Volume 87 Number 1
Letters to the Editor
14 9
Editorial correspondence
"Editorial Correspondence" or letters to the Editor relative to articles published in the JOURNAL or to topics of current interest are subject to critical review and to current editorial policy in respect to publication in part or in full.
Amebic encephalitis To the Editor: Perhaps the parenthetical inclusion of Entamoeba histolytiea in Dr. Taylor's discussion in the Clinical-Pathological Conference (July, 1974) 1 was not meant to refer to primary amebic meningoencephalitis but the subsequent reference to spread from a primary intestinal or hepatic site. It is my understanding 2.~ that the term "primary amebic encephalitis" is reserved for infection with the facultative parasites Naegleria, more frequently, or Acanthamoeba reported in persons o n immunosuppressants. Cerebral infections with E. histolytica would be secondary to an invasive (perhaps asymptomatic) site elsewhere. Ruth M. Goehle, M.D. Medical Officer--Nigeria World Friendship ,House Falkner Square Liverpool L8 7NX England REFERENCES
1.
2. 3.
Sotelo-Avila C, Taylor FM, and Ewing CW: Primary amebic meningoencephalitis in a healthy 7-year-old boy, J PEDIATR 85:131, 1974. WoodruffAW, et al: Medicine in the tropics, London, 1974, J & A Churchill, Ltd, p 137. Wilcocks C, and Manson-Bahr PEC: Manson's tropical diseases, ed 17, London, 1972, Bailli~re, Tindall & Cox, Ltd, p 185.
Nasal erosion with nasotracheal intubation To the Editor: In the September, 1974, issue of TKE JOURNAL Jung and Thomas 1 report a new complication of nasotracheal intubation.
This article is extremely timely in reporting a possible iatrogenic complication associated with improved care and outcome in critically ill neonates. We have seen this complication in our nursery, but follow-up studies have not shown otitis media or nasal congestion to be significant problems. Reconstructive surgery has not been necessary in any o f our four infants. In light of this new complication, we have altered our patient care in nasotracheal intubation. In agreement with Jung and Thomas, we have used the smallest nasotracheal tube which provides adequate ventilation without excessive air leaks, x, 2 Most newborn infants requiring nasotracheal intubation can be adequately managed with either the 3.0 or 3.5 mm clear Portex tube. Use of the 3.5 m m adapter for either tube allows adequate suctioning with a No. 8 French suction catheter. Fixation of the tube is probably the major etiologic factor in complications of the nares. Attaching the respirator to the tube directly above the neonate's nose as recommended by Dailey and Smith 3 may place undue traction on the nose. Lack of, blood supply as a result is manifest by blanching of the tissue surrounding the nares. Continued malpositioning of the tube could subsequently result in necrosis and erosion of the skin and mucosa. Adequate tube fixation requires that the respirator be attached to the nasotracheal tube over the infant's mouth. This allows the tube to exit the nose in the direction the nares are oriented. Securing the tube to prevent motion in this fashion will cut down on nasal irritation and erosion. Alternating the nares utilized for nasotracheal intubation as mentioned by the authors 1 and supported by Gregory 2 without attention to the problem of nasal erosion could make a minor problem major in an obligate nose breather. We agree that nasotracheal intubation is preferred over orotracheal intubation. Careful attention to nursing care problems such as this will do much to help eliminate iatrogenic complications of improved newborn care. Gary Pettett, M.D., Major M C Neonatology Fellow GeraM B. Merenstein, M.D., Lieutenant Colonel, MC Chief, Newborn Service Department of Pediatrics Fitzsimons Army Medical Center Denver, Colo. 80240
150
Letters to the Editor
REFERENCES 1. Jung AL, and Thomas GK; Stricture ofth~ Jt~t~tt ve~uoule: A complication of nasotracheal intubation in newborn infants, J PEDIATR 85:412, 1974. 2. Gregory TA: Respiratory care of newborn infants, Pediatr Clin North Am 19:311, 1972. 3. Dailey WJR, and Smith PC: Mechanical ventilation of the newborn infant, Part II, Probl Pediatr 1:8, 1971.
Is there a sex difference in juvenile diabetes?
