CORRESPONDENCE
HIV TESTING IN WOMEN WITH VAGINAL CANDIDIASIS To the Editor: Sadly, the specter of human immunodeficiency virus (HIV) infection looms over ever more clinical situations, and the article by Imam et al [1] is most helpful in drawing our attention to the special concerns of female patients. In making r e c o m m e n d a t i o n s a b o u t H I V testing of women, however, they imply that a first episode of candidal vaginosis ought tb p r o m p t routine HIV testing. I do not believe their data can be construed to support this, and the costs nationwide, both financially and emotionally, would be enormous. Testing in women with new-onset recurrent disease, as they suggest, may be more appropriate.
more careful analysis by the patient of possible risk factors during the past decade. Probably most N o r t h American women will not find it appropriate to have HIV testing after a single episode of non-antibiotic-associated vaginal candidiasis. Those women, however, who choose testing after such an episode will presumably be a self-selected group at greater than average risk for HIV infection; some members of this group may benefit greatly from early diagnosis and management of asymptomatic HIV infection. We believe that the cost of offering HIV testing routinely under these circumstances will be small relative to the benefits gained by individuals in whom HIV infection is recognized at an early stage.
DEL J. DEHART, M.D.
NAIYER IMAM, M.D. KENNETH H. MAYER, M.D. AL VAN FISHER, M.D. CHARLES C.J. CARPENTER, M.D. MICHAEL STEIN, M.D. STEPHANIE B. DANFORTH, R.N.
Bowman-Gray School of Medicine Winston-Salem, North Carolina 1. Imam N, Carpenter CCJ, Mayer KH, Fisher h, Stein M, Danforth SB. Hierarchical pattern of mucosal candida infections in HIV-seropositive women. Am J Med 1990; 89: 142-6.
Brown University Providence, Rhode Island
Submitted August 28, 1990, and accepted November 19, 1990
The Reply: We appreciate the thoughtful comments by Dr. DeHart in regard to our recent article on mucosal infections in HIV-positive women. We did not intend to imply that a first episode of vaginal candidiasis should prompt routine HIV testing, but rather that it prompt candid discussion with the patient of the possibility of underlying HIV infection. The article states that, in this setting, HIV testing with pre- and posttest counseling should be offered routinely and carried out when appropriate. We have found that offering HIV testing under, these circumstances often leads to a 536
EXTRACEPHALIC MANIFESTATIONS OF GIANT CELL ARTERITIS To the Editor: Reich et al [1] described extraocular and extracephalic complications of giant cell arteritis (GCA). They have performed a great service by bringing together most neurologic m a n i f e s t a t i o n s of GCA. I would like to add other extracephalic and extraocular manifestations of GCA not mentioned in their review article. Extracephalic GCA occurs in about 10% to 15% of patients with temporal arteritis, with the aorta and its branches being most often involved [2]. GCA in the aorta and its branches is encountered in 1.4% to 1.7% of unselected sub-
April1991 The AmericanJournalof Medicine Volume90
jects at autopsy [3]. Granulomatous giant cell aortitis may give rise to progressive aortic aneurysmat dilatation, aortic valve ring dilatation, and aortic regurgitation [2,4,5]. Occlusion of the coronary arteries by granulomatous GCA may lead to ischemic heart disease and myocardial infarction [2,3,6,7]. All these extracephalic c o m p l i c a t i o n s of GCA have a bearing on cerebral circulation and may result in cerebral ischemia and stroke. ALBERT C. CUETTER, M.D.
