References 1. ENGEL GL: A life setting conducive to illness. Ann Intern Med 69: 293, 1968 2. SCHMALE All: Relationship of separation and depression to disease. Psychosom Med 20: 259, 1958 3. ENGEL GL: Sudden and rapid death during psychological stress. Ann Intern Med 74: 771, 1971 4. GREENE WA, GOLDsTEIN 5, Moss AJ: Psychosocial aspects of sudden death. Arch Intern Med 129: 725, 1972
Acute rheumatic fever
To the editor: In his review "Acute rheumatic fever" (Can Med Assoc J 111: 818, 1974) Dr. Gordon R. Cumming states "Infectious disease experts tell us to culture throat swabs of all patients with upper respiratory tract infection.., but in most office practices in Canada it can be argued that this is neither practical nor justified on the basis of the low incidence of rheumatic fever." This statement requires comment because the principle of establishing a diagnosis as exactly as possible is essential to modern primary care practice. It is well documented that office bacteriologic studies are both practical and justified. The cost is minimal and the incidence of false-positives and negatives is low.1 A practitioner's experience over 20 years with this method of diagnosis should be read by all practising physicians.1 Dr. Cumming goes on to say "It is not justifiable to prescribe penicillin for all cases of pharyngitis.. .". He acknowledges the difficulty of differentiating nonstreptococcal from streptococcal disease and the dangers of excessive use of antibiotics, yet he believes it is not justifiable to carry out simple, inexpensive and reliable office laboratory procedures to solve both problems. Modern practitioners must educate themselves in these techniques if they are to maintain reasonable standards of care for their patients with respiratory infections. MELVIN I. MARKS, MD
Director, infectious diseases The Montr6al Children's Hospital Montr6al, Qu6.
Reference 1. PAGANO JS: Culturing beta-hemolytic streptococci in pediatric practice: observation after twenty years. J Pedlatr 75: 164, 1969
To the editor: I had expected the statement to which Dr. Marks refers would generate controversy, for there is no uniformity in the use of throat cultures in office practice. Because there is no reliable clinical guideline to determine which patient with pharyngitis is harbouring streptococci, he makes a case for routine culture in all patients with pharyngitis. No one can fault the ideal of accuracy in diagnosis. If it is true that .dl
patients seeking medical care because of sore throat should have throat cultures, should we not also recommend that all citizens with a sore throat seek medical attention and have a throat culture done? Throat culture to determine the presence or absence of /3-hemolytic streptococci in our hospital patients was subjected to a cost analysis, and a value of about $5.50 was arrived at. The current Medicare laboratory fee in Manitoba for a throat culture is $4.50. This excludes physician time, cost of swab and container, transportation to laboratory, getting the report and acting on it. The office of Dr. Breeze (referred to by Dr. Marks), with four physicians, processed over 10 000 throat cultures in 1 year (Medicare cost, $45 000). In parts of Canada a group of four pediatricians or primary care physicians might not see a single patient with acute rheumatic fever in 2 to 3 years. Because of this I favour the selective use of throat cultures in pharyngitis patients with a family history of rheumatic fever, in patients from crowded or lowincome areas, in patients in whom there is a strong clinical suspicion of streptococcal infection, and in communities where streptococcal disease is prevalent or the incidence of rheumatic fever is high. Perhaps a large clinical study comparing the incidence of rheumatic fever in private medical practices in which this approach is used with the incidence in those in which the routine culture approach is used might settle the issue. GORDON R. CUMMING, MD
Head, section of cardiology, Children's centre Health Sciences Centre Winnipeg, Man.
