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Letters JAOA • Vol 103 • No 3• March 2003 • 117 LETTERS Beware of combining erythromycin with a statin To the Editor: For the first time in 40 years as a scientist, I have information I believe is so important that I want to share it immediately with as many people as possible. The medical com-munity and the public need to know about the increased risk of cataracts associated with concurrent use of the common antibi-otic erythromycin and cholesterol-lowering statins. Among the most prescribed drugs in the United States, statins work by inhibiting cholesterol biosynthesis. The review of patient records at the Uni-versity Hospital of Basel, Switzerland, by Christopher Meier, PhD, MSc,1 and our studies with animals at the Kirksville Col-lege of Osteopathic Medicine2 indicate that brief exposure to high blood levels of statins can markedly increase the risk of cataracts in humans and animals. Results of the case-controlled analysis by Schlienger et al,1 re-vealed that a single course of erythro-mycin therapy combined with simvastatin doubled the risk for cataracts and that two courses of erythromycin with simvastatin tripled the risk for cataracts. Erythromycin can block the metabolism of many statins and vastly increase blood levels of choles-terol- lowering drugs. In January 2003, we reported that treat-ment of a specific strain of rats (Chbb: Thom) with a high dose of simvastatin for 2 weeks committed the ocular lens to forming cataracts.2 We believe this strain of rat has a defect in regulating one of the key enzymes in cholesterol biosynthesis that prevents it from defending against stress caused by high blood levels of sim-vastatin. Combining drugs other than erythro-mycin with statins may also place the eye at increased risk. These drugs include vera-pamil hydrocholoride, cyclosporine, itra-conazole, and ketoconazole. Each drug can inhibit the metabolism of simvastatin, ator-vastatin calcium, cerivastatin and lovas-tatin by the cytochrome P450 system. There-fore, great care should be taken when combining any of these drugs with statins. Richard J. Cenedella, PhD Professor and Chair Department of Biochemistry Kirksville College of Osteopathic Medicine Kirksville, Missouri References 1. Schlienger RG, Haefeli WE, Jick H, Meier CR. Risk of cataract in patients treated with statins. Arch Intern Med. 2001;161:2021-2026. 2. Cenedella RJ, Kuszak JR, Al-Ghoul KJ, Qin S, Sexton PS. Discordant expression of the sterol pathway in lens underlies simvastatin-induced cataracts in Chbb: Thom rats. J Lipid Res. 2003; 44:198-211. Time to forge affiliations between osteopathic medical schools and hospitals To the Editor: When my wife and I moved to south Florida a few years ago, we asked neighbors where they go for healthcare needs. They told us that they go to the airport—an inter-esting response. We soon found that although there are some good physicians and a few adequate community hospitals in our community, there is a lack of academics in our area. There are no teaching hospi-tals nearby, no residency programs of note, and no recognizable affiliations with the local osteopathic medical school or the allo-pathic medical school in Miami, Florida. I trained and practiced in the Northeast, which was abundant in predoctoral and postdoctoral educational programs. As an intern and resident and later as a faculty member of a teaching hospital, I was con-stantly involved with case reports, teaching rounds, journal clubs, conferences, and chal-lenges from house staff. The most explosive thing in the world is an idea. Besides brimming with fresh ideas, residents often have healthy aggression, inquisitive minds, and enlightened atti-tudes. As a result, many original and stim-ulating research papers have come from our resident programs. As an attending physician, it was gratifying to channel that energy into areas of clinical and laboratory research. It was fun to discuss new ideas and developments in our field of practice. Hospital residency programs foster an atmosphere of enlightenment and an atti- As the scholarly publication of the osteopathic medical profession, JAOA—The Journal of the American Osteopathic Association encourages osteopathic physicians, faculty members at osteopathic medical colleges, students, and others—as consistent with the mission of the JAOA—to submit their comments to the JAOA. Letters to the editor are considered for publication if they have not been published elsewhere and are not simultaneously under consideration by any other publication. All accepted letters to the editor are subject to copyediting. On request, the corresponding author is responsible for providing