Texas Tech University Health Sciences Center El Paso, Texas 1. Reich KA, Giansiracusa DF, Strongwater SL. Neurologic manifestations of giant cell arteritis. Am J Med 1990: 89: 67-72. 2. Lie JT, Failoni DD, Davis DC. Temporal arteritis with giant cell aortitis, coronary arteritis, and myocardial infarction. Arch Pathol Lab Med 1986:110: 857-60. 3. Paulley JW. Coronary ischaemia and occlusion in giant cell (temporal) arteritis. Acta Med Scand 1980; 208: 257-63. 4. Klinkhoff AV, Reid GD, Moscovich M. Aortic regurgitation in giant cell arteritis. Arthritis Rheum 1985; 28: 582-5. 5. Bowles C, Hunder GG. Aortic valve involvement in temporal arteritis. Arthritis Rheum 1984; 27 (Suppl): S86. 6. Lie JT. Coronary vasculitis: a review in the current scheme of classification of vasculitis. Arch Pathol Lab Med 1987; 111: 224--33. 7.81och T, Waller BF, Vakili ST. Giant cell arteritis of the coronary arteries. Indiana Med 1987; 80: 2624. Submitted September 4, 1990, and accepted October 1, 1990
FLEXIBLE SIGMOIDOSCOPY FOR COLORECTAL NEOPLASIA To the Editor: The article by Gupta et al [1] on screening for colorectal carcinoma was of great interest to us. We have recently reviewed our experience in a university-based staff model health maintenance organization using 35-cm flexible sigmoidoscopy (35FS) [2]. We do believe effective screening can be
CORRESPONDENCE
done at considerably lower costs than they have reported. In our clinical setting, salaried primary care physicians (general internists and family practitioners) perform 35FS in an outpatient/office setting with two to three p a t i e n t s s c h e d u l e d per hour. Our cost estimate is $35 per examination (based on hourly rates of physician--S40, nurse assistant-S13, receptionist--S10, and overhead and supplies per examination--S10). Patient preparation costs are less than
tially curable (i.e., Duke's A) carcinoma detected. This compares favorably with the $47,174 reported by Gupta et al. When we combined our a s y m p t o m a t i c , FOBT-negative and FOBT-positive patients undergoing 35FS, the estimated cost was $12,638 per potentially curable carcinoma detected. Although our yield with 35FS is lower than that reported by Gupta with 60FS, our results are comparable to those reported by others using 35FS and 60FS [5,6]. $5.00. Whether this can be totally exGupta et al estimate the cost plained by differences in patient for 60-cm flexible sigmoidoscopy population, p r e - e x a m i n a t i o n (60FS) alone to be $365 ($15-- FOBT conditions, length of flexip r e p a r a t i o n , $ 1 7 5 - - p h y s i c i a n ble sigmoidoscopy, and observer charges, $175--hospital fee). If training is not known. Interestthese estimates were used and ingly, a recent review of the literAmerican Cancer Society guide- ature found no difference in the lines were followed, medical costs cancer detection rate between for 60FS performed every 3 to 5 35FS and 60FS [7]. years in the 60 million Americans Demonstration of a clear reover age 50 would approach $6 duction in mortality from screenbillion per year [3,4]. ing and definitive cost-benefit Adding to this enormous cost analysis must await the results of would be charges for further test- several large ongoing prospective ing such as colonoscopy, estimat- studies [8]. Particularly given our ed by Gupta to be $925 per exam- lower costs, we agree with the auination. We believe this addition- thors that flexible sigmoidoscopy al cost can be reduced by having is useful in screening asymptomsalaried gastroenterologists or atic, average-risk patients over surgeons perform colonoscopy in the age of 50. We make these an office setting. comments to encourage screenIn our asymptomatic, fecal oc- ing flexible sigmoidoscopy by pricult blood test (FOBT)-negative mary care physicians and to offer patients (average age = 59 years, an approach that may reduce n -- 645), we detected adenoma- screening costs. tous polyps in 35 (5.4%) and carRUDOLPH MUELLER, M.D. cinomas in two (0.31%) patients. ANDREW DA VIS, M.D. ANCHOR Organization for Health The estimated cost of 35FS in Maintenance asymptomatic, FOBT-negative Rush University patients was $24,193 per potenChicago, Illinois
