Letters to the editor - Letter to the Editor

Date: March 15, 2003

Hypertension Should Be Confirmed Before Treatment

TO THE EDITOR: I would like to thank Dr. Niedfeldt and American Family Physician for the fine article, "Managing Hypertension in Athletes and Physically Active Patients." (1) However, I would like to add a point to this statement: "If (hypertension) is diagnosed, appropriate treatment should be started to reduce the risk of morbidity and mortality associated with cardiovascular disease." (1) I believe that it is important to be sure that the patient does indeed have hypertension. Some athletes have extra large or extra small upper arms and have been screened with an inappropriately sized cuff when taking their blood pressure. (2) Other athletes exhibit "white coat" hypertension. (3) Therefore, when diagnosing hypertension, physicians should use appropriately sized cuffs for those "extra" sized athletes. I have found that the use of ambulatory pressure monitors has saved many athletes with white coat hypertension from taking unnecessary medication.

JOHN PHILIP SHERROD, M.D.University of North Carolina at Chapel HillDepartment of Family MedicineManning Dr.Chapel Hill, NC 27514


(1.) Niedfeldt MW. Managing hypertension in athletes and physically active patients. Am Fam Physician 2002;66:445-52.

(2.) Zitelli BJ, Davis HW (eds). Atlas of pediatric physical diagnosis. 3d ed. St. Louis: Mosby-Wolfe, 1997.

(3.) Noble J, Greene HL. Textbook of primary care medicine. 2d ed. St. Louis: Mosby, 1996.

Early Diagnosis and Treatment Vital in Cases of Foot Fractures

TO THE EDITOR: I read with great interest the article, "Foot Fractures Frequently Misdiagnosed as Ankle Sprains," (1) which provided a thorough discussion of the various types of talus fractures and how they can be missed initially on physical examination. This is of particular importance in children, because talus fractures in children are extremely rare (2-4) and may lead to lifelong morbidity unless they are diagnosed and treated appropriately. Furthermore, a large percentage of confirmed talus fractures are read as normal on initial radiographs. (1,3)

During a seven-year period, only 15 patients (average age: five years, five months) were identified at our institution who had either a talar head, neck, or body fracture (avulsion fractures and osteochondral fractures were excluded). (2) The most common mechanism of injury was a motor vehicle crash, and the second most common was a fall from a height. Additionally, in 12 of these patients, the talar fracture occurred in conjunction with other ipsilateral lower extremity fractures. The initial radiographic diagnosis of these fractures was missed in 33 percent of the cases in the emergency department, which is similar to results found by Drs. Judd and Kim in the literature concerning lateral process fractures of the talus in adults. (1)

Talus fractures in children often present with concomitant injuries to the lower limb, causing them to be missed on initial examination. Even though they are rare, it is important for the physician to have a high index of suspicion for these injuries and to perform a complete history and physical examination of every child. A clear understanding of the epidemiology of these injuries, as well as appropriate radiologic studies of the foot and ankle, are necessary to help ensure positive clinical outcomes in children and adults.

WILLIAM M. STRUB, M.D.University of Cincinnati College of MedicineDepartment of Radiology234 Goodman St. ML 0761Cincinnati, OH 45219


(1.) Judd DB, Kim DH. Foot fractures frequently misdiagnosed as ankle sprains. Am Fam Physician 2002; 66:785-94.

(2.) Strub WM, Mehlman CT, Todd LT Jr. Talus fractures in children. J Am Osteopath Acad Orthop 2000; 37:38-41.

(3.) Letts RM, Gibeault D. Fractures of the neck of the talus in children. Foot Ankle 1980;1:74-7.

(4.) Louw JA, Grabe RP. Fracture of the talus in childhood. A case report. S Afr Med J 1985;68:598-9.

