The Treatment of Persons Exposed to Rabies To the Editor.\p=m-\Thearticle by Drs Co-
rey and Hattwick (232:272, 1975) presents a dilemma because of the
prophylaxis algorithm. If a normally behaving but unvaccinated dog, such pup under 1 year of age, licks a on the mouth or on a skinned knee, then the "no" arrow drops to box number 8 that indicates killing as a
child
the animal for flourescent antibody examination of the brain! Whereas I recognize the intent and value of this article, there may soon be many unnecessarily dead dogs around. Would Drs Corey and Hattwick wish to make some additional modifications to the prophylaxis al-
gorithm?
Jonathan B. Rosefsky, MD
Binghamton,
NY
Reply.\p=m-\Weappreciate Dr Rosefsky's comments regarding the rabies treatment algorithm. It certainly is
States are under 1 year of age, and 8% are less than 4 months old. Thus, even young dogs must be considered a potential hazard. In the event it is not possible to kill and examine the biting dog, the phy¬ sician has the alternative of placing the animal under a ten-day quaran¬ tine for observation. Unfortunately, this
approach
persons either
the other hand, it is the intent of the algorithm to provide guidelines for the physician confronted with a patient exposed to a possibly rabid animal, and the first question in the algorithm asks whether a person has been exposed to a possibly rabid animal. If the physician decides the animal could not possibly be rabid, we recommend no treatment. There are, no doubt, many children licked or nipped by unvaccinated but normally behaving puppies in whom the possibility of rabies is never seriously considered. But if the physician does consider rabies a possibility, we recommend that he decide on the basis outlined in the algorithm whether or not to treat the patient. Because of the morbidity associated with postexposure rabies prophylaxis, we think it is reasonable to kill a possibly rabid animal to determine whether postexposure prophylaxis is indicated. Consequently, as stated in box 8 of our algorithm, in areas where rabies is known or suspected to be present in dogs, we recommend that dogs involved in bona fide human ex¬ posure be sacrificed, unless they are normally behaving and vaccinated. The Public Health Service recom¬ mends that all dogs be immunized against rabies when they reach 3 months of age.1 At this time, they are immunologically competent and are at risk of exposure in the general pop¬ ulation. A recent study shows that 28% of rabid dogs in the United
fered unless there was normal cardiovascular status. I believe that the same prerequisite holds for adults as well as children and that imipramine should probably not be given in large doses when there is any preexisting cardiovascular disease on complete evaluation.
sarily if the dog survives or not being treated promptly if the dog dies dur¬ ing quarantine.
When the decision to treat or not treat can have severe or fatal implica¬
tions for the patient if an incorrect decision is made, and an accurate de¬ cision can be made by testing the dog, it seems appropriate to us to opt for examining the dog. Lawrence Corey, MD Michael A. W. Hattwick, MD Communicable Disease Center Atlanta
In
not our intent to initiate a program to destroy all unvaccinated dogs. On
may result in many
being treated unneces¬
taking more than 5 mg/kg of imipramine daily. It was noted in our brief paragraph that imipramine not be of-
1. Compendium of Animal Rabies Vaccines. Atlanta, US Department of Health, Education, and Welfare, Center for Disease Control, 1972.
Some Hope Remains To the Editor.\p=m-\There is no such word "indeterminant" (233:253, 1975). The word is "indeterminate," and there doesn't seem to be any advantage in changing the spelling of it. "Hopefully," (I see this once-offensive expression has been admitted to The Journal's pages [233:252, 1975] despite previous objections of journal editors and others) the copy editors can be instructed to repair this blunder if it turns up again. as
Harry L. Arnold, Jr, MD, Editor
Hawaii Medical Journal Honolulu
/ suppose we cannot explain away "inde¬ terminant" as a typographical error, as it appeared twice. We hopefully await the rapid demise of "hopefully," except in its proper role as a directly attached adverb. Its appearance in The Journal as a sentence adverb enhances neither the propriety of such usage nor our editorial
self-esteem.—Ed.
