Letters to the Editor

Resources for Management of Cutaneous Leishmaniasis

TO THE EDITOR: We were pleased to see the recent review on cutaneous leishmaniasis by Markle and Makhoul.1 Cutaneous leishmaniasis is a significant health concern for the U.S. Armed Forces with more than 650 cases diagnosed over a nine-month period, primarily acquired in Iraq.2 It is common for family physicians or other primary care clinicians to make the initial diagnosis. Given the number of Reserve and National Guard personnel serving in this conflict, it is important for physicians who care for these patients to recognize and be aware of management guidelines because they may see returning military servicemen who did not seek care initially or had late activation of their infection (incubation period can vary from 30 days to six months).3

The authors note that trauma is a potential source of disease reactivation. Returning soldiers infected with cutaneous leishmaniasis should be alerted that tattoos can lead to local dissemination of disease over the tattoo site.4

Since 1978, Walter Reed Army Medical Center (WRAMC) in Washington, D.C., and, more recently, Brooke Army Medical Center (BAMC) in San Antonio, are the military sites for treatment of leishmaniasis. The authors state that sodium stibogluconate (Pentostam) is available from the Centers for Disease Control and Prevention, but it is important to mention that this medication also is available under protocol at WRAMC and BAMC. Service members with deployment-related infection for up to two years after the end of deployment can be referred to these centers for care. Questions should be referred to the Department of Defense Deployment Health Clinical Helpline, telephone: 866-559-1627, or http://www.pdhealth.mil. Health care professionals may refer patients to the treatment centers at WRAMC, telephone: 202-782-1663, or BAMC, telephone: 210-916-5554. Assistance with diagnostic support can be obtained from the military Leishmania Diagnostic Laboratory in Silver Spring, Md., at 301-319-9956.

While pentavalent antimony for 20 days remains the standard treatment duration for cutaneous leishmaniasis (when Pentostam is elected for treatment), a recent clinical trial demonstrated that 10 days of treatment was effective and associated with fewer side effects.5 A controlled trial of heat treatment recently has been completed at WRAMC.

JOSHUA D. HARTZELL, CPT, MC, USA
NAOMI ARONSON, COL, MC, USA

Walter Reed Army Medical Center
Washington, DC 20307

REFERENCES

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Army Medical Department or the U.S. Army Service at large.

Patients' "Wants" Should Not Determine Decision-Making

to the editor: I must take exception with the Curbside Consultation in the February 1, 2004, issue of American Family Physician.1 The authors confuse the terms "needs" and "wants," and in doing so create a situation where patient expectations trump sound medical decision-making. In the case presented, the authors state: "Although the physician wants to perform a complete diabetes work-up, it would be incongruent with the needs of this patient." I disagree whole-heartedly. What the patient needs first and foremost is improved blood glucose control, but also a complete examination to look for already existing complications of diabetes, laboratory work including chemistries, a lipid panel, A1C levels, urine test for microalbuminuria, dilated funduscopic examination, diabetes education, and routine follow-up. What the patient wants is a one-stop, quick fix including a prescription for medication that may have possible adverse effects.

Physicians are routinely faced with patients who "need" antibiotics for a two-day viral upper respiratory infection, cortisone injections for benign rashes, and prescriptions for the latest drug they saw advertised on television. As physicians, we cannot give in to these requests, or we will be guilty of not providing quality care, opening ourselves to medical liability and a lack of credibility in the community. When faced with such patients, physicians have the responsibility to fully inform the patient that their request is outside usual practice, and then document this discussion. Physicians should not be made to feel that they must accommodate these patient requests.

CHRISTINE EADY, D.O.

15808 Hwy. 620 N., Ste. 100
Austin, TX 78717

REFERENCES

In reply: Dr. Eady presents an important reflection on our article.1 We fully agree with her that "as physicians, we cannot give in to these requests" for inappropriate treatments such as antibiotics for viral infections and cortisone injections for benign rashes. However, when interacting with patients whose frame of reference for chronic disease is different from our own, we should work to negotiate with the patient and the family to meet the patient's needs. In the original article,1 the patient wanted a quick fix for new-onset diabetes. Obviously, diabetes is not amenable to a quick fix, but one could initiate some treatment to help with symptoms and blood glucose control without ordering a battery of tests and consults. Our intent was not to suggest that physicians should acquiesce to every patient request, but to acknowledge that there is room to negotiate a plan of diagnosis and treatment (particularly when dealing with patients from a different culture) that may be beneficial for the patient and satisfying for the physician. This is offered as a challenging, but acceptable, alternative to refusing care for patients.

greg ogrinc, m.d.

White River Junction Veterans Affairs Medical Center
215 N. Main St.
White River Junction, VT 05009-0001

REFERENCES

Correction

The article, "Introducing the AAFP's 2005 Annual Clinical Focus on Genomics" ("Inside AFP," November 1, 2004, page 1617), incorrectly listed the sponsors and supporters of the 2005 Annual Clinical Focus (ACF). The 2005 ACF program on genomics is made possible by the support and participation of the Maternal and Child Health Bureau of the Health Resources and Service Administration; National Human Genome Research Institute; National Coalition for Health Professional Education in Genetics; National Heart, Lung, and Blood Institute; GlaxoSmithKline; Roche; and the Susan G. Komen Breast Cancer Foundation. Other participating partners include the American Academy of Nurse Practitioners, American Academy of Pediatrics, American Academy of Physician Assistants, American Cancer Society, American College of Medical Genetics, American College of Physicians, American Heart Association, American Society of Human Genetics, Centers for Disease Control and Prevention, March of Dimes, and the National Society of Genetic Counselors, Inc.

The online version of this article has been corrected.