CORRESPONDENCE.

(Letters to the Editor are welcomed. They may report new clinical or laboratory observations and new developments in medical care or may contain comments on recent contents of the Journal. They will be published, if found suitable, as space permits. Like other material submitted for publication, letters must be typewritten, double-spaced, and submitted in duplicate. They must not exceed two typewritten pages in length. No more than five references and one figure or table may be used. See "Information for Authors" for format of references, tables, and figures. Editing, possible abridgment, and acceptance remain the prerogative of the Editors.)

Racial Differences in Congestive Heart Failure Hospitalizations

To the Editor: Congestive heart failure (CHF) is a major public health problem in the United States. CHF is one of the leading causes of morbidity and mortality for Americans. [1] CHF is responsible for more than 5 million hospital days and $8 billion in expenditures annually. [1] Not only is CHF one of the most common reasons for hospitalizations in adults, it is also associated with a high incidence of rehospitalization. [2, 3]

To our knowledge, there are no published reports on CHF hospitalizations in central Florida. We examined racial differences in CHF hospital discharge rates in residents of Orange County, an urban county in central Florida (resident population of 869,838 in 2000), for the period 1992 through 1998. The public use hospital discharge file of the Florida Agency for Health Care Administration (AHCA) was the source of patient data. The study population comprised 13,678 records of patients who had a principal discharge diagnosis of CHF. The AHCA public use file contains clinical and demographic information on individuals hospitalized in Florida hospitals. The diagnoses in the AHCA database are coded using the ICD, 9th Revision, Clinical Modification. Only records of patients who were white or African-American were included in the study Patients of Hispanic ethnicity were included in the sample.

The study sample was stratified into the following age groups: 0-54 years, 55-64, 65-74, 75-84, and [greater than or equal to] 85. The race-specific number of discharges for each age group were summed for the years 1992-1998 and divided by the sums of the race-specific resident population estimates for Orange County for the same time frame. Population estimates were obtained from the website of the Florida Department of Health. [4] The SAS System for Windows, Release 8.00 (The SAS Institute, Cary, NC) was used to manage data and perform chi-square tests.

The study sample included 2,389 African-American discharge records and 11,289 white discharge records (Table). Although the crude discharge rates for African-Americans and whites are identical (approximately 26 discharges per 10,000), there was an African-American excess in every age group.

These results indicate that African-Americans in Orange County, Florida, have a high risk of hospitalization, and possibly rehospitalization, due to CHF. The most frequent cause of chronic CHF is left ventricular dysfunction due to coronary heart disease. [1] Educational efforts aimed at preventing coronary heart disease, including acute myocardial infarction, must be directed toward the African-American population of Orange County. Furthermore, residents who are at high risk of readmission due to CHF must be targeted for appropriate intervention. Prevention of repeated hospitalizations in CHF patients could improve quality of life and reduce health care expenditures. Risk factors for readmission include noncompliance with medication regimens, noncompliance with an appropriate diet, a failed social support system, and failure to seek medical attention promptly when symptoms recur. [3]

Zuber D. Mulla, MSPH 

Bureau of Epidemiology

Florida Department of Health

604 Courtland St, Suite 200

Orlando, FL 32804

References

(1.) Funk M, Krumholz HM: Epidemiologic and economic impact of advanced heart failure. J Cardiovasc Nurs 1996;10:1-10

(2.) Alexander M, Grumbach K, Selby J, et al: Hospitalization for congestive heart failure. explaining racial differences. JAMA 1995;274:1037-1042

(3.) Vinson JM, Rich MW, Sperry JC, et al: Early readmission of elderly patients with congestive heart failure. J Am Geriatr Soc 1990;38:1290-1295

(4.) Florida Department of Health: http://www.doh.state.fl.us. Accessed January 25, 2001

Routine Drug Screening in Trauma Patients

To the Editor: As a forensic pathologist, I read with interest and a slight bit of angst the recent article in the Southern Medical Journal by Bast et al (Bast RP, Helmer SD, Henson SR, et al: Limited utility of routine drug screening in trauma patients. South Med J 2000; 93:397-399) regarding the limited utility of routine drug screening in trauma patients. I find the paper to represent an elegant and well thought-out study, and I certainly agree with the conclusion that, not including alcohol, "routine toxicology does not alter or improve the immediate [emphasis mine] care of the injured patient." I would maintain to the readership of the Journal, however, that as physicians we should also acknowledge more long-term issues of public health; hence, the authors' next statement in their conclusion is the source of my unease: "Routine drug screening is expensive, and benefits were not easily documented." I would agree with the first clause, and in the context of the question addressed in the paper's title, the second clause is true; alas, the long-term benefits to society of drug testing in the context of trauma, while not a revenue center for a hospital, are incalculable.

One benefit is cited by Dr. Bast and his colleagues: a qualitatively positive drug screen indicates that the patient may be at risk for chemical dependency, thus placing him at increased risk for more trauma (and future costs to the hospital and to all us taxpayers, we same taxpayers who are often subsidizing trauma care) in the future and serving as a call for evaluating the patient for possible substance abuse treatment.

