Letters to the Editor - November 1, 2000 - American Family Physician

Letters to the Editor

Screening for Domestic Violence

TO THE EDITOR: While I commend Drs. Nicolette and Nuovo for their in-depth editorial entitled "Reframing Our Approach to Domestic Violence: The Cyclic Batterer Syndrome,"¹ it simply missed its mark. Let's face it folks, we are missing the forest for the trees here. We all know that it is a well documented fact that 90 percent of America's physicians are not even asking the question. Until we step up to the plate and take serious ownership of a universal domestic violence screening program, we will never improve our miserable performance in this public health crisis.

We cannot complicate the process, or make it more cumbersome than it already is, for the physician in the trenches. Simply put, "RADAR"²(http://www.ultranet.com/biz/NewStandard/projects/DomVio/radar.html), a screening tool created by the Massachusetts College of Emergency Physicians and sponsored by such organizations as Physicians for Social Responsibility and Physicians for a Violence-Free Society, and their educational initiative "DOCumentation," is on target and easy to implement. It simplifies a complicated intervention problem for all of us. Quite frankly, it is, and should continue to be, the standard bearer for health care domestic violence screening, identification, safety assessment and referral.

I challenge our state Academies, the American Academy of Family Physicians, the American College of Emergency Physicians, the American Academy of Obstetrics and Gynecology and the American Medical Association to adopt and implement this program. A famous author once said, "we cannot change everything that we face, but we will not change anything unless we face it."

F. STEVEN LAND, M.D.
Chairman, Indiana State Medical Association's Committee on Family Violence
Westfield, IN 46074

REFERENCES

Nocolette J, Nuovo J. Reframing our approach to domestic violence: the cyclic batterer syndrome [Editorial]. Am Fam Physician 1999;60:2498-501.

RADAR. Massachusetts College of Emergency Physicians. Retrieved August 17, 2000, from the World Wide Web: http://www.ultranet.com/biz/NewStandard/projects/DomVio/radar.HTML.

EDITOR'S NOTE: This letter was sent to the authors of "Reframing our Approach to Domestic Violence: The Cyclic Batterer Syndrome," who declined to reply.

Acute Gastroenteritis in Children

TO THE EDITOR: The excellent article by Dr. Burkhart¹ summarized the evaluation of children with the common problem of acute gastroenteritis and reaffirmed the usefulness of simple treatments in uncomplicated cases. However, the article contains a few niggling inconsistencies, including an endorsement of foods such as "yogurt, fruit" for children with acute gastroenteritis without dehydration (page 2559 under the subheading entitled "No Dehydration") and an admonition against foods such as "juices and soft drinks" on the basis of their high sugar content.

One look at food labels demonstrates little difference in the sugar content among whole fruit, fruit juice and soft drinks. Fruit-flavored yogurt may also have a substantial content of simple sugar per serving.

This admonition against foods with a high content of simple sugars is confusing because foods with a similar content of simple sugars appear on the list of endorsed foods and the list of foods to avoid. In addition, no reason is given as to why foods with a high content of simple sugars are to be avoided in children with acute gastroenteritis without dehydration.

The article then states that the antidiarrheal medications, including yogurt, are generally not indicated "because of lack of evidence that they are effective and because of concerns that adverse effects may outweigh any benefits" (page 2562 under the subheading "Management of Symptoms").¹ This, too, is confusing because the text endorses yogurt as a food for children with acute gastroenteritis (page 2559) and later advises against yogurt for children with acute gastroenteritis with diarrhea.

FREDRIC M. STEINBERG, M.D.
6452 Mill Pointe Circle
Delray Beach, FL 33484

REFERENCE

Burkhart DM, Management of acute gastroenteritis in children. Am Fam Physician 1999;60:2555-63.

TO THE EDITOR: I would like to point out an error in the article¹ on acute gastroenteritis in children. Dr. Burkhart states that "Antidiarrheal medications . . . [e.g., Pepto-Bismol] . . . are generally not indicated in children with acute gastroenteritis because of the lack of convincing evidence that they are effective and because of concerns that adverse effects may outweigh any benefits."

Contrary to this advice, two well-designed studies,^2,3 both conducted in South America (a challenging environment for the treatment of children with gastroenteritis), found that bismuth subsalicylate (Pepto-Bismol) at a dosage of 1.14 mL per kg every four hours decreased stool output and the duration of symptoms.

Moreover, results of a placebo-controlled, randomized trial² involving 275 infants (mean age of 13.5 months) revealed that stool output, duration of diarrhea and hospital stay were significantly decreased in patients treated with bismuth subsalicylate versus placebo, with no observed adverse reactions. That study concluded that bismuth subsalicylate is "a safe and effective adjunct to oral rehydration therapy for infants and young children with watery diarrhea."

NEAL F. DEVITT, M.D.
La Familia Medical Center
1035 Alto St.
Santa Fe, NM 87505

REFERENCES

Burkhart DM. Management of acute gastroenteritis in children. Am Fam Physician 1999;60:2555-63.

Figueroa-Quintanilla D, Salazar-Lindo E, Sack RB, Leon-Barua R, Sarabia-Arce S, Campos-Sanchez M, et al. A controlled trial of bismuth subsalicylate in infants with acute watery diarrheal disease. N Engl J Med 1993;328:1653-8.

Soriano-Brucher H, Avendano P, O'Ryan M, Braun SD, Manhart MD, Balm TK, et al. Bismuth subsalicylate in the treatment of acute diarrhea in children: a clinical study. Pediatrics 1991;87:18-27.

EDITOR'S NOTE: These letters were sent to the author of "Management of Acute Gastroenteritis in Children," who did not reply.

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672; fax:913-906-6080; e-mail: afplet@aafp.org. Please include your complete address, telephone number and fax number. Letters should be double-spaced, fewer than 500 words and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter constitutes transfer of copyright to the American Academy of Family Physicians. The editors may edit letters to meet style and space requirements.

Correction*

The article "Successful Management of the Obese Patient" (June 15, 2000, page 3615) contained an error in Table 1 (page 3618). Orlistat (Xenical) is incorrectly listed as a DEA schedule IV medication; orlistat does not have a DEA listing. The corrected table is reprinted below. An error was also made in the biography; Dr. Poston is co-director of behavioral cardiology research, not of the residency program.

*This correction has been made to the online version of AFP. The link above will take you to the corrected items, which remain part of the online issues in which they were originally published.

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