the editor with photocopies of referenced material. When sent by mail or fax, letters must be typewritten and double-spaced. Except in rare instances, the text of a letter should not exceed 500 words and should not include any more than five references and two tables or illustrations. JAOA encourages its readers to submit letters electronically to jaoa@aoa-net.org. Letter writers must include their full professional title(s) and affiliation(s), complete address, day and evening telephone numbers, fax number(s), and e-mail address(es). Letter writers are responsible for disclosing financial associations or other possible conflicts of interest. Although JAOA cannot acknowledge the receipt of your letter, we will notify you if the letter has been accepted for publication. Rejected letters and illustrations will not be returned unless accompanied by a self-addressed stamped envelope. Address letters to: Gilbert E. D’Alonzo, Jr, DO, Editor in Chief, JAOA, American Osteopathic Association, 142 E Ontario St, Chicago, IL 60611-2864. Fax: (312) 202-8200. E-mail: jaoa@aoa-net.org. 118 • JAOA • Vol 103 • No 3 • March 2003 Letters tude of excellence; therefore, training hos-pitals are usually a cut above the others. It used to be said that if you got two osteopathic physicians together, you had an argument; if you got three together, you had a hospital. In today’s environment of uncertainty about the fate of hospitals, three osteopathic physicians may constitute a task force. Perhaps it is time for the Board of Trustees of the American Osteopathic Association to convene such a group to study the issue of affiliations and develop recommendations for the future. It is a demographic fact that most of our graduates and residents practice in hospi-tals near colleges of osteopathic medicine. As the people and institutions to initiate new affiliation agreements are in place, the lack of motivation and the lack of a mech-anism for implementation have to be ad-dressed. Our new public relations efforts, as seen in leading magazines throughout the country, are wonderful and are a formi-dable step in bringing national recognition to our profession. We should couple that initiative with this all-out effort to expand our base by identifying osteopathic medical schools as having strong affiliation agree-ments with nearby hospitals. Affiliations must be mutually beneficial to schools and hospitals. That is not an easy task, as issues that involve conflicting interests often arise. However, differences can be worked out; hospitals should be identified as major teaching affiliates for colleges of osteopathic medicine, as university medical centers. The challenge for our profession is before us—a challenge to forge such agree-ments, to develop centers of excellence in these institutions, and to fulfill our mission of service, education, and research to our communities and our country. Our profes-sion has done a fine job of identifying with primary care in this country, but as is so often said in the sports world, it is time to take it to the next level. It is time to show our stuff, to expand our horizons. Daniel H. Belsky, DO Boca Raton, Florida A proposal that benefits all To the Editor: The article by Shirley M. Johnson, PhD, MPH, MSW, and Margot E. Kurtz, PhD, “Conditions and diagnoses for which osteo-pathic primary care physicians and spe-cialists use osteopathic manipulative treat-ment” (J Am Osteopath Assoc. 2002;102: 527-540), points out what most osteopathic physicians have known for a long time: Osteopathic manipulative treatment (OMT) is being used less and less by osteopathic physicians. I believe that if we, as osteo-pathic physicians, do not use OMT in our practices, osteopathic medicine will cease to exist as a separate profession. Some osteopathic physicians believe that the profession has produced little scientific evidence to prove that OMT is of value for treating musculoskeletal complaints and less evidence that treating segmental-related somatic dysfunction improves the outcome of patients with visceral disease. Other osteopathic physicians are willing to accept the value of OMT for the treatment of mus-culoskeletal and visceral complaints but believe that the procedure is an inefficient use of time. Therefore, many osteopathic physicians fail to learn or to use necessary techniques to practice OMT effectively. What strategy can the osteopathic pro-fession implement to maintain itself as a vital, separate philosophy of medicine as proposed by A.T. Still, MD, DO? We are doomed if we believe we are solving the problem by preaching to osteopathic physi-cians that they need to learn OMT and use the procedure in their practices. This will not