The Journal of Pediatrics July 1975
patients in the 3 to 19 year age group made 787,000 contacts with private practicing physicians for diabetes; over one-fourth of these contacts were in hospital. The F / M of these contacts is by now familiar, 1.03. For all 466.5 million contacts by this age group the F/M was 1.13. In the age group 10-19 that accounts for 78% of the diabetes contacts, the F / M for all contacts is 1.26, while that for diabetes alone is 0.96. Thus the 25% greater frequency of consultation with private physicians by girls in the second decade of life does not apply to contacts for diabetes, unless one were to assume that there are more boys with this diagnosis than girls. Contemporary data do not support a significant difference in the sex distribution of childhood and adolescent diabetes melli-
tus. Arlan L. Rosenbloom, M.D. Beverly Giordano, R.N. Division of Genetics, Endocrinology and Metabolism Department of Pediatrics University of Florida College of Medicine Gainesville, Fla.
To the Editor: The basic question that must be asked of any epidemiologic study is whether the sample is a complete or representative population. Monteleone and associatesI have noted that more girls than boys are admitted to their hospital with newly diagnosed diabetes mellitus. This observation cannot be projected into a statement about the sex distribution of the condition without assurance that the hospitalized population is an unselected and statistically valid sample of all youngsters with diabetes in the area served by their hospital. In our own practice most new patients are not hospitalized. One potential bias may be lesser expectation of independence for female patients.2 This could be why our camp sex ratio corresponds to that found by Monteleone and associates; in 1974, 59% of 230 campers 7 to 20 years of age were girls. There also may be a greater tendency to ignore the early symptoms of diabetes in girls, ~ so that they are more ill when the diabetes is discovered.~ Whatever the bias, it is less in our referral patient population, where the female to male ratio (F/M) is l . l l (52.8% of 195 patients are girls). Sultz and associates3 have published diabetes hospitalization data for the years 1946 to 1961 for all children under 16 in Erie county, N. Y. In the years 1946 to 1953 the F / M was 1.81 for 90 new cases, but male middle- and upper-class patients were inexplicably not represented as they were after 1953; this was not true of girls. The magnitude of this discrepancy is adequate to explain the high F/M. After 1953 the ratio becomes 1.03 for the 277 new cases. Gorwitz and associates' have come closest to the ideal by surveying 75% of Michigan schoolchildren for known diabetes. In each age year from 5 to 18+ the F/M did not vary from the range of 1.00 to 1.03. For the entire population of 2,816 youngsters with diabetes, the ratio was 1.03. Another approach to this question can be made from projections of private practice data? In the year ending March, 1974,
Supported by The Division of Children's Medical Services of the Department of Health and Rehabilitative Services of the State of Florida and a faculty development awardfrom the University of Florida.
REFERENCES 1. Monteleone JA, Peden VH, and Hale RE: Sex difference in juvenile diabetes meUitus, J Pediatr 85:874, 1974, 2. Howell MC: What medical schools teach about women, N Engl J Med 291:304, 1974. 3. Sultz HA, Schlesinger ER, Mosher WE, and Feldman JQ: Childhood diabetes mellitus, in Sultz HA, et al, editors: Long-term childhood illness, Pittsburgh, 1972, University of Pittsburgh Press, pp 223-248. 4. Gorwitz K, Thompson T, and Howen GG: The prevalence of diabetes in school age children, presented at the 101st Annual Meeting of the American Public Health Assoc, San Francisco, Nov. 8, 1973. 5. National Disease and Therapeutic Index; reference file, diagnosis, April 1973-March 1974: IMS America, Ambler, Pa.
Reply To the Editor: We would like to thank Dr. Rosenbloom and Ms. Giordano for their interest in our paper. We are convinced that the sample given is not selective and is representative of the juvenile diabetics in our area. Two of us (J.A.M., V.H.P.) are hospital based and follow about 120 juvenile diabetics. After noting the increased number of girls in our private patients, we expanded the study to the hospital population (which included our patients, clinic patients, and patients of other private pediatricians). The expanded population ratio was almost identical to the smaller population. It has been our policy to admit to the hospital all new diabetics, regardless of severity or sex. Table I illustrates the distribution by age and sex of juvenile diabetes mellitus in our study. The incidence of diabetes is greater in females in all age groups until adolescence (12-15 years), the greatest significance being at 4 to 7
Letters to the Editor
14 9
Editorial correspondence
"Editorial Correspondence" or letters to the Editor relative to articles published in the JOURNAL or to topics of current interest are subject to critical review and to current editorial policy in respect to publication in part or in full.
