5/12/00

JOURNAL CLUB, AMIR ARTICLE, CONTINUATION …

        Both Lisa Amir's and Carol L'Esperance's postings have 
succeeded in appropriately categorizing and describing the Amir 
article.

        As Carol points out, "Studies like this are very necessary to 
add to our beginning body of knowledge (of mastitis)."  In other 
words, the Amir article with its retrospective design helps to 
document and describe how 'mastitis' is assessed, diagnosed and 
treated in a particular community by a particular group of healthcare 
providers.  Because all retrospective studies are, by definition, 
conducted upon subjects in order to collect historical data, the 
veracity of the findings and the strength of the conclusions are 
largely limited by the strength and completeness of the data.  If 
certain data was not collected the importance of findings may be 
limited.  Quotations are used with the word mastitis because, as Lisa 
stated in her posting, "it (the study) can't really be used to work 
out the signs and symptoms of mastitis - b/c we are limited to relying 
on what the doctor wrote."  As can be evidenced from the study, the 
documentation found in these ED (emergency dept.) charts often failed 
to include some of the classic signs and symptoms of the disorder.  In 
other words, we will never really know which patients truly had 
mastitis.  However, thanks to Lisa and her colleagues, we have a much 
better description of the approach to and probably the knowledge of 
(by the healthcare providers) mastitis.  Lisa correctly states, "A 
review of records obviously raises more questions than it answers, but 
it does give some idea of what is happening in the real world."
        As the first author of the paper, Lisa's description of the 
genesis and evolution of this study are certainly an invaluable 
contribution to the analysis and discussion of this article.  As she 
mentions, this retrospective study was conducted partly to help in the 
design of a future prospective study of this disorder.  One can only 
optimally conduct a prospective study if one has an understanding of 
how the problem is currently approached and treated.  The data 
collected via chart review also may hint at ways in which the 
diagnosis and/or treatment may need to be modified.  For example, if 
one learns (via reviewing 200 ED cases of pneumonia) that pneumonia 
(as detected on a chest x-ray) is rarely treated with antibiotics, one 
can then design a prospective study in which patients are randomized 
to antibiotics or placebo.  Comparing the morbidity and mortality of 
the 2 groups will then hopefully enable one to conclude whether the 
current practice (no antibiotics for a positive chest x-ray) needs to 
modified or improved upon.

Danny Hirsch, MD
Director, Lactation Institute of Westchester
Assistant Professor of Pediatrics
New York Medical College
Valhalla, NY, USA

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