Letters to the Editor - December 1, 1999 - American Academy of Family Physicians

Letters to the Editor

Treatment Choices for Plantar Fasciitis

TO THE EDITOR: I read the article by Drs. Barrett and Mosby¹ and as a family physician who has incorporated acupuncture into daily practice, my experience with plantar fasciitis may be of interest. With a combination of acupuncture, strapping and exercises to stretch the plantar fascia, all patients I have treated experienced relief. Generally, four to six treatments are necessary. I have observed a good response even in patients who have failed to respond to all other treatments, including steroid injections and casting.

MARIE STEINMETZ, M.D.
5249 Duke Street, Suite 212
Alexandria, VA 22304

REFERENCES

Barrett SL, O'Malley R. Plantar fasciitis and other causes of heel pain. Am Fam Physician 1999;59: 2200-6.

IN REPLY: As a physician who specializes in diseases and disorders of the human foot, with a subspecialization in heel pain, it is difficult to respond comprehensively to Dr. Steinmetz's letter because of the complexity of conservative care for the treatment of plantar fasciitis. While it is difficult for me to believe that Dr. Steinmetz's treatment regimen of acupuncture, strappings and stretching exercises cures everyone, these modalities (with the exception of acupuncture) are fundamental in the sound treatment of patients with plantar fasciitis.

I would add that we have an extremely high success rate with our conservative care regimen that includes strappings and stretching. I think what is important is that the success of conservative care for the treatment of patients with plantar fasciitis requires a "concert" of modalities. Rarely, without some type of biomechanical control, will any of these modalities alone be effective. In addition, I have had patients who related that acupuncture had indeed helped them; albeit, they already had biomechanical control intervention.

It is a great injustice for a patient to be declared a conservative care failure and subsequently taken to surgery, when in fact, the only conservative care the patient received was a misguided and fragmented approach to treatment. Can a physician of any specialty believe that without any other modality (i.e., biomechanical control), an isolated injection or two of a steroid will really help a patient with plantar fasciitis?

The importance of Dr. Steinmetz's letter is that it reflects a multifaceted approach in the treatment of plantar fasciitis with biomechanical control. One final comment: just because a patient fails to return to the office does not necessarily mean that a "cure" was achieved. I have seen many new patients presenting with plantar fasciitis who possess a bag of several different pairs of orthotic devices. I am sure that each one of the previous prescribers believed that the patient had been "cured."

STEPHEN L. BARRETT, D.P.M
25227 Borough Park Drive
Spring, TX 77380

Use of Intravenous Colchicine for Podagra

TO THE EDITOR: I would like to offer a few comments on the article by Pittman and Bross¹ on the diagnosis and management of gout.

It is nice to see that the authors recommend intravenous colchicine for the relief of podagra. The use of this agent represents one of those "dramatic" moments in clinical medicine. The patient hobbles into the examining room in acute pain and walks out just minutes later with almost total relief.

This dramatic relief of pain after administration of colchicine is also an important diagnostic clue in gout--and the thought of injecting an acutely inflamed joint to aspirate diagnostic synovial fluid to look for urate crystals . . . well, just the thought gives one real pause.

Intravenous colchicine is not only helpful therapeutically, it is also helpful diagnostically.

EUGENE GUAZZO, M.D.
Maryland Infirmary
Chaptico, MD 20621

REFERENCES

Pittman JR, Bross MH. Diagnosis and management of gout. Am Fam Physician 1999;59:1799-1806.

Delusions of Parasitosis

TO THE EDITOR: A 41-year-old nurse requested a second opinion about a bowel disorder. She related her symptoms to a previous trip to Mexico, where she acquired a self-limited diarrheal illness. She complained of recurrent diarrhea that she believed was caused by a parasite acquired while she was in Mexico.

Findings on initial physical examination were unremarkable, and stool studies were negative. Because of persistent symptoms, the patient requested a gastroenterology referral. Results of multiple tests (ova and parasites, cryptosporidium antigen, giardia antigen, colonoscopy, esophagogastroduodenoscopy, mucosal biopsies and serum chemistries) were all within normal limits.

I reassured the patient that there was no evidence of an occult parasitic infection. At the time of this presentation, the patient was well groomed and appeared in no distress. She calmly explained her dilemma. She suffered no adverse consequences in other areas of her life and was not depressed. She only wanted to find and eliminate the parasite that was tormenting her. Findings on repeat physical examination were normal, and psychotherapeutic referral was suggested. The patient became hostile, promptly left the office and was lost to follow-up.

Originally described in 1894,¹ delusions of parasitosis (DOP) has been variously referred to as dermatophobia, parasitophobic neurodermatitis, parasitophobia or entomophobia.² Central to the diagnosis is a fixed, false belief of a parasitic infestation. Patients are usually fully functional in all other areas.