reverse the trend of osteopathic physi-cians using less and less OMT. Besides producing scientific evidence confirming what many osteopathic physi-cians know intuitively regarding OMT’s effectiveness, I believe it is time to consider a new concept that will provide the prac-ticing osteopathic primary care physician and osteopathic specialist the means to incorporate OMT in their practices. The concept involves creating another layer of osteopathic medicine providers—providers trained in osteopathic medical diagnosis and manipulative treatment who practice under the guidance of osteopathic primary care physicians or specialists. The position would be similar to that of a physician’s assistant and could be called an osteopathic manipulative assistant. This assistant would be trained at existing osteopathic colleges of medicine, joining osteopathic medical stu-dents for the first 2 years of education and then completing a 1-year internship in OMT. An expanded student population and the resulting increased revenue would help secure the financial stability of osteopathic medical schools. The osteopathic manipu-lative assistant would become a partner in delivering osteopathic medical care. Osteo-pathic physicians would be able to bill for these services in the same way that physi-cians bill for the services of physician assis-tants and nurse practitioners. This would bring added revenue to the practice and provide OMT to patients who would not ordinarily receive the treatment. Imple-menting the proposal will secure osteo-pathic medicine as a separate medical pro-fession, increase enrollment in colleges of osteopathic medicine, and provide OMT to a greater number of patients. This suggestion might be considered absurd by some osteopathic physicians, especially those who have devoted their lives to the specialty practice of OMT and those in the colleges of osteopathic medicine who have spent their lives teaching OMT, but I believe it would benefit them greatly. Physicians who use OMT in their practices would have extenders allowing them to see more patients and therefore survive the problem of ever-diminishing reimburse-ment for services, as these physicians have so few billable codes available to generate income. Those who teach OMT would have an enthusiastic group of students who are committed to learning and practicing OMT. The primary care specialist would also ben-efit by having more billable services to render and by being identified as a unique healthcare provider who offers compre-hensive care in an ever more competitive environment. Patients would perceive that they were receiving better care for their healthcare dollars when visiting an osteo-pathic physician whose practice provides OMT regularly. Greater numbers of patients are recog-nizing the value of manipulative therapy, but they are going to providers outside the osteopathic medical profession for this care. LETTERS JAOA • Vol 103 • No 3 • March 2003 • 119 LETTERS Letters/Book review The practices of chiropractors, physical ther-apists, massage therapists, and other body manipulation providers are flourishing and competing with osteopathic physicians for the medical dollar. I believe that dialogue about the value of this proposal should be entertained by the leadership of the osteopathic medical pro-fession and by leaders of colleges of osteo-pathic medicine. Emmett M. Bentley, DO St. Louis, Missouri Intern on call He rises in the dead of night From the bowels of the earth Where he was curled beneath a white sheet. Nestled Under Same Day Surgery Dreaming of hands reaching out to him. He is comfortable Three doors down from the morgue. He wipes sleep from his eyes, Pats down his tousled hair, And turns on the light. Somewhere above him He is needed. He finds her on the third floor. Lost Confused and betrayed by shadows And voices that tell her lies, Stealing her breath. She reaches a fragile blue-veined hand Toward his face. “I am the doctor,” he says. “Can I help?” The words hold magic in the night. Power This power is so new to him He isn’t sure he believes in it, But she has faith enough for them both. He assesses, he notes, he orders All the things he thinks are right. Then goes back beneath the ground, Slides under the cool, white sheet, And dreams of the hands. Rita Roberts, MSIV Ohio University of Osteopathic Medicine Athens, Ohio Medical Evaluation of Child Sexual Abuse: A Practical Guide Edited by Martin A. Finkel, DO, and Angelo P. Giar-dino, MD. 298 pps. 2nd ed. Sage Publications Inc, 2455 Teller Rd, Thousand Oaks, CA 91320-2002. $79.95. Past president of the American College of Osteopathic Pediatricians, Martin A. Finkel, DO, and coauthor, Angelo P. Giardino, MD, have