Importance of Colorectal Cancer Screening

TO THE EDITOR: I read with great interest the article "Recent Developments in Colorectal Cancer Screening and Prevention," (1) in American Family Physician. This article hit home on a personal level since my father died of colorectal cancer in 2001. The article1 provided an excellent literature update that confirmed that screening for colorectal cancer by fecal occult blood testing (FOBT), flexible sigmoidoscopy, double-contrast barium enema, or colonoscopy is cost-effective when compared with no screening. Screening with colonoscopy alone every 10 years, or with the combination of flexible sigmoidoscopy and FOBT, were the most effective strategies in terms of life-years saved. (1)

Further work needs to be done to improve the specificity of FOBT while preserving its sensitivity for detecting curable cancers and smaller polyps. Although the findings of one trial (2) suggest that FOBT can reduce the incidence of colorectal cancer, FOBT has many limitations, including a low sensitivity for polyps, especially the smaller ones. Many screens are false positive, and the test has a low sensitivity for detecting cancers located in the proximal colon. In addition, the topography of colorectal cancer varies by race, which creates racial differences in the utility of such screening tests as flexible sigmoidoscopy and FOBT. (3)

Furthermore, patients have preferences for colorectal cancer screening techniques that are modestly sensitive to information about test performance and strongly sensitive to the out-of-pocket cost. (4)

The screening and prevention of colorectal cancer will continue to be an important issue for family physicians. It is vital that training programs for family physicians and students stress the importance of screening for colorectal cancer. Colorectal cancer screening should be offered based on national guidelines and on shared decision-making between the patient and the physician.

JOSEPH S. HURST, M.D.Columbus Regional Family Practice Residency Program1900 10th Ave., Suite 100Columbus, GA 31901


(1.) Pignone M, Levin B. Recent developments in colorectal cancer screening and prevention. Am Fam Physician 2002;66:297-302.

(2.) Mandel JS, Church TR, Bond JH, Ederer F, Geisser MS, Mongin SJ, et al. The effect of fecal occult-blood screening on the incidence of colorectal cancer. N Engl J Med 2000;343:1603-7.

(3.) Theuer CP, Taylor TH, Brewster WR, Campbell BS, Becerra JC, Anton-Culver H. The topography of colorectal cancer varies by race/ethnicity and affects the utility of flexible sigmoidoscopy. Am Surg 2001;Dec;67:1157-61.

(4.) Pignone M, Bucholtz D, Harris R. Patient preferences for colon cancer screening. J Gen Intern Med 1999;14:432-7.

Possible Side Effects Should Be Discussed with Patients

TO THE EDITOR: I enjoyed reading the article, "Managing Hypertension in Athletes and Physically Active Patients," (1) in American Family Physician. As a primary care physician, I concur with the importance of screening this target group of athletes and other physically active persons for high blood pressure, and the emphasis on lifestyle modifications. The article1 provided an extensive review of pharmacologic therapy, including various drug side effect profiles. However, in my experience with treating patients, sexual dysfunction is a major side effect of antihypertensive medicine that is especially relevant to athletes and physically active patients and is a significant cause of patient noncompliance with medication regimens. (2,3) Up to 25 percent of cases of sexual dysfunction, especially erectile dysfunction, are related to medication side effect. (4) High blood pressure medicines are commonly associated with various types of sexual dysfunction.

All patients should be informed of the possible side effect of sexual dysfunction, especially athletes and physically active patients, because this may have a tremendous impact on their lives. Family physicians need to be prepared to discuss this issue with patients to avoid noncompliance.

JOY ADEGBILE, M.D., M.P.H.Associate DirectorColumbus Regional Family Practice Residency Program1900 10th Ave., Suite 100Columbus, GA 31901


(1.) Niedfeldt MW. Managing hypertension in athletes and physically active patients. Am Fam Physician 2002;66:445-52.

(2.) Brock GB, Lue TF. Drug-induced male sexual dysfunction. An update. Drug Saf 1993;8:414-26.

(3.) Finger WW, Lund M, Slagle MA. Medications that may contribute to sexual disorders. A guide to assessment and treatment in family practice. J Fam Pract 1997;44:33-43.

(4.) NIH Consensus Conference. Impotence. NIH Consensus Development Panel on Impotence. JAMA 1993;270:83-90.

Update on Prescribing Information for Pantoprazole

The high cost and possible lack of prescription benefits to cover sildenafil may preclude frequent use; however, our experience suggests that sildenafil may be useful for difficult catheterizations in men with penile hypotonia.

DEEPA VASUDEVAN, M.D.6410 Fannin St., Suite 250Houston, TX 77030

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2672; fax: 913-906-6080; e-mail: afplet@ aafp.org. Please include your complete address, telephone number, and fax number. Letters should be submitted on disk, double-spaced, fewer than 500 words, and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.

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