The prevalence of DOP is not known. The condition is more common in middle-age women. No risk factors have been identified, and no predilections among socioeconomic, occupational or racial backgrounds is evident. In 12 percent of patients, the delusion of parasitic infestation is shared by a significant other--a condition known as "folie a deux."³

Patients often seek the advice of multiple physicians to seek sympathy. They often present with a container holding the purported parasite (the "matchbox sign"⁴). Patients often have received multiple treatments from multiple physicians and will also use self-concocted preparations to rid themselves of the perceived infestation.

Following a thorough history and physical examination, appropriate initial laboratory studies include a complete blood count, serum electrolytes, thyroid function tests, rapid plasma reagin, urinalysis and a drug screen. An electroencephalogram, B₁₂/folate levels or computed tomography may be appropriate based on specific patient presentation.

Successful treatment of delusional parasitosis is difficult and requires formulating a sense of trust with the patient. A multidisciplinary approach is preferred. The following steps are useful in approaching patients with DOP⁵:

Ensure that the diagnosis is correct.

Listen empathetically.

Ask how the condition has affected the patient's quality of life.

Establish the trust of the patient.

Be alert to any area where the patient will allow you to help.

Reduce the patient's sense of isolation.

Consider use of medication to ease the patient's anxiety or psychosis.

Pimozide (Orap), a neuroleptic agent, has traditionally been the drug of choice for the treatment of DOP.⁶ The initial dosage is 1 mg per day. This can be increased weekly by 1-mg increments until a clinical response is achieved. Most patients respond at a dosage of 4 to 10 mg per day.³ The maximum dosage is 20 mg per day.

MARK B. STEPHENS, LCDR, MC, USN
Department of Family Medicine
Uniformed Services University of the Health Sciences
4301 Jones Bridge Road
Bethesda, MD 20814-4799

The opinions and assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the U.S. Navy or the U.S. Department of Defense.

REFERENCES

Musalek M, Bach M, Passweg V, Jaeger S. The position of delusional parasitosis in psychiatric nosology and classification. Psychopatholgy 1990;23:115-24.

Johnson GC, Anton RF. Delusions of parasitosis: differential diagnosis and treatment. South Med J 1985;78:914-8.

Koo J, Gambla C. Delusions of parasitosis and other forms of monosymptomatic hypochondriacal psychosis. General discussion and case illustrations. Dermatol Clin 1996;14:429-38.

Gould WM, Gragg TM. Delusions of parasitosis: an approach to the problem. Arch Dermatol 1976; 112:1745-8.

Winsten M. Delusional parasitosis: a practical guide for the family practitioner in evaluation and treatment strategies. J Am Osteopath Assoc 1997; 97:95-9.

Safer DL, Wenegrat B, Roth WT. Resperidone in the treatment of delusional parasitosis: a case report. J Clin Psychopharmacol 1997;17:131-2.

Resources for Patients with Amyotrophic Lateral Sclerosis

TO THE EDITOR: Walling's recent review of amyotrophic lateral sclerosis (ALS)¹ was thorough and informative, but your readers might also like to know that the Muscular Dystrophy Association (MDA) is the nation's leading nonprofit, nongovernmental organization funding research and services for people with ALS.

For diagnosis and other medical services, physicians may wish to refer patients whom they suspect may have ALS to any of the 230 hospital-affiliated MDA clinics in our nationwide network or to one of the 19 MDA/ALS research/clinical facilities located at various major medical centers across the country. A directory of these facilities and information on ALS clinical trials, potential treatments and current research is available on the MDA Web site (http://www.mdausa.org).

MDA's services for patients with ALS and their families also include support groups and up-to-date information.

For copies of any MDA publications and videos about ALS, or referrals to the nearest MDA facility, physicians may check our Web site or call us at 800-572-1717.

ROBERT ROSS
Muscular Dystrophy Association
National Headquarters
3300 East Sunrise Drive
Tucson, AZ 85718-3208

REFERENCES

Walling AD. Amyotrophic lateral sclerosis: Lou Gehrig's disease. Am Fam Physician 1999;59: 1489-96.

Surgical Options for Male Pattern Baldness

TO THE EDITOR: I read with interest the article entitled "Medical Treatment for Balding in Men."¹ While the title aptly describes the article's content and its focus on medical therapies, I was disappointed that it almost completely ignored surgical options.

Surgical solutions for androgenetic alopecia include autografts, flaps and lifts, scalp reduction and scalp extenders. The ideal candidate for autograft is a man with dense hair on the sides or back of his head. Micro, mini or standard grafting (ranging from three to 100 hairs per graft) are successful in many cases, especially in frontotemporal balding areas that have not been amenable to medical therapy.

The average cost of grafting is $50 per plug, multiplied by an average of 300 plugs per case, or approximately $15,000. While this may seem expensive, it compares favorably with the 30- to 40-year lifetime costs of a daily dosage of full-strength minoxidil and/or finasteride. Moreover, beyond the inherent small risk of surgery, no long-term side effects are evident.