collected and edited a compendium so powerful that it may ultimately become the definitive text on child sexual abuse. Dr Finkel, Director of the Center for Children’s Support at the University of Medicine and Dentistry of New Jersey, is one of those rarities—an osteopathic physi-cian whose book is going into a second printing. Quite a recommendation. Although comprehensive and minutely detailed, the book never becomes pedantic, and although all aspects of evaluating child sexual abuse are thoroughly covered—med-ical, legal, forensics, sexually transmitted diseases, nursing, psychological—the book never loses sight of its primary goal: concern for the care and treatment of children. The authors stress that goal by using repeated and varied emphases throughout the book. Although chapters are written by sev-eral authorities, each preserves the conti-nuity and easy reading of the text, and all are outstanding. Scattered throughout the volume are illustrations, figures, and side-bars with detailed explanations, which aptly expand the text. However, the chapter “Medical Evaluation and Physical Exami-nation” is a masterpiece of information, with specifics that are most educational. The text’s approach to taking a medical history and talking with and examining a child could be a freestanding basic text in pediatrics. In addition to cohesive chapters, Finkel and Giardino include 19 line drawings, 13 pages of colpophotographic case studies in full color, and an appendix of the most important questions parents ask, with ap-propriate answers that are exactly worded. As I have known Dr Finkel since he was a child (which could conceivably influence my view of this book) and out of respect for him as a colleague, I sneaked a look at several other reviews to test my views. Unsurprisingly, those articles were at least as enthusiastic, laudatory, and commenda-tory as mine, and all of them strongly rec-ommended use of the book. This volume should be placed in every medical library and emergency room. It easily serves as a great backup reference for every primary care physician who sees chil-dren. It is also great leisure reading for anyone interested in this field. All uses of this book would greatly benefit children, which is the authors’ goal. Arnold Melnick, DO Aventura, Florida BOOK REVIEW
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Transcript | Letters JAOA • Vol 103 • No 3• March 2003 • 117 LETTERS Beware of combining erythromycin with a statin To the Editor: For the first time in 40 years as a scientist, I have information I believe is so important that I want to share it immediately with as many people as possible. The medical com-munity and the public need to know about the increased risk of cataracts associated with concurrent use of the common antibi-otic erythromycin and cholesterol-lowering statins. Among the most prescribed drugs in the United States, statins work by inhibiting cholesterol biosynthesis. The review of patient records at the Uni-versity Hospital of Basel, Switzerland, by Christopher Meier, PhD, MSc,1 and our studies with animals at the Kirksville Col-lege of Osteopathic Medicine2 indicate that brief exposure to high blood levels of statins can markedly increase the risk of cataracts in humans and animals. Results of the case-controlled analysis by Schlienger et al,1 re-vealed that a single course of erythro-mycin therapy combined with simvastatin doubled the risk for cataracts and that two courses of erythromycin with simvastatin tripled the risk for cataracts. Erythromycin can block the metabolism of many statins and vastly increase blood levels of choles-terol- lowering drugs. In January 2003, we reported that treat-ment of a specific strain of rats (Chbb: Thom) with a high dose of simvastatin for 2 weeks committed the ocular lens to forming cataracts.2 We believe this strain of rat has a defect in regulating one of the key enzymes in cholesterol biosynthesis that prevents it from defending against stress caused by high blood levels of sim-vastatin. Combining drugs other than erythro-mycin with statins may also place the eye at increased risk. These drugs include vera-pamil hydrocholoride, cyclosporine, itra-conazole, and ketoconazole. Each drug can inhibit the metabolism of simvastatin, ator-vastatin calcium, cerivastatin and lovas-tatin by the cytochrome P450 system. There-fore, great care should be taken when combining any of these drugs with statins. Richard J. Cenedella, PhD Professor and Chair Department of Biochemistry Kirksville College of Osteopathic Medicine Kirksville, Missouri References 1. Schlienger RG, Haefeli WE, Jick H, Meier CR. Risk of cataract in patients treated with statins. Arch Intern Med. 2001;161:2021-2026. 