April 1991
1.Gupta TP, Jaszewski R, Luk GD. Efficacy of screening flexible sigmoidoscopy for colorectal neoplasia in asymptomatic subjects. Am J Med 1989; 86: 547-50. 2. Mueller RJ, DavisAM, Rollow WC. Colorectal carcinoma: a staff model HMO's experience with screening and hospital utilization. HMO Practice, July-August 1989; Vol 3. 3. Baskin WN. Early detection of colon cancer: current concepts. Cancer for Physicians 1986; 8: 1-3. 4. US Bureau of the Census. National data book and guide. 108th ed. Washington, DC: US Government Printing Office, 1987: 13, 86. 5. Groveman HE}, Sanowski RA, Klauber MR. Training primary care physicians in flexible sigmoidoscopy--performance evaluation of 17,167 procedures. West J Med 1987; 148: 221-4. 6. Yao Y. Colorectal cancer detection with the 60 crn flexible sigmoidoscope in a solo internist's office. J Am Geriatr Soc 1988; 36: 914-8. 7. Fleischer DE, Golclberg SB, Browning TH, et al. Detection and surveillance of colorectal cancer. JAMA 1989; 261: 580-5. 8. Selby JV, Friedman GD. Sigmoidoscopy in the periodic health examination of asymptomatic adults. JAMA 1989; 261: 595-601. Submitted June 8, 1989, and accepted October 1, 1990
Correction: "Twelve-Year Incidence of Coronary Heart Disease in Middle-Aged Adults During the Era of Hypertensive Therapy" The article "Twelve-Year Incidence of Coronary Heart Disease in Middle-Aged Adults During the Era of Hypertensive Therapy: The Framingham Offspring Study" by Wilson et al (January 1991, pages 11 to 16) contains two numerical errors. In Table III (page 16), the prevalence of hypertensive therapy at 8-year follow-up in the offspring group is 72%, not 7.2%. Also, line 10 in the l e f t - h a n d column on page 16 should read "therapy rates were higher for the offspring at entry (28%) . . . . "
The American Journal of Medicine Volume 90
537
HIV TESTING IN WOMEN WITH VAGINAL CANDIDIASIS To the Editor: Sadly, the specter of human immunodeficiency virus (HIV) infection looms over ever more clinical situations, and the article by Imam et al [1] is most helpful in drawing our attention to the special concerns of female patients. In making r e c o m m e n d a t i o n s a b o u t H I V testing of women, however, they imply that a first episode of candidal vaginosis ought tb p r o m p t routine HIV testing. I do not believe their data can be construed to support this, and the costs nationwide, both financially and emotionally, would be enormous. Testing in women with new-onset recurrent disease, as they suggest, may be more appropriate.
more careful analysis by the patient of possible risk factors during the past decade. Probably most N o r t h American women will not find it appropriate to have HIV testing after a single episode of non-antibiotic-associated vaginal candidiasis. Those women, however, who choose testing after such an episode will presumably be a self-selected group at greater than average risk for HIV infection; some members of this group may benefit greatly from early diagnosis and management of asymptomatic HIV infection. We believe that the cost of offering HIV testing routinely under these circumstances will be small relative to the benefits gained by individuals in whom HIV infection is recognized at an early stage.
DEL J. DEHART, M.D.
NAIYER IMAM, M.D. KENNETH H. MAYER, M.D. AL VAN FISHER, M.D. CHARLES C.J. CARPENTER, M.D. MICHAEL STEIN, M.D. STEPHANIE B. DANFORTH, R.N.
Bowman-Gray School of Medicine Winston-Salem, North Carolina 1. Imam N, Carpenter CCJ, Mayer KH, Fisher h, Stein M, Danforth SB. Hierarchical pattern of mucosal candida infections in HIV-seropositive women. Am J Med 1990; 89: 142-6.