Amebic encephalitis To the Editor: Perhaps the parenthetical inclusion of Entamoeba histolytiea in Dr. Taylor's discussion in the Clinical-Pathological Conference (July, 1974) 1 was not meant to refer to primary amebic meningoencephalitis but the subsequent reference to spread from a primary intestinal or hepatic site. It is my understanding 2.~ that the term "primary amebic encephalitis" is reserved for infection with the facultative parasites Naegleria, more frequently, or Acanthamoeba reported in persons o n immunosuppressants. Cerebral infections with E. histolytica would be secondary to an invasive (perhaps asymptomatic) site elsewhere. Ruth M. Goehle, M.D. Medical Officer--Nigeria World Friendship ,House Falkner Square Liverpool L8 7NX England REFERENCES
1.
2. 3.
Sotelo-Avila C, Taylor FM, and Ewing CW: Primary amebic meningoencephalitis in a healthy 7-year-old boy, J PEDIATR 85:131, 1974. WoodruffAW, et al: Medicine in the tropics, London, 1974, J & A Churchill, Ltd, p 137. Wilcocks C, and Manson-Bahr PEC: Manson's tropical diseases, ed 17, London, 1972, Bailli~re, Tindall & Cox, Ltd, p 185.
Nasal erosion with nasotracheal intubation To the Editor: In the September, 1974, issue of TKE JOURNAL Jung and Thomas 1 report a new complication of nasotracheal intubation.
This article is extremely timely in reporting a possible iatrogenic complication associated with improved care and outcome in critically ill neonates. We have seen this complication in our nursery, but follow-up studies have not shown otitis media or nasal congestion to be significant problems. Reconstructive surgery has not been necessary in any o f our four infants. In light of this new complication, we have altered our patient care in nasotracheal intubation. In agreement with Jung and Thomas, we have used the smallest nasotracheal tube which provides adequate ventilation without excessive air leaks, x, 2 Most newborn infants requiring nasotracheal intubation can be adequately managed with either the 3.0 or 3.5 mm clear Portex tube. Use of the 3.5 m m adapter for either tube allows adequate suctioning with a No. 8 French suction catheter. Fixation of the tube is probably the major etiologic factor in complications of the nares. Attaching the respirator to the tube directly above the neonate's nose as recommended by Dailey and Smith 3 may place undue traction on the nose. Lack of, blood supply as a result is manifest by blanching of the tissue surrounding the nares. Continued malpositioning of the tube could subsequently result in necrosis and erosion of the skin and mucosa. Adequate tube fixation requires that the respirator be attached to the nasotracheal tube over the infant's mouth. This allows the tube to exit the nose in the direction the nares are oriented. Securing the tube to prevent motion in this fashion will cut down on nasal irritation and erosion. Alternating the nares utilized for nasotracheal intubation as mentioned by the authors 1 and supported by Gregory 2 without attention to the problem of nasal erosion could make a minor problem major in an obligate nose breather. We agree that nasotracheal intubation is preferred over orotracheal intubation. Careful attention to nursing care problems such as this will do much to help eliminate iatrogenic complications of improved newborn care. Gary Pettett, M.D., Major M C Neonatology Fellow GeraM B. Merenstein, M.D., Lieutenant Colonel, MC Chief, Newborn Service Department of Pediatrics Fitzsimons Army Medical Center Denver, Colo. 80240
150
Letters to the Editor
REFERENCES 1. Jung AL, and Thomas GK; Stricture ofth~ Jt~t~tt ve~uoule: A complication of nasotracheal intubation in newborn infants, J PEDIATR 85:412, 1974. 2. Gregory TA: Respiratory care of newborn infants, Pediatr Clin North Am 19:311, 1972. 3. Dailey WJR, and Smith PC: Mechanical ventilation of the newborn infant, Part II, Probl Pediatr 1:8, 1971.
Is there a sex difference in juvenile diabetes?