2. Cenedella RJ, Kuszak JR, Al-Ghoul KJ, Qin S, Sexton PS. Discordant expression of the sterol pathway in lens underlies simvastatin-induced cataracts in Chbb: Thom rats. J Lipid Res. 2003; 44:198-211. Time to forge affiliations between osteopathic medical schools and hospitals To the Editor: When my wife and I moved to south Florida a few years ago, we asked neighbors where they go for healthcare needs. They told us that they go to the airport—an inter-esting response. We soon found that although there are some good physicians and a few adequate community hospitals in our community, there is a lack of academics in our area. There are no teaching hospi-tals nearby, no residency programs of note, and no recognizable affiliations with the local osteopathic medical school or the allo-pathic medical school in Miami, Florida. I trained and practiced in the Northeast, which was abundant in predoctoral and postdoctoral educational programs. As an intern and resident and later as a faculty member of a teaching hospital, I was con-stantly involved with case reports, teaching rounds, journal clubs, conferences, and chal-lenges from house staff. The most explosive thing in the world is an idea. Besides brimming with fresh ideas, residents often have healthy aggression, inquisitive minds, and enlightened atti-tudes. As a result, many original and stim-ulating research papers have come from our resident programs. As an attending physician, it was gratifying to channel that energy into areas of clinical and laboratory research. It was fun to discuss new ideas and developments in our field of practice. Hospital residency programs foster an atmosphere of enlightenment and an atti- As the scholarly publication of the osteopathic medical profession, JAOA—The Journal of the American Osteopathic Association encourages osteopathic physicians, faculty members at osteopathic medical colleges, students, and others—as consistent with the mission of the JAOA—to submit their comments to the JAOA. Letters to the editor are considered for publication if they have not been published elsewhere and are not simultaneously under consideration by any other publication. All accepted letters to the editor are subject to copyediting. On request, the corresponding author is responsible for providing the editor with photocopies of referenced material. When sent by mail or fax, letters must be typewritten and double-spaced. Except in rare instances, the text of a letter should not exceed 500 words and should not include any more than five references and two tables or illustrations. JAOA encourages its readers to submit letters electronically to jaoa@aoa-net.org. Letter writers must include their full professional title(s) and affiliation(s), complete address, day and evening telephone numbers, fax number(s), and e-mail address(es). Letter writers are responsible for disclosing financial associations or other possible conflicts of interest. Although JAOA cannot acknowledge the receipt of your letter, we will notify you if the letter has been accepted for publication. Rejected letters and illustrations will not be returned unless accompanied by a self-addressed stamped envelope. Address letters to: Gilbert E. D’Alonzo, Jr, DO, Editor in Chief, JAOA, American Osteopathic Association, 142 E Ontario St, Chicago, IL 60611-2864. Fax: (312) 202-8200. E-mail: jaoa@aoa-net.org. 118 • JAOA • Vol 103 • No 3 • March 2003 Letters tude of excellence; therefore, training hos-pitals are usually a cut above the others. It used to be said that if you got two osteopathic physicians together, you had an argument; if you got three together, you had a hospital. In today’s environment of uncertainty about the fate of hospitals, three osteopathic physicians may constitute a task force. Perhaps it is time for the Board of Trustees of the American Osteopathic Association to convene such a group to study the issue of affiliations and develop recommendations for the future. It is a demographic fact that most of our graduates and residents practice in hospi-tals near colleges of osteopathic medicine. As the people and institutions to initiate new affiliation agreements are in place, the lack of motivation and the lack of a mech-anism for implementation have to be ad-dressed. Our new public relations efforts, as seen in leading magazines throughout the country, are wonderful and are a formi-dable step in bringing national recognition to our profession. We should couple that initiative with this all-out effort to expand our base by identifying osteopathic medical schools as having strong affiliation agree-ments with nearby hospitals. Affiliations must be mutually