Diagnostic tests recommended for GC specimens To the editor: We would like to bring to the attention of CMAJ readers the following recommendations of the Working Party on GC Methodology: Men 1. The presence of gram-negative intracellular diplococci in the smear of a urethral exudate constitutes sufficient basis for a routine diagnosis of gonorrhea. Positive smears should be double-checked by a coworker. Routine cultural confirmation is unnecessary. 2. When culture is considered neces4Members of the Working Party on GC Methodology are Dr. C. R. Amies, Toronto; Dr. R. W. Butler, St. Johns; Dr. J. M. S. Dixon, Edmonton; Dr. S. Toma, Toronto; Dr. B. B. Diena, Ottawa (chairman); and Dr. F. E. Ashton, Ottawa (secretary). The working party was convened by Dr. J. A. McKiel, director general of the laboratory centre for disease control of Health and Welfare Canada. Its purpose was to make recommendations for studies on the standardization of procedures for the transport and identification of specimens suspected to contain Neisseria gonorrhoeae.
sary the specimen should be inoculated on GC selective medium and incubated with added carbon dioxide. The combination of gramnegative diplococci, typical colonial morphology and positive oxidase reaction is sufficient for a positive diagnosis. 3. A confirmatory laboratory test (fluorescent antibody [FA] technique and! or biochemical activity and growth requirements) has to be used under the following conditions: (a) When one or more of the above methods does not produce typical findings. (b) When the source of the specimen is not stated or known, or when the specimen has been taken from an area other than the urethra, such as pharynx, anal canal, eye, etc. (c) In special cases, such as patients who are minors, medicolegal cases, surveys of different population groups, asymptomatic cases, and cultures referred for identification. Remark: All positive results should be recorded in red ink. Women 1. Culture specimens obtained from the genitourinary tract, preferably from the endocervical canal, should be inoculated on GC medium and incubated with added carbon dioxide. The combination of gram-negative diplococci, typical colonial morphology and positive oxidase reaction is sufficient for a positive diagnosis. The additional use of a confirmatory test (FA technique and! or biochemical activity and growth requirements) is strongly recommended. 2. A confirmatory laboratory test (FA technique and! or biochemical activity and growth requirements) should be used under the following conditions: (a) When one or more of the above methods does not produce typical findings. (b) When the source of the specimen is not stated or known, or when the specimen has been taken from an area other than the urethra, such as pharynx, anal canal, eye, etc. (c) In special cases, such as patients who are minors, medicolegal cases, surveys of different population groups, asymptomatic cases, and cultures referred for identification. Remark: All positive results should be recorded in red ink. B. B. DIENA, PH D
Chief of bacterial immunology Laboratory centre for disease control Health protection branch Health and Welfare Canada
OMA JOURNAL1JANUARY 25, 1975/VOL. 112 139
Acute rheumatic fever
To the editor: In his review "Acute rheumatic fever" (Can Med Assoc J 111: 818, 1974) Dr. Gordon R. Cumming states "Infectious disease experts tell us to culture throat swabs of all patients with upper respiratory tract infection.., but in most office practices in Canada it can be argued that this is neither practical nor justified on the basis of the low incidence of rheumatic fever." This statement requires comment because the principle of establishing a diagnosis as exactly as possible is essential to modern primary care practice. It is well documented that office bacteriologic studies are both practical and justified. The cost is minimal and the incidence of false-positives and negatives is low.1 A practitioner's experience over 20 years with this method of diagnosis should be read by all practising physicians.1 Dr. Cumming goes on to say "It is not justifiable to prescribe penicillin for all cases of pharyngitis.. .". He acknowledges the difficulty of differentiating nonstreptococcal from streptococcal disease and the dangers of excessive use of antibiotics, yet he believes it is not justifiable to carry out simple, inexpensive and reliable office laboratory procedures to solve both problems. Modern practitioners must educate themselves in these techniques if they are to maintain reasonable standards of care for their patients with respiratory infections. MELVIN I. MARKS, MD
Director, infectious diseases The Montr6al Children's Hospital Montr6al, Qu6.
