown. It is therefore to be expected that Aschoff bodies will rarely be seen at a time when rheumatic valvular subjects have clinical disability sufficient to justify operation. It is to be anticipated that the Aschoff body will soon be of historical interest only, but we should not mimic our political associates who continuously rewrite history. Louis A. SOLOFF, M.D. Division of Cardiology
Temple University Philadelphia, Pennsylvania 19140
References 1. Virmani R, Roberts WC: Aschoff bodies in operatively excised atrial appendages and in papillary muscle. Circulation 55: 559, 1977 2. Connor CAR: The diagnosis and management of rheumatic fever. Am J Med 1:376, 1946
The authors reply: To the Editor: Doctor Soloff's experience with patients with acute rheumatic fever is extensive and therefore we read carefully his letter commenting on our report. In our report we avoided making or commenting on possible implications of our study but simply described the frequency of Aschoff bodies in operatively excised atrial appendages and papillary muscles, and also described certain clinical features present in our patients who had Aschoff bodies. For omissions we had, if any, we are sorry. We welcome others to report objectively their experiences with Aschoff bodies. RENU VIRMANI, M.D. WILLIAM C. ROBERTS, M.D. Pathology Branch National Heart, Lung, and Blood Institute Bethesda, Maryland 20014
Athletic Echoes To the Editor: The paper by Allen and his colleagues entitled "Quantitative echocardiographic study of champion childhood swimmers" has been based on very carefully collected data and raises some interesting questions. We wish to take issue with the conclusion that the echocardiograms are quantitatively different from normal. It seems that there are three possible explanations for these findings. First, that the confidence limits (or percentile values) drawn during the original study of normal children1 2 are too narrow; second, that the data come from the same population but with the sample populations coming from opposite ends of the normal Gaussian distribution curve; and third, that the data come from two different populations. We regard the first possibility, that the confidence limits of the original study are too narrow, as the most likely explanation for the disparate findings between these two studies. There are several reasons for our opinion. First, in the original study of two hundred normal patients by the authors the correlation coefficients quoted for the thickness of the right ventricular anterior wall, ventricular septum and left ventricular posterior wall are r = 0.21, r = 0.32
VOL 56, No 3, SEPTEMBER 1977
and r = 0.74, respectively. These seem incongruous with such narrow confidence limits of fraction of a millimeter which are beyond the limits of resolution and measurement by echocardiography. These narrow confidence lines might well have been valid for the line but could they be the wrong confidence lines for the data points? We consider that the findings of the left ventricular wall thickness, left ventricular cavity dimensions, left atrial dimensions and aorta below as well as above the 95 percent confidence limits in their childhood athlete population would support our supposition. Second, in a study of some 80 normal children (in whom we have not elicited a history of physical activity) we found that our data points also exceed the 95 percent confidence limits in a similar manner to that shown in their study of athletic children. Our measurements were obtained using the same method described in the text.' 2 These authors might have allayed our concern by publishing the data points and the confidence lines of their original study together with the data from the present study. With regard to the second possibility the authors point out that athletic children who swim were compared to a group of nonathletic children whom they have defined as normal. We are not informed whether the group of children from Indiana was equally unathletic. If this was so, are the confidence limits established for these children valid for children of normal activity? One must propose that a normal population should consist of children with a Gaussian distribution of levels of activity as well. The authors have adopted the third possibility, namely that the data from this study and the normal data are from two different population groups. To explain the differences they have compared the findings of increased cardiac wall thickness to data from two groups who have examined adult champion athletes.2 The study by Morganroth et al.2 showed that world class swimmers have normal left ventricular wall thickness and increased cavity size which is the opposite of that found in the childhood athletes; the authors have offered no explanation for this difference. The study by Roeske et al.4 is more in keeping with that of the current study but Roeske's study was one of professional basketball players who had both left ventricular wall hypertrophy and increase in left ventricular cavity size. Whatever the outcome of this study may prove to be, we consider the need to establish normal data in children important because measurements of chamber and wall dimensions in health and disease can only be compared to normal. To date Dr. Allen and his colleagues are the only group to have attempted this task. NORMAN H. SILVERMAN, M.D. CLAUDE L. L. ROGi, M.D. Department of Pediatrics University of California San Francisco, California 94143
References 1. Goldberg SJ, Allen HD, Sahn DJ: Pediatric and Adolescent Echocardiography: A Handbook. Chicago, Year Book Medical Publishers, 1975 2. Epstein M, Goldberg SJ, Allen HD, Konecke L, Wood J: Great vessels, cardiac chamber and wall growth patterns in normal children. Circulation 51: 1124, 1975 3. Morganroth J, Maron B, Henry WL, Epstein SE: Comparative left ventricular dimensions in trained athletes. Ann Intern Med 82:521, 1975 4. Roeske WR, O'Rourke RA, Klein A, Leopold G, Karliner JS: Noninvasive evaluation of ventricular hypertrophy in professional athletes. Circulation 53: 286, 1976
The authors reply: To the Editor: We would like to thank Drs. Silverman and Roge for their comments about our paper.1 They raised some interesting questions. They questioned the confidence limits of our original study of normal children,2' wondering whether these confidence limits might be too narrow and perhaps explain the differences between
Downloaded from http://circ.ahajournals.org/ by guest on April 28, 2015
Athletic echoes. N H Silverman and C L Roge Circulation. 1977;56:500-501 doi: 10.1161/01.CIR.56.3.500 Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 1977 American Heart Association, Inc. All rights reserved. Print ISSN: 0009-7322. Online ISSN: 1524-4539
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://circ.ahajournals.org/content/56/3/500.citation
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Circulation can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: http://www.lww.com/reprints Subscriptions: Information about subscribing to Circulation is online at: http://circ.ahajournals.org//subscriptions/
Downloaded from http://circ.ahajournals.org/ by guest on April 28, 2015