beneficial to schools and hospitals. That is not an easy task, as issues that involve conflicting interests often arise. However, differences can be worked out; hospitals should be identified as major teaching affiliates for colleges of osteopathic medicine, as university medical centers. The challenge for our profession is before us—a challenge to forge such agree-ments, to develop centers of excellence in these institutions, and to fulfill our mission of service, education, and research to our communities and our country. Our profes-sion has done a fine job of identifying with primary care in this country, but as is so often said in the sports world, it is time to take it to the next level. It is time to show our stuff, to expand our horizons. Daniel H. Belsky, DO Boca Raton, Florida A proposal that benefits all To the Editor: The article by Shirley M. Johnson, PhD, MPH, MSW, and Margot E. Kurtz, PhD, “Conditions and diagnoses for which osteo-pathic primary care physicians and spe-cialists use osteopathic manipulative treat-ment” (J Am Osteopath Assoc. 2002;102: 527-540), points out what most osteopathic physicians have known for a long time: Osteopathic manipulative treatment (OMT) is being used less and less by osteopathic physicians. I believe that if we, as osteo-pathic physicians, do not use OMT in our practices, osteopathic medicine will cease to exist as a separate profession. Some osteopathic physicians believe that the profession has produced little scientific evidence to prove that OMT is of value for treating musculoskeletal complaints and less evidence that treating segmental-related somatic dysfunction improves the outcome of patients with visceral disease. Other osteopathic physicians are willing to accept the value of OMT for the treatment of mus-culoskeletal and visceral complaints but believe that the procedure is an inefficient use of time. Therefore, many osteopathic physicians fail to learn or to use necessary techniques to practice OMT effectively. What strategy can the osteopathic pro-fession implement to maintain itself as a vital, separate philosophy of medicine as proposed by A.T. Still, MD, DO? We are doomed if we believe we are solving the problem by preaching to osteopathic physi-cians that they need to learn OMT and use the procedure in their practices. This will not reverse the trend of osteopathic physi-cians using less and less OMT. Besides producing scientific evidence confirming what many osteopathic physi-cians know intuitively regarding OMT’s effectiveness, I believe it is time to consider a new concept that will provide the prac-ticing osteopathic primary care physician and osteopathic specialist the means to incorporate OMT in their practices. The concept involves creating another layer of osteopathic medicine providers—providers trained in osteopathic medical diagnosis and manipulative treatment who practice under the guidance of osteopathic primary care physicians or specialists. The position would be similar to that of a physician’s assistant and could be called an osteopathic manipulative assistant. This assistant would be trained at existing osteopathic colleges of medicine, joining osteopathic medical stu-dents for the first 2 years of education and then completing a 1-year internship in OMT. An expanded student population and the resulting increased revenue would help secure the financial stability of osteopathic medical schools. The osteopathic manipu-lative assistant would become a partner in delivering osteopathic medical care. Osteo-pathic physicians would be able to bill for these services in the same way that physi-cians bill for the services of physician assis-tants and nurse practitioners. This would bring added revenue to the practice and provide OMT to patients who would not ordinarily receive the treatment. Imple-menting the proposal will secure osteo-pathic medicine as a separate medical pro-fession, increase enrollment in colleges of osteopathic medicine, and provide OMT to a greater number of patients. This suggestion might be considered absurd by some osteopathic physicians, especially those who have devoted their lives to the specialty practice of OMT and those in the colleges of osteopathic medicine who have spent their lives teaching OMT, but I believe it would benefit them greatly. Physicians who use OMT in their practices would have extenders allowing them to see more patients and therefore survive the problem of ever-diminishing reimburse-ment for services, as these physicians have so few billable codes available to generate income. Those who teach OMT would have an enthusiastic group of students who are committed to learning and practicing OMT. The primary care