The Journal of Pediatrics July 1975
patients in the 3 to 19 year age group made 787,000 contacts with private practicing physicians for diabetes; over one-fourth of these contacts were in hospital. The F / M of these contacts is by now familiar, 1.03. For all 466.5 million contacts by this age group the F/M was 1.13. In the age group 10-19 that accounts for 78% of the diabetes contacts, the F / M for all contacts is 1.26, while that for diabetes alone is 0.96. Thus the 25% greater frequency of consultation with private physicians by girls in the second decade of life does not apply to contacts for diabetes, unless one were to assume that there are more boys with this diagnosis than girls. Contemporary data do not support a significant difference in the sex distribution of childhood and adolescent diabetes melli-
tus. Arlan L. Rosenbloom, M.D. Beverly Giordano, R.N. Division of Genetics, Endocrinology and Metabolism Department of Pediatrics University of Florida College of Medicine Gainesville, Fla.
To the Editor: The basic question that must be asked of any epidemiologic study is whether the sample is a complete or representative population. Monteleone and associatesI have noted that more girls than boys are admitted to their hospital with newly diagnosed diabetes mellitus. This observation cannot be projected into a statement about the sex distribution of the condition without assurance that the hospitalized population is an unselected and statistically valid sample of all youngsters with diabetes in the area served by their hospital. In our own practice most new patients are not hospitalized. One potential bias may be lesser expectation of independence for female patients.2 This could be why our camp sex ratio corresponds to that found by Monteleone and associates; in 1974, 59% of 230 campers 7 to 20 years of age were girls. There also may be a greater tendency to ignore the early symptoms of diabetes in girls, ~ so that they are more ill when the diabetes is discovered.~ Whatever the bias, it is less in our referral patient population, where the female to male ratio (F/M) is l . l l (52.8% of 195 patients are girls). Sultz and associates3 have published diabetes hospitalization data for the years 1946 to 1961 for all children under 16 in Erie county, N. Y. In the years 1946 to 1953 the F / M was 1.81 for 90 new cases, but male middle- and upper-class patients were inexplicably not represented as they were after 1953; this was not true of girls. The magnitude of this discrepancy is adequate to explain the high F/M. After 1953 the ratio becomes 1.03 for the 277 new cases. Gorwitz and associates' have come closest to the ideal by surveying 75% of Michigan schoolchildren for known diabetes. In each age year from 5 to 18+ the F/M did not vary from the range of 1.00 to 1.03. For the entire population of 2,816 youngsters with diabetes, the ratio was 1.03. Another approach to this question can be made from projections of private practice data? In the year ending March, 1974,
Supported by The Division of Children's Medical Services of the Department of Health and Rehabilitative Services of the State of Florida and a faculty development awardfrom the University of Florida.
REFERENCES 1. Monteleone JA, Peden VH, and Hale RE: Sex difference in juvenile diabetes meUitus, J Pediatr 85:874, 1974, 2. Howell MC: What medical schools teach about women, N Engl J Med 291:304, 1974. 3. Sultz HA, Schlesinger ER, Mosher WE, and Feldman JQ: Childhood diabetes mellitus, in Sultz HA, et al, editors: Long-term childhood illness, Pittsburgh, 1972, University of Pittsburgh Press, pp 223-248. 4. Gorwitz K, Thompson T, and Howen GG: The prevalence of diabetes in school age children, presented at the 101st Annual Meeting of the American Public Health Assoc, San Francisco, Nov. 8, 1973. 5. National Disease and Therapeutic Index; reference file, diagnosis, April 1973-March 1974: IMS America, Ambler, Pa.
Reply To the Editor: We would like to thank Dr. Rosenbloom and Ms. Giordano for their interest in our paper. We are convinced that the sample given is not selective and is representative of the juvenile diabetics in our area. Two of us (J.A.M., V.H.P.) are hospital based and follow about 120 juvenile diabetics. After noting the increased number of girls in our private patients, we expanded the study to the hospital population (which included our patients, clinic patients, and patients of other private pediatricians). The expanded population ratio was almost identical to the smaller population. It has been our policy to admit to the hospital all new diabetics, regardless of severity or sex. Table I illustrates the distribution by age and sex of juvenile diabetes mellitus in our study. The incidence of diabetes is greater in females in all age groups until adolescence (12-15 years), the greatest significance being at 4 to 7