Imipramine-Induced Heart Block To the Editor.\p=m-\Irefer to the article by Kantor et al, entitled "Imipramine-Induced Heart Block" (231:1364, 1975). My colleagues and I have undertaken an extensive look at children receiving therapeutic doses of imipramine and have reported preliminary data (224:902, 1973). Since that time, first-degree heart block has been noted in an occasional patient
Downloaded From: http://jama.jamanetwork.com/ by a Carleton University User on 06/21/2015
Gilbert I. Martin, MD Covina, Calif
Errors in Course Listings. \p=m-\Thefollowing errors occurred in the "Continuing Education Courses for Physicians" supplement, published with the Aug 11 issue (233:585-748,1975):
On page 589, in the second complete paragraph in column 1, the page number for the Figure was omitted. The final statement in the paragraph should read: "(See page
594.)"
On page 619, under Minnesota, the title of the course sponsored by the Univ of Minn Med Sch should have been Colon & Rectal Surgery. On page 634, under California, the item on the course titled Ambulatory Health Care Delivery\p=m-\Clin&
Systems Approach (sponsored by the Naval Regional Med Ctr) should
have listed the dates as 2/11/76 to 2/13/76. On page 659, under New Jersey, the entry for the Renal Disease Symposium (sponsored by the Helene Fuld Med Ctr) should have listed the date as 10/29/75. On page 700, under Pennsylvania, the listing for the Child Development course (sponsored by the Amer Acad of Pediatrics) should have indicated that the course would be held at St. Christopher's Hosp for Children. On page 731, under New York, the entry for Critical Problems in Vas¬ cular Surg (sponsored by the Montefiore Hosp & Med Ctr) should have listed the fees as $250 for practicing physicians and $125 for residents. On page 740, in the second com¬ plete item in column 1, the last two titles listed—Current Concepts in the Diagnosis & Treatment of Ver¬ tigo and A Close Look at Hel¬ minths-should not have been in¬ cluded in that entry. Those two titles are distributed by the Roerig Div, Pfizer Pharmaceuticals Inc, 235 E 42nd St, New York, NY 10017.
rey and Hattwick (232:272, 1975) presents a dilemma because of the
prophylaxis algorithm. If a normally behaving but unvaccinated dog, such pup under 1 year of age, licks a on the mouth or on a skinned knee, then the "no" arrow drops to box number 8 that indicates killing as a
child
the animal for flourescent antibody examination of the brain! Whereas I recognize the intent and value of this article, there may soon be many unnecessarily dead dogs around. Would Drs Corey and Hattwick wish to make some additional modifications to the prophylaxis al-
gorithm?
Jonathan B. Rosefsky, MD
Binghamton,
NY
Reply.\p=m-\Weappreciate Dr Rosefsky's comments regarding the rabies treatment algorithm. It certainly is
States are under 1 year of age, and 8% are less than 4 months old. Thus, even young dogs must be considered a potential hazard. In the event it is not possible to kill and examine the biting dog, the phy¬ sician has the alternative of placing the animal under a ten-day quaran¬ tine for observation. Unfortunately, this
approach
persons either
the other hand, it is the intent of the algorithm to provide guidelines for the physician confronted with a patient exposed to a possibly rabid animal, and the first question in the algorithm asks whether a person has been exposed to a possibly rabid animal. If the physician decides the animal could not possibly be rabid, we recommend no treatment. There are, no doubt, many children licked or nipped by unvaccinated but normally behaving puppies in whom the possibility of rabies is never seriously considered. But if the physician does consider rabies a possibility, we recommend that he decide on the basis outlined in the algorithm whether or not to treat the patient. Because of the morbidity associated with postexposure rabies prophylaxis, we think it is reasonable to kill a possibly rabid animal to determine whether postexposure prophylaxis is indicated. Consequently, as stated in box 8 of our algorithm, in areas where rabies is known or suspected to be present in dogs, we recommend that dogs involved in bona fide human ex¬ posure be sacrificed, unless they are normally behaving and vaccinated. The Public Health Service recom¬ mends that all dogs be immunized against rabies when they reach 3 months of age.1 At this time, they are immunologically competent and are at risk of exposure in the general pop¬ ulation. A recent study shows that 28% of rabid dogs in the United
fered unless there was normal cardiovascular status. I believe that the same prerequisite holds for adults as well as children and that imipramine should probably not be given in large doses when there is any preexisting cardiovascular disease on complete evaluation.
sarily if the dog survives or not being treated promptly if the dog dies dur¬ ing quarantine.