specialist would also ben-efit by having more billable services to render and by being identified as a unique healthcare provider who offers compre-hensive care in an ever more competitive environment. Patients would perceive that they were receiving better care for their healthcare dollars when visiting an osteo-pathic physician whose practice provides OMT regularly. Greater numbers of patients are recog-nizing the value of manipulative therapy, but they are going to providers outside the osteopathic medical profession for this care. LETTERS JAOA • Vol 103 • No 3 • March 2003 • 119 LETTERS Letters/Book review The practices of chiropractors, physical ther-apists, massage therapists, and other body manipulation providers are flourishing and competing with osteopathic physicians for the medical dollar. I believe that dialogue about the value of this proposal should be entertained by the leadership of the osteopathic medical pro-fession and by leaders of colleges of osteo-pathic medicine. Emmett M. Bentley, DO St. Louis, Missouri Intern on call He rises in the dead of night From the bowels of the earth Where he was curled beneath a white sheet. Nestled Under Same Day Surgery Dreaming of hands reaching out to him. He is comfortable Three doors down from the morgue. He wipes sleep from his eyes, Pats down his tousled hair, And turns on the light. Somewhere above him He is needed. He finds her on the third floor. Lost Confused and betrayed by shadows And voices that tell her lies, Stealing her breath. She reaches a fragile blue-veined hand Toward his face. “I am the doctor,” he says. “Can I help?” The words hold magic in the night. Power This power is so new to him He isn’t sure he believes in it, But she has faith enough for them both. He assesses, he notes, he orders All the things he thinks are right. Then goes back beneath the ground, Slides under the cool, white sheet, And dreams of the hands. Rita Roberts, MSIV Ohio University of Osteopathic Medicine Athens, Ohio Medical Evaluation of Child Sexual Abuse: A Practical Guide Edited by Martin A. Finkel, DO, and Angelo P. Giar-dino, MD. 298 pps. 2nd ed. Sage Publications Inc, 2455 Teller Rd, Thousand Oaks, CA 91320-2002. $79.95. Past president of the American College of Osteopathic Pediatricians, Martin A. Finkel, DO, and coauthor, Angelo P. Giardino, MD, have collected and edited a compendium so powerful that it may ultimately become the definitive text on child sexual abuse. Dr Finkel, Director of the Center for Children’s Support at the University of Medicine and Dentistry of New Jersey, is one of those rarities—an osteopathic physi-cian whose book is going into a second printing. Quite a recommendation. Although comprehensive and minutely detailed, the book never becomes pedantic, and although all aspects of evaluating child sexual abuse are thoroughly covered—med-ical, legal, forensics, sexually transmitted diseases, nursing, psychological—the book never loses sight of its primary goal: concern for the care and treatment of children. The authors stress that goal by using repeated and varied emphases throughout the book. Although chapters are written by sev-eral authorities, each preserves the conti-nuity and easy reading of the text, and all are outstanding. Scattered throughout the volume are illustrations, figures, and side-bars with detailed explanations, which aptly expand the text. However, the chapter “Medical Evaluation and Physical Exami-nation” is a masterpiece of information, with specifics that are most educational. The text’s approach to taking a medical history and talking with and examining a child could be a freestanding basic text in pediatrics. In addition to cohesive chapters, Finkel and Giardino include 19 line drawings, 13 pages of colpophotographic case studies in full color, and an appendix of the most important questions parents ask, with ap-propriate answers that are exactly worded. As I have known Dr Finkel since he was a child (which could conceivably influence my view of this book) and out of respect for him as a colleague, I sneaked a look at several other reviews to test my views. Unsurprisingly, those articles were at least as enthusiastic, laudatory, and commenda-tory as mine, and all of them strongly rec-ommended use of the book. This volume should be placed in every medical library and emergency room. It easily serves as a great backup reference for every primary care physician who sees chil-dren. It is also great leisure reading for anyone interested in this field. All uses of this book would greatly benefit children, which is the authors’ goal. Arnold Melnick, DO Aventura, Florida BOOK REVIEW |
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