Brown University Providence, Rhode Island
Submitted August 28, 1990, and accepted November 19, 1990
The Reply: We appreciate the thoughtful comments by Dr. DeHart in regard to our recent article on mucosal infections in HIV-positive women. We did not intend to imply that a first episode of vaginal candidiasis should prompt routine HIV testing, but rather that it prompt candid discussion with the patient of the possibility of underlying HIV infection. The article states that, in this setting, HIV testing with pre- and posttest counseling should be offered routinely and carried out when appropriate. We have found that offering HIV testing under, these circumstances often leads to a 536
EXTRACEPHALIC MANIFESTATIONS OF GIANT CELL ARTERITIS To the Editor: Reich et al [1] described extraocular and extracephalic complications of giant cell arteritis (GCA). They have performed a great service by bringing together most neurologic m a n i f e s t a t i o n s of GCA. I would like to add other extracephalic and extraocular manifestations of GCA not mentioned in their review article. Extracephalic GCA occurs in about 10% to 15% of patients with temporal arteritis, with the aorta and its branches being most often involved [2]. GCA in the aorta and its branches is encountered in 1.4% to 1.7% of unselected sub-
April1991 The AmericanJournalof Medicine Volume90
jects at autopsy [3]. Granulomatous giant cell aortitis may give rise to progressive aortic aneurysmat dilatation, aortic valve ring dilatation, and aortic regurgitation [2,4,5]. Occlusion of the coronary arteries by granulomatous GCA may lead to ischemic heart disease and myocardial infarction [2,3,6,7]. All these extracephalic c o m p l i c a t i o n s of GCA have a bearing on cerebral circulation and may result in cerebral ischemia and stroke. ALBERT C. CUETTER, M.D.
Texas Tech University Health Sciences Center El Paso, Texas 1. Reich KA, Giansiracusa DF, Strongwater SL. Neurologic manifestations of giant cell arteritis. Am J Med 1990: 89: 67-72. 2. Lie JT, Failoni DD, Davis DC. Temporal arteritis with giant cell aortitis, coronary arteritis, and myocardial infarction. Arch Pathol Lab Med 1986:110: 857-60. 3. Paulley JW. Coronary ischaemia and occlusion in giant cell (temporal) arteritis. Acta Med Scand 1980; 208: 257-63. 4. Klinkhoff AV, Reid GD, Moscovich M. Aortic regurgitation in giant cell arteritis. Arthritis Rheum 1985; 28: 582-5. 5. Bowles C, Hunder GG. Aortic valve involvement in temporal arteritis. Arthritis Rheum 1984; 27 (Suppl): S86. 6. Lie JT. Coronary vasculitis: a review in the current scheme of classification of vasculitis. Arch Pathol Lab Med 1987; 111: 224--33. 7.81och T, Waller BF, Vakili ST. Giant cell arteritis of the coronary arteries. Indiana Med 1987; 80: 2624. Submitted September 4, 1990, and accepted October 1, 1990
FLEXIBLE SIGMOIDOSCOPY FOR COLORECTAL NEOPLASIA To the Editor: The article by Gupta et al [1] on screening for colorectal carcinoma was of great interest to us. We have recently reviewed our experience in a university-based staff model health maintenance organization using 35-cm flexible sigmoidoscopy (35FS) [2]. We do believe effective screening can be
CORRESPONDENCE
done at considerably lower costs than they have reported. In our clinical setting, salaried primary care physicians (general internists and family practitioners) perform 35FS in an outpatient/office setting with two to three p a t i e n t s s c h e d u l e d per hour. Our cost estimate is $35 per examination (based on hourly rates of physician--S40, nurse assistant-S13, receptionist--S10, and overhead and supplies per examination--S10). Patient preparation costs are less than