Reference 1. PAGANO JS: Culturing beta-hemolytic streptococci in pediatric practice: observation after twenty years. J Pedlatr 75: 164, 1969
To the editor: I had expected the statement to which Dr. Marks refers would generate controversy, for there is no uniformity in the use of throat cultures in office practice. Because there is no reliable clinical guideline to determine which patient with pharyngitis is harbouring streptococci, he makes a case for routine culture in all patients with pharyngitis. No one can fault the ideal of accuracy in diagnosis. If it is true that .dl
patients seeking medical care because of sore throat should have throat cultures, should we not also recommend that all citizens with a sore throat seek medical attention and have a throat culture done? Throat culture to determine the presence or absence of /3-hemolytic streptococci in our hospital patients was subjected to a cost analysis, and a value of about $5.50 was arrived at. The current Medicare laboratory fee in Manitoba for a throat culture is $4.50. This excludes physician time, cost of swab and container, transportation to laboratory, getting the report and acting on it. The office of Dr. Breeze (referred to by Dr. Marks), with four physicians, processed over 10 000 throat cultures in 1 year (Medicare cost, $45 000). In parts of Canada a group of four pediatricians or primary care physicians might not see a single patient with acute rheumatic fever in 2 to 3 years. Because of this I favour the selective use of throat cultures in pharyngitis patients with a family history of rheumatic fever, in patients from crowded or lowincome areas, in patients in whom there is a strong clinical suspicion of streptococcal infection, and in communities where streptococcal disease is prevalent or the incidence of rheumatic fever is high. Perhaps a large clinical study comparing the incidence of rheumatic fever in private medical practices in which this approach is used with the incidence in those in which the routine culture approach is used might settle the issue. GORDON R. CUMMING, MD
Head, section of cardiology, Children's centre Health Sciences Centre Winnipeg, Man.
Diagnostic tests recommended for GC specimens To the editor: We would like to bring to the attention of CMAJ readers the following recommendations of the Working Party on GC Methodology: Men 1. The presence of gram-negative intracellular diplococci in the smear of a urethral exudate constitutes sufficient basis for a routine diagnosis of gonorrhea. Positive smears should be double-checked by a coworker. Routine cultural confirmation is unnecessary. 2. When culture is considered neces4Members of the Working Party on GC Methodology are Dr. C. R. Amies, Toronto; Dr. R. W. Butler, St. Johns; Dr. J. M. S. Dixon, Edmonton; Dr. S. Toma, Toronto; Dr. B. B. Diena, Ottawa (chairman); and Dr. F. E. Ashton, Ottawa (secretary). The working party was convened by Dr. J. A. McKiel, director general of the laboratory centre for disease control of Health and Welfare Canada. Its purpose was to make recommendations for studies on the standardization of procedures for the transport and identification of specimens suspected to contain Neisseria gonorrhoeae.
sary the specimen should be inoculated on GC selective medium and incubated with added carbon dioxide. The combination of gramnegative diplococci, typical colonial morphology and positive oxidase reaction is sufficient for a positive diagnosis. 3. A confirmatory laboratory test (fluorescent antibody [FA] technique and! or biochemical activity and growth requirements) has to be used under the following conditions: (a) When one or more of the above methods does not produce typical findings. (b) When the source of the specimen is not stated or known, or when the specimen has been taken from an area other than the urethra, such as pharynx, anal canal, eye, etc. (c) In special cases, such as patients who are minors, medicolegal cases, surveys of different population groups, asymptomatic cases, and cultures referred for identification. Remark: All positive results should be recorded in red ink. Women 1. Culture specimens obtained from the genitourinary tract, preferably from the endocervical canal, should be inoculated on GC medium and incubated with added carbon dioxide. The combination of gram-negative diplococci, typical colonial morphology and positive oxidase reaction is sufficient for a positive diagnosis. The additional use of a confirmatory test (FA technique and! or biochemical activity and growth requirements) is strongly recommended. 2. A confirmatory laboratory test (FA technique and! or biochemical activity and growth requirements) should be used under the following conditions: (a) When one or more of the above methods does not produce typical findings. (b) When the source of the specimen is not stated or known, or when the specimen has been taken from an area other than the urethra, such as pharynx, anal canal, eye, etc. (c) In special cases, such as patients who are minors, medicolegal cases, surveys of different population groups, asymptomatic cases, and cultures referred for identification. Remark: All positive results should be recorded in red ink. B. B. DIENA, PH D
Chief of bacterial immunology Laboratory centre for disease control Health protection branch Health and Welfare Canada
OMA JOURNAL1JANUARY 25, 1975/VOL. 112 139