Modern plastic surgery involves the advanced techniques of scalp lifts and flaps, scalp reduction and scalp extenders. These surgical treatments have met with great success and resulted in good cosmetic results.

I would also like to point out that the U.S. Food and Drug Administration's original label approval for finasteride was contingent on its use with Neutrogena T/Gel shampoo, which adds to the total costs of treatment. A full discussion of all potential treatments (medical and surgical) for male pattern baldness is indicated for our patients.

STEPHEN ELGERT, M.D.
7300 Dexter Ann Arbor Rd.
Dexter, MI 48130

REFERENCES

Scow DT, Nolte RS, Shaughnessy AF. Medical treatments for balding in men. Am Fam Physician 1999; 59:2189-94.

IN REPLY: Although our article¹ focused on the medical treatments of male pattern baldness, Dr. Elgert rightly points out that surgery is also an option.

DEAN THOMAS SCOW, M.D.
ALLEN SHAUGHNESSY, PHARM.D.
Harrisburg Family Practice Residency
PO Box 8700
Harrisburg, PA 17105-8700

REFERENCES

Scow DT, Nolte RS, Shaughnessy AF. Medical treatments for balding in men. Am Fam Physician 1999; 59:2189-94.

Folic Acid Requirements for Women of Childbearing Age

TO THE EDITOR: I especially appreciated the point made by Hark and Deen¹ in their recent review of nutrition screening in American Family Physician--that family physicians should find the time to address nutrition and dietary behavior issues within the context of an office visit. Physicians must take advantage of every opportunity to educate and improve the nutritional behavior of their patients. Unfortunately, the section on folates in this article missed an opportunity to emphasize prevention of birth defects and infant mortality and morbidity through vitamin B supplementation.

Each year in the United States, about 4,000 pregnancies are affected by neural tube defects. In 1992, the U.S. Public Health Service recommended that all women of childbearing years consume 400 µg per day of the B vitamin folic acid to reduce the risk of these defects.² More specifically, in 1998, the Food and Nutrition Board of the Institute of Medicine recommended that all women of childbearing age consume 400 µg per day of synthetic folic acid from fortified foods or vitamin supplements in addition to natural food folate.³ The body can more easily absorb synthetic folic acid than natural food folate. It is crucial to provide this advice to all women of childbearing age, because an estimated 50 percent of all pregnancies in the United States are unintended.⁴ The neural tube closes during the first month of pregnancy, before many women even know they are pregnant; thus, it is important that an adequate amount of folic acid be in a woman's system before conception.

In 1998, the March of Dimes launched a $10 million, multi-year campaign to increase awareness among women about the importance of folic acid, and to inform women about how they can consume the required 400 µg per day by following a healthy diet and taking a daily multivitamin. The goal is to reduce serious brain and spine defects in the United States by at least 30 percent by the year 2001. The campaign includes professional education, community outreach programs, new material, advertising and publicity.

So yes, I agree that each office visit should be used advantageously for nutritional education, but physicians should always provide complete information--especially when it can prevent thousands of severe birth defects.

DONALD R. MATTISON, M.D.
March of Dimes National Office
1275 Mamaroneck Avenue
White Plains, NY 10605

Free patient education flyers, waiting room posters and information sheets are available to health care providers by writing to: March of Dimes, The Folic Acid Campaign, 1275 Mamaroneck Avenue, White Plains, NY 10605.

REFERENCES

Hark L, Deen D. Taking a nutrition history: a practical approach for family physicians. Am Fam Physician 1999;59:1521-8.

Recommendations for the use of folic acid to reduce the number of cases of spina bifida and other neural tube defects. Morb Mortal Wkly Rep 1992;41:1-7.

Institute of Medicine (U.S.) Dietary reference intake: proposed definition and plan for review of dietary antioxidants and related compounds. Washington, D.C.: National Academy Press, 1998. Compass Series.

Henshaw SK. Unintended pregnancy in the United States. Fam Plann Perspect 1998;30:24-9, 46.

IN REPLY: We completely agree with Dr. Mattison's comments about the important issue of the prevention of neural tube defects. While we believe that primary care physicians should discuss the issue of folic acid supplementation with all women of childbearing years, space considerations in our article did not allow us to pay attention to specific issues of importance at different stages of the life cycle. We appreciate Dr. Mattison's thoughtful comments and believe that conversations regarding preventive issues related to specific nutrients should be conducted in the context of a conversation about patients' usual dietary intake and other health maintenance behaviors.

DARWIN DEEN, JR, M.D., M.S.
Albert Einstein College of Medicine
of Yeshiva University
Bronx, NY 10461
LISA HARK, PH.D., R.D.
University of Pennsylvania School of Medicine
3450 Hamilton Walk
Philadelphia, PA 19104-6087

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.

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