Mar 8, 2018 - Timothy M.E. Davis, D.Phil., F.R.A.C.P.. Wendy A. Davis, M.P.H., Ph.D. University of ... and Bryant (Dec. 7 issue)1 discuss necrotizing soft-tissue ...
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consultant to the World Health Organization for its Make Listening Safe program. No other potential conflict of interest relevant to this letter was reported. 1. National Institute on Deafness and Other Communication Disorders. Noise-induced hearing loss (https://w ww.nidcd.nih .gov/health/noise-induced-hearing-loss). 2. Fink DJ. What is a safe noise level for the public? Am J Public Health 2017;107:44-5. DOI: 10.1056/NEJMc1800570
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There was no such relationship in older persons. Dysglycemia may contribute to hearing loss, but interventions to prevent diabetes, or improve long-term glycemic control in established diabetes, have not been evaluated in protecting hearing. Timothy M.E. Davis, D.Phil., F.R.A.C.P. Wendy A. Davis, M.P.H., Ph.D. University of Western Australia Medical School Fremantle, WA, Australia tim.davis@uwa.edu.au
To the Editor: Cunningham and Tucci comment on an apparently inconsistent relationship Michael Hunter, Ph.D. among age, glycemia, and hearing loss on the Busselton Population Medical Research Institute basis of data from patients with or without dia- Busselton, WA, Australia No potential conflict of interest relevant to this letter was rebetes from the Beaver Dam Eye Study1 and Naported. tional Health and Nutrition Examination Survey.2 In 1864 persons who participated in the popula- 1. Cruickshanks KJ, Nondahl DM, Dalton DS, et al. Smoking, tion-based Busselton Health Aging Study, we central adiposity, and poor glycemic control increase risk of hearing impairment. J Am Geriatr Soc 2015;63:918-24. found an association between increasing mid- 2. Bainbridge KE, Hoffman HJ, Cowie CC. Risk factors for range hearing loss and worsening glucose toler- hearing impairment among U.S. adults with diabetes: National ance (from normoglycemia to prediabetes and Health and Nutrition Examination Survey 1999-2004. Diabetes Care 2011;34:1540-5. diabetes) in persons younger than 60 years of age 3. Sommer J, Brenann-Jones CG, Eikelboom RH, et al. A popuafter adjustment for confounding variables in- lation-based study of the association between dysglycaemia and cluding cardiovascular risk factors, chronic mid- hearing loss in middle age. Diabet Med 2017;34:683-90. dle-ear infection, and previous noise exposure.3 DOI: 10.1056/NEJMc1800570
Necrotizing Soft-Tissue Infections To the Editor: In their review article, Stevens and Bryant (Dec. 7 issue)1 discuss necrotizing soft-tissue infections. Early diagnosis is missed in 85 to 100% of cases.2 In Figure 2 of the article (available at NEJM.org), the authors propose an algorithm that is based on the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score. However, Borschitz et al.3 found that serum sodium and glucose levels are of less value than the erythrocyte count and fibrinogen levels, which is why they proposed a modified LRINEC scoring system. They exchange the sodium and glucose levels for the erythrocyte count (1 point for a count of 750 mg per deciliter) — changes that result in an increase in the positive predictive value to 72%. Finally, the addition of clinical variables such as pain (2 points for severe pain, 1 point for intermediate pain, and 0 points for mild or no pain), fever (2 points for a temperature of ≥38.0°C, 1 point for 37.6 to 37.9°C, and 0 points for ≤37.5°C), 970
tachycardia (1 point for a heart rate of >100 beats per minute), and signs of acute kidney injury (1 point) increases the positive predictive value to 80% and the negative predictive value to 91%. This modified scoring system seems to be more appropriate than the standard LRINEC scoring system and can lead to better disease outcomes by enabling rapid adequate therapy. Halil Yildiz, M.D. J. Cyr Yombi, M.D. Cliniques Universitaires Saint-Luc Brussels, Belgium halil.yildiz@uclouvain.be No potential conflict of interest relevant to this letter was reported. 1. Stevens DL, Bryant AE. Necrotizing soft-tissue infections. N Engl J Med 2017;377:2253-65. 2. Bennett M. Is early diagnosis of necrotizing fasciitis important? ANZ J Surg 2008;78:947-8. 3. Borschitz T, Schlicht S, Siegel E, Hanke E, von Stebut E. Improvement of a clinical score for necrotizing fasciitis: ‘pain out of proportion’ and high CRP levels aid the diagnosis. PLoS One 2015;10(7):e0132775. DOI: 10.1056/NEJMc1800049
