Online Letters to the Editor

Treatment of Obese Patients Should Include Weight Loss

TO THE EDITOR: I would like to commend the National Task Force on the Prevention and Treatment of Obesity for their article offering advice to family physicians who wish to help obese patients improve their health.¹ The article illustrates many of the barriers to health care that are encountered by persons who are obese and offers a variety of excellent suggestions that physicians can use proactively to lessen these barriers.

While it is extremely important to address all the health issues confronted by patients who are obese, physicians should realize that these patients are also counting on their physicians to assist them in losing weight. In our practice, we surveyed 105 patients with a body mass index (BMI) greater than30.Of these patients, 95 percent thought weight loss was important, and 84 percent felt that their family physician could help them to lose weight.² Unfortunately, both in our practice and nationwide, physicians have yet to even broach the issue of weight loss with most obese patients.³

I very much agree with the statement that, for patients who are obese, “physicians can encourage improvements in healthy behaviors, regardless of the patient’s desire for, or success with, weight loss treatment.”¹ Clearly, our patients who are obese are waiting and hoping for their physicians to do exactly that, and more.

MICHAEL B. POTTER, M.D.
Department of Family and Community Medicine
University of California, San Francisco
500 Parnassus Ave., MU-3 East
San Francisco, CA 94143-0900

1. Medical care for obese patients: advice for health care professionals. Am Fam Physician 2002;65:81-8.
2. Potter MB, Vu JD, Croughan-Minihane M. Weight management: what patients want from their primary care physicians. J Fam Pract 2001;50:513-8.
3. Mokdad AH, Serdula MK, Dietz WH, Bowman BA, Marks JS, Koplan JP. The spread of the obesity epidemic in the United States, 1991-1998. JAMA 1999;282:1519-22.

Babesiosis and Transfusion Medicine

TO THE EDITOR: The article by Dr. Mylonakis provides an excellent overview of the management of babesiosis.¹ I would like to point out, however, that the degree of parasitemia need not always parallel the severity of clinical symptoms.² This disparity may be attributed to some of the indirect, harmful effects related to parasitemia within the host. Usually, this is evident when anemia is disproportionate to the degree of parasitemia.³ The reason for such incongruity is related to the fact that both parasitized and healthy erythrocytes get destroyed, as a result of an infection-mediated, autoimmune, hemolytic process.The production of anti-erythrocytic autoantibodies, possibly aimed at Rh antigens on the red cell,⁴ explains why some persons may have a positive Coombs test during infection.

Dr. Mylonakis recommends exchange transfusion, together with antibabesial chemotherapy, for critically ill patients with a blood parasitemia of more than 10 percent, massive hemolysis and asplenia.¹ Indeed, prompt institution of exchange transfusion, in combination with appropriate drug therapy, can be life-saving; however, reliance solely on the level of parasitemia or the degree of hemolysis alone to advocate this form of therapy may be misleading, for the reasons alluded to above. Cases that are refractory to appropriate antibiotic therapy may also respond to exchange transfusion. Moreover, exchange transfusion may be of value to persons who cannot tolerate drugs because of toxicities or adverse effects. Transfusions are not to be recommended for routine management because of the hazards posed by multiple blood exposures. The benefits of this treatment, however, clearly outweigh the risks when it is clinically indicated. Until controlled trials are available to clarify the specific indications, merit and goals of exchange transfusion in the management of babesiosis, clinical judgment is probably still the best guide.

LIRON PANTANOWITZ, M.D.
Beth Israel Deaconess Medical Center
330Brookline Avenue
Boston, MA 02215

REFERENCES

1. Mylonakis E. When to suspect and how to monitor babesiosis. Am Fam Physician 2001;63:1969-74.
2. Sun T, Tenenbaum MJ, Greenspan J, Teichberg S, Wang RT, Degnan T, et al. Morphologic and clinical observations in human infection with Babesia microti. J Infect Dis1983;148:239-48.
3. Carson CA, Phillips RS. Immunologic response of the vertebrate host to babesia. In: Babesiosis. Ristic M, Kreier JP, eds. New York: Academic Press;1981.
4. Wolf CF, Resnick G, Marsh WL, Benach J, Habicht G. Autoimmunity to red blood cells in babesiosis. Transfusion 1982;22:538-9.

IN REPLY: I would like to thank Dr. Pantanowitz for his interest in my article. In his letter, Dr. Pantanowitz suggests that "clinical judgment" is the best guide for the use of exchange transfusion in the management of babesiosis. I wholeheartedly agree, and this is stated clearly and unequivocally in my paper.¹

Dr. Pantanowitz also writes that "exchange transfusion may be of value to persons who cannot tolerate drugs because of toxicities or adverse effects."I would like to caution care providers that the use of exchange transfusion without antimicrobial chemotherapy is untested. The appropriate management of patients who are ill enough to require exchange transfusion and cannot tolerate an antimicrobial regimen is to try another regimen, not to use exchange transfusion alone. In a large study among patients with babesiosis, 97.5 percent of patients were able to complete a course of azithromycin with atovaquone with excellent results,² and a number of other treatment options are available.

ELEFTHERIOS MYLONAKIS, M.D.
Infectious Diseases Division
Massachusetts General Hospital
55 Fruit St.
Boston, MA 02114

REFERENCES

1. Mylonakis E. When to suspect and how to monitor babesiosis. Am Fam Physician 2001;63:1969-74.
2. Krause PJ, Lepore T, Sikand VK, Gadbaw J JR, Burke G, Telford SR 3d, et al. Atovaquone and azithromycin for the treatment of babesiosis. N Engl J Med 2000;343:1454-8.

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