Inflammatory Bowel Disease

Letters Management of Adolescent Pregnancy The comprehensive approach to the pregnant adolescent, with emphasis on psychosocial issues and preventable morbidity as advocated by Van Winter and Simmons in the August 1990 issue ofthe Proceedings (pages 1061 to 1066), may indeed improve perinatal outcome. Combining the expertise of the obstetrician and pediatrician is logical, but why reinvent the wheel? Family medicine is already dedicated to longterm family-centered care, with emphasis on preventive medicine and psychosocial issues. Family physicians are well trained in routine prenatal and wellchild care; with their additional training in behavioral medicine, they have a unique combination of clinical skills to offer the pregnant adolescent. For example, the tool for assessment of preterm labor risk recommended by the authors was developed in a rural family practice by two family physicians interested in a "low-tech" approach to the prevention of preterm labor. Using only the history and pelvic examination to identify patients at risk, they were able to achieve a 60% reduction in preventable preterm births in their practice.' One physician-a family physician-can provide comprehensive medical care for the adolescent, her family, and the newborn. Knowing the family and community, he also orchestrates appropriate social support. As stated by Van Winter and Simmons, "Combining obstetric and pediatric visits in one setting facilitates care for the pregnant adolescent and her family." Richard J. Ackermann, M.D. Department of Family Practice Naval Hospital Jacksonville, Florida

Jo T. Van Winter, M.D. Patricia S. Simmons, M.D.

Inflammatory Bowel Disease The article "Streptokinase Therapy for Extensive Venous Thromboses in a Patient With Severe Ulcerative Colitis" by Van Woert and colleagues, which was published in the August 1990 issue of the Proceedings (pages 1144 to 1149), illustrates an increased incidence of venous thrombosis in patients with inflammatory bowel disease. Might venous thrombosis be another extraintestinal manifestation based on Tcell-specific antigen? The type of severe ulcerative colitis described may be further aided by the immunosuppressive agent cyclosporine, used as an enema along with intravenous corticosteroid therapy.P Lawrence Braslow, M.D. Riverside, California

REFERENCES

1. Brynskov J, Freund L, Thomsen 00, Andersen CB, Rasmussen SN, Binder V: Treatment of refractory ulcerative colitis with cyclosporin enemas (letter to the editor). Lancet 1:721-722, 1989 2, Sachar DB: Cyclosporine treatment for inflammatory bowel disease: a step backward or a leap forward? (editorial). N Engl J Med 321:894-896, 1989

Dr. Fleming replies

REFERENCE

1. Yawn BP, Yawn RA: Preterm birth prevention in a rural practice. JAMA 262:230-233, 1989

The authors reply We appreciate the letter from Dr. Ackermann. He rightly points out the role of the family physician in providing one-center medical care for the pregnant adolescent and her family. Indeed, this approach serves many well. Our proposal represents an alternative for the patient who may elect to have an obstetrician and pediatrician and for complicated Mayo Clin Proc 65:1630-1632,1990

pregnancies, deliveries, and newborn situations in which the combined service approach is useful.

My coauthors and I appreciated Dr. Braslow's comments. I suspect that cyclosporine is most likely to benefit those patients with a chronically refractory course of inflammatory bowel disease; however, further studies will clarify its role. The potential for severe toxicity must temper one's enthusiasm for the casual use of cyclosporine. Our patient proved refractory to an acute flare that was accompanied by a lifethreatening complication-venous occlusion in three of his extremities. The opportunity to offer him a rectal-saving operation (that is, ileoanal) and remove the disease provided a solution that was very satisfactory to the patient.

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C. Richard Fleming, M.D.