Medical evaluation of child sexual abuse: a practical guide [see comments]

              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