tially curable (i.e., Duke's A) carcinoma detected. This compares favorably with the $47,174 reported by Gupta et al. When we combined our a s y m p t o m a t i c , FOBT-negative and FOBT-positive patients undergoing 35FS, the estimated cost was $12,638 per potentially curable carcinoma detected. Although our yield with 35FS is lower than that reported by Gupta with 60FS, our results are comparable to those reported by others using 35FS and 60FS [5,6]. $5.00. Whether this can be totally exGupta et al estimate the cost plained by differences in patient for 60-cm flexible sigmoidoscopy population, p r e - e x a m i n a t i o n (60FS) alone to be $365 ($15-- FOBT conditions, length of flexip r e p a r a t i o n , $ 1 7 5 - - p h y s i c i a n ble sigmoidoscopy, and observer charges, $175--hospital fee). If training is not known. Interestthese estimates were used and ingly, a recent review of the literAmerican Cancer Society guide- ature found no difference in the lines were followed, medical costs cancer detection rate between for 60FS performed every 3 to 5 35FS and 60FS [7]. years in the 60 million Americans Demonstration of a clear reover age 50 would approach $6 duction in mortality from screenbillion per year [3,4]. ing and definitive cost-benefit Adding to this enormous cost analysis must await the results of would be charges for further test- several large ongoing prospective ing such as colonoscopy, estimat- studies [8]. Particularly given our ed by Gupta to be $925 per exam- lower costs, we agree with the auination. We believe this addition- thors that flexible sigmoidoscopy al cost can be reduced by having is useful in screening asymptomsalaried gastroenterologists or atic, average-risk patients over surgeons perform colonoscopy in the age of 50. We make these an office setting. comments to encourage screenIn our asymptomatic, fecal oc- ing flexible sigmoidoscopy by pricult blood test (FOBT)-negative mary care physicians and to offer patients (average age = 59 years, an approach that may reduce n -- 645), we detected adenoma- screening costs. tous polyps in 35 (5.4%) and carRUDOLPH MUELLER, M.D. cinomas in two (0.31%) patients. ANDREW DA VIS, M.D. ANCHOR Organization for Health The estimated cost of 35FS in Maintenance asymptomatic, FOBT-negative Rush University patients was $24,193 per potenChicago, Illinois
April 1991
1.Gupta TP, Jaszewski R, Luk GD. Efficacy of screening flexible sigmoidoscopy for colorectal neoplasia in asymptomatic subjects. Am J Med 1989; 86: 547-50. 2. Mueller RJ, DavisAM, Rollow WC. Colorectal carcinoma: a staff model HMO's experience with screening and hospital utilization. HMO Practice, July-August 1989; Vol 3. 3. Baskin WN. Early detection of colon cancer: current concepts. Cancer for Physicians 1986; 8: 1-3. 4. US Bureau of the Census. National data book and guide. 108th ed. Washington, DC: US Government Printing Office, 1987: 13, 86. 5. Groveman HE}, Sanowski RA, Klauber MR. Training primary care physicians in flexible sigmoidoscopy--performance evaluation of 17,167 procedures. West J Med 1987; 148: 221-4. 6. Yao Y. Colorectal cancer detection with the 60 crn flexible sigmoidoscope in a solo internist's office. J Am Geriatr Soc 1988; 36: 914-8. 7. Fleischer DE, Golclberg SB, Browning TH, et al. Detection and surveillance of colorectal cancer. JAMA 1989; 261: 580-5. 8. Selby JV, Friedman GD. Sigmoidoscopy in the periodic health examination of asymptomatic adults. JAMA 1989; 261: 595-601. Submitted June 8, 1989, and accepted October 1, 1990
Correction: "Twelve-Year Incidence of Coronary Heart Disease in Middle-Aged Adults During the Era of Hypertensive Therapy" The article "Twelve-Year Incidence of Coronary Heart Disease in Middle-Aged Adults During the Era of Hypertensive Therapy: The Framingham Offspring Study" by Wilson et al (January 1991, pages 11 to 16) contains two numerical errors. In Table III (page 16), the prevalence of hypertensive therapy at 8-year follow-up in the offspring group is 72%, not 7.2%. Also, line 10 in the l e f t - h a n d column on page 16 should read "therapy rates were higher for the offspring at entry (28%) . . . . "
The American Journal of Medicine Volume 90
537