Another benefit not cited is the utility of such drug screens in assisting prosecuting agencies in keeping impaired drivers off the road. While I realize that such a consideration is not foremost in any physician's mind while treating a trauma victim, the reality of care of the injured driver is that all involved in that care are potentially practicing "forensic medicine," ie, one may be called upon to testify in a legal proceeding as to the state of intoxication of a driver. I would maintain that to do so is any physician's duty, should it help to keep intoxicated drivers from killing or maiming innocent individuals.

Also of great cost-savings to us taxpayers is the potential of a positive drug screen with subsequent confirmation in facilitating a plea bargain without the quite expensive cost of a jury trial. In considering halting routine drug screens of alleged operators of motor vehicles, I would maintain that we as a society may be penny-wise and pound-foolish.

My last minor concern with this otherwise exemplary paper is the statement that "...a significant number of false-positive results may occur in patients referred from outlying hospitals to a trauma center, since they may receive opiates or benzodiazepines either at the outside facility or during transport." Such a result would indeed not be a false positive; it would be a true positive, as the drugs would truly be in the patients' urine. The receiving physician would only have to refer to the documentation provided by the outlying center or emergency medical services records to quickly realize that such medications were given.

Gregory J. Davis, MD

Office of the Associate Chief Medical Examiner

Department of Pathology and Laboratory Medicine

University of Kentucky College of Medicine 

100 Sower Blvd, Suite 202 Frankfort, KY 40601

Delayed Death From Pulmonary Tuberculosis: Unsuspected Subtherapeutic Drug Levels

To the Editor: We read with interest the case report by Morehead [1] in which he described a patient who died from complications of pulmonary tuberculosis (TB). Despite appropriate antitubercular drugs and aggressive treatment in the intensive care unit, including mechanical ventilatory support, the patient died of her illness. Postmortem examination confirmed extensive necrotizing pulmonary TB. The author offered evidence that subtherapeutic rifampin blood levels may have contributed to this patient's death.

We have recently observed six patients who failed to respond clinically to 3 months of standard directly-observed oral antitubercular therapy (isoniazid, rifampin, pyrazinamide, and ethambutol). Each of these patients had subtherapeutic serum levels of rifampin while taking 600 mg of this medication. The serum rifampin levels in five patients was therapeutic when their dose was increased to 900 mg. The sixth patient required 1,500 mg before his serum rifampin level was therapeutic. None of the tubercular organisms isolated were drug-resistant. No other antitubercular medications were added or increased in these patients' antitubercular therapy. Increasing the dosage of these patients' rifampin therapy resulted in clinical improvement in all of the patients. We, therefore, concur with the author's conclusion that inadequate rifampin dosing should be considered in TB patients who are slow to respond to standard treatment.

As the author illustrates, a delay in the institution of chemotherapy, drug resistance, and comorbid illness all play a part in the mortality associated with TB. [2] However, patients with respiratory failure who require mechanical ventilation deserve special consideration. In this subset pf patients, nutritional status, as reflected by the patient's serum albumin level and hemoglobin level, is an important marker for patient mortality. [3] These observations suggest that early and aggressive attention to improving the patient's nutritional status may be as important as effective antitubercular therapy and mechanical ventilatory support in salvaging these patients.

Ryland P. Byrd, Jr., MD

Jay B. Mehta, MD

Cheryl L. Fields, MD

Thomas M. Roy, MD

Pulmonary and Critical Care Medicine

James H. Quillen College of Medicine

Veterans Affairs Medical Center (111B)

Mountain Home, TN 37684

References

(1.) Morehead RS: Delayed death from pulmonary tuberculosis: unsuspected subtherapeutic drug levels. South Med J 2000; 93:507-510

(2.) Pablos-Mendez A, Sterling TR, Frieden TR: The relationship between delayed or incomplete treatment and all-cause mortality in patients with tuberculosis. JAMA 1996; 276:1223-1228

(3.) Mehta JB, Fields CL, Byrd RP Jr, et al: Nutritional status and mortality in respiratory failure caused by tuberculosis. Tenn Med 1996; 89:369-371

TABLE. Discharges From Hospitals in Florida of
Orange County Residents Due to Congestive Heart
Failure, and Congestive Heart Failure Discharge
Rates per 10,000 Population, 1992-1998
Age                             No. of            Discharge
Group                         Discharges            Rate
(Years)                           AA       White     AA      White
[less than or equal to]54         744        949     9.4       2.8
55-64                             502      1,535    96.3      43.5
65-74                             579      3,299   169.8     108.0
75-84                             389      3,604   235.5     204.5
[greater than or equal to]85      175      1,902   375.4     368.1
  All ages                      2,389     11,289    26.5      26.1
Age
Group                                P
(Years)                            Value
[less than or equal to]54     [less than].0001
55-64                         [less than].0001
65-74                         [less than].0001
75-84                                    .007
[greater than or equal to]85             .802
  All ages                               .444