n engl j med 378;10 nejm.org March 8, 2018
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Correspondence
The authors reply: Our review article emphasizes that severe pain is an important clinical symptom that is useful in distinguishing necrotizing infections from more superficial ones. Our algorithm indicates that tachycardia and elevated levels of creatine kinase, C-reactive protein, and creatinine as well as a LRINEC score of more than 6 suggest a necrotizing process. The retrospective study conducted by Borschitz et al. included 27 patients over a 10-year period who had a diagnosis based on codes from the International Classification of Diseases, 9th Revision, among patients who had been hospitalized for more than 10 days.1 They, too, found that severe pain and high C-reactive protein levels were important, and they modified the LRINEC scoring system to give pain more analytic weight and changed other variables. In doing so, they increased the positive and negative predictive values. However, Borschitz et al. did not discuss whether the patients in their study underwent surgery, the time to surgery, or overall mortality. Yet, the time from onset to surgery is a crucial
variable in patients with necrotizing infections. It remains unclear whether their modifications to the LRINEC scoring system would shorten this critical window. Their modifications have also not been verified in an independent series of patients — a minimum requirement for the establishment of a reliable prognostic scheme. Clearly, the optimization of existing surrogate marker systems or the identification of new biomarkers to facilitate earlier diagnosis and improve outcomes is worthy of prospective study. Dennis L. Stevens, Ph.D., M.D. Amy E. Bryant, Ph.D. Veterans Affairs Medical Center Boise, ID amy.bryant@va.gov Since publication of their article, the authors report no further potential conflict of interest. 1. Borschitz T, Schlicht S, Siegel E, Hanke E, von Stebut E. Improvement of a clinical score for necrotizing fasciitis: ‘pain out of proportion’ and high CRP levels aid the diagnosis. PLoS One 2015;10(7):e0132775. DOI: 10.1056/NEJMc1800049
Management of Acute Hip Fracture To the Editor: Bhandari and Swiontkowski, in their recent review (Nov. 23 issue),1 describe current evidence regarding operative and perioperative management of acute hip fractures. The evidence to support the use of bisphosphonates after a hip fracture pertains specifically to zoledronic acid, which, when administered intravenously 2 to 12 weeks after a hip fracture, was found to be associated with a significantly greater increase in bone mass and a lower risk of subsequent fractures and death than was placebo.2 There is also evidence that the administration of denosumab neither delays healing nor compromises the union of a hip fracture if administered within 6 weeks before or after the fracture occurs.3 Finally, according to a recent metaanalysis, teriparatide treatment after a hip fracture is associated with a shorter radiologic fracture-healing time and a better functional outcome than alendronate treatment, calcium or vitamin D supplementation, or placebo.4 Thus, early administration of denosumab or teripara-
tide may be encouraged as an alternative to treatment with zoledronic acid. Panagiotis Anagnostis, M.D., Ph.D. Aristotle University of Thessaloniki Thessaloniki, Greece anagnwstis.pan@yahoo.gr
Stavroula A. Paschou, M.D., Ph.D. National and Kapodistrian University of Athens Athens, Greece
Dimitrios G. Goulis, M.D., Ph.D. Aristotle University of Thessaloniki Thessaloniki, Greece No potential conflict of interest relevant to this letter was reported. 1. Bhandari M, Swiontkowski M. Management of acute hip fracture. N Engl J Med 2017;377:2053-62. 2. Eriksen EF, Lyles KW, Colón-Emeric CS, et al. Antifracture efficacy and reduction of mortality in relation to timing of the first dose of zoledronic acid after hip fracture. J Bone Miner Res 2009;24:1308-13. 3. Adami S, Libanati C, Boonen S, et al. Denosumab treatment in postmenopausal women with osteoporosis does not interfere with fracture-healing: results from the FREEDOM trial. J Bone Joint Surg Am 2012;94:2113-9.
n engl j med 378;10 nejm.org March 8, 2018
The New England Journal of Medicine Downloaded from nejm.org on March 8, 2018. For personal use only. No other uses without permission. Copyright © 2018 Massachusetts Medical Society. All rights reserved.
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