When the decision to treat or not treat can have severe or fatal implica¬
tions for the patient if an incorrect decision is made, and an accurate de¬ cision can be made by testing the dog, it seems appropriate to us to opt for examining the dog. Lawrence Corey, MD Michael A. W. Hattwick, MD Communicable Disease Center Atlanta
In
not our intent to initiate a program to destroy all unvaccinated dogs. On
may result in many
being treated unneces¬
taking more than 5 mg/kg of imipramine daily. It was noted in our brief paragraph that imipramine not be of-
1. Compendium of Animal Rabies Vaccines. Atlanta, US Department of Health, Education, and Welfare, Center for Disease Control, 1972.
Some Hope Remains To the Editor.\p=m-\There is no such word "indeterminant" (233:253, 1975). The word is "indeterminate," and there doesn't seem to be any advantage in changing the spelling of it. "Hopefully," (I see this once-offensive expression has been admitted to The Journal's pages [233:252, 1975] despite previous objections of journal editors and others) the copy editors can be instructed to repair this blunder if it turns up again. as
Harry L. Arnold, Jr, MD, Editor
Hawaii Medical Journal Honolulu
/ suppose we cannot explain away "inde¬ terminant" as a typographical error, as it appeared twice. We hopefully await the rapid demise of "hopefully," except in its proper role as a directly attached adverb. Its appearance in The Journal as a sentence adverb enhances neither the propriety of such usage nor our editorial
self-esteem.—Ed.
Imipramine-Induced Heart Block To the Editor.\p=m-\Irefer to the article by Kantor et al, entitled "Imipramine-Induced Heart Block" (231:1364, 1975). My colleagues and I have undertaken an extensive look at children receiving therapeutic doses of imipramine and have reported preliminary data (224:902, 1973). Since that time, first-degree heart block has been noted in an occasional patient
Downloaded From: http://jama.jamanetwork.com/ by a Carleton University User on 06/21/2015
Gilbert I. Martin, MD Covina, Calif
Errors in Course Listings. \p=m-\Thefollowing errors occurred in the "Continuing Education Courses for Physicians" supplement, published with the Aug 11 issue (233:585-748,1975):
On page 589, in the second complete paragraph in column 1, the page number for the Figure was omitted. The final statement in the paragraph should read: "(See page
594.)"
On page 619, under Minnesota, the title of the course sponsored by the Univ of Minn Med Sch should have been Colon & Rectal Surgery. On page 634, under California, the item on the course titled Ambulatory Health Care Delivery\p=m-\Clin&
Systems Approach (sponsored by the Naval Regional Med Ctr) should
have listed the dates as 2/11/76 to 2/13/76. On page 659, under New Jersey, the entry for the Renal Disease Symposium (sponsored by the Helene Fuld Med Ctr) should have listed the date as 10/29/75. On page 700, under Pennsylvania, the listing for the Child Development course (sponsored by the Amer Acad of Pediatrics) should have indicated that the course would be held at St. Christopher's Hosp for Children. On page 731, under New York, the entry for Critical Problems in Vas¬ cular Surg (sponsored by the Montefiore Hosp & Med Ctr) should have listed the fees as $250 for practicing physicians and $125 for residents. On page 740, in the second com¬ plete item in column 1, the last two titles listed—Current Concepts in the Diagnosis & Treatment of Ver¬ tigo and A Close Look at Hel¬ minths-should not have been in¬ cluded in that entry. Those two titles are distributed by the Roerig Div, Pfizer Pharmaceuticals Inc, 235 E 42nd St, New York, NY 10017.
