Letters to the Editor

Letters to the Editor

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 8880 Ward Pkwy., Kansas City,

MO 64114; fax: 816-333-0303; 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.

The Role of Government in Controlling the HIV Epidemic

To the editor: For about 50 years, reporting cases of syphilis and tuberculosis, as well as a host of other communicable infectious diseases, to the U.S. Public Health Service (USPHS) has been mandatory. The USPHS is also required to follow patients who have these diseases and the persons with whom they come in contact. Issues of civil liberties, stigma and discrimination associated with mandatory reporting of infectious diseases were addressed long ago. In the case of Jacobson v. Massachusetts 197 U.S. 11 (1905), the Supreme Court ruled: “An individual can be made to submit to vaccination against contagious diseases because of the governmental and societal interest in preventing the spread of disease.”1

Why does this ruling not apply to persons who are infected with human immunodeficiency virus (HIV)? Why have citizens of the United States been told for the past 20 years of the HIV epidemic that it is for “political reasons” that our government leaders have abandoned the science of public health and have given the responsibility of controlling such diseases to the people? The “political reasons” for this decision have never been explained; therefore, we must draw our own conclusions.

A hint of the reasoning comes from an editorial in The New York Times, which stated: HIV tracking “. . . is justified by the changing nature of the epidemic . . .”2 Another editorial in The New York Times read: “The changing nature of the AIDS epidemic . . . make[s] it necessary to rethink the public health response to the disease.”3

Twenty years ago, the HIV epidemic was essentially confined to persons who were homosexual or used intravenous drugs. This confinement occurred simultaneously with massive closings of public health hospitals and cutbacks in public health funding. These groups of people must have been considered “marginal”; our government leaders must have believed they were expendable. This belief fit perfectly with the promotion of the rationale that we need to “protect their civil liberties” by not reporting them to the USPHS. Now millions of persons who were infected with HIV have died with their civil liberties intact.

Pandora’s box is open; the people are angry at the government’s betrayal of our trust and are demanding laws to protect the public health. Richard N. Gottfried, a New York State Assemblyman, said: “Large parts [of a proposed bill on HIV] look like someone just Xeroxed a 45-year-old statute dealing with syphilis and changed syphilis to HIV.”4 This is exactly what has happened. The government should get back to the basics that were previously abandoned. Dr. Lloyd Novick, Health Commissioner of Onondaga County, said about the HIV bill that was proposed in New York: “This is a major step forward for the prevention of HIV infection.”4 Is this truly a step forward, or is it a step backward into a plan that worked in the past?

Nayvin Gordon, M.D.

350 30th Street, #405

Oakland, CA 94609


1. Jacobson vs. Massachusetts. United States Supreme Court. 197 U.S., 11 (1905). Vol. 197, Book 49:645-55.

2. Tracking H.I.V. infections in New York. The New York Times 1998 Jan 15;Sect. A:20 (col. 1).

3. Partner notification for H.I.V. (New York State consider law requiring notification of the partners of infected people [Editorial]. The New York Times 1998 Jun 9; Sect. A:26 (col. 1).

4. Richardson L. Wave of laws aimed at people with H.I.V.; protection of public in tough measures is shift in focus. The New York Times 1998 Sep 25;Sect. A:1 (col. 2).

Prophylaxis for STDs After Sexual Assault

To the editor: I enjoyed the excellent article, “Management of Female Sexual Assault,” by Drs. Petter and Whitehill.1 I have a comment related to the discussion of prophylactic treatment of sexually transmitted diseases (STDs) in victims of sexual assault. The authors state that treatment “. . . should include prophylaxis for gonorrhea, Chlamydia, and syphilis . . . ,” but that “. . . trichomoniasis should be treated only if seen on the wet mount

examination.” The Centers for Disease Control and Prevention (CDC) disagrees.

The CDC’s document “1998 Guidelines for Treatment of Sexually Transmitted Diseases”2 regarding sexual assault and STDs recommends empiric postexposure prophylaxis, not only for Chlamydia, gonorrhea and hepatitis (if the patient is not immunized), but also for Trichomonas and bacterial vaginosis, by adding one 2-g oral dose of metronidazole to the usual prophylactic therapy for STDs.

Edward L. Fieg, Major, USAF, MC

51 Medical Group/SGOME

PSC #3, Box 2724

Osan AB, Korea

APO AP 96266


1. Petter LM, Whitehill DL. Management of female sexual assault. Am Fam Physician 1998;58:920-6.

2. Centers for Disease Control and Prevention. 1998 guidelines for treatment of sexually transmitted diseases. MMWR Morb Mortal Wkly Rep 1998; 47(RR-1):110.

Editor’s note: This letter was sent to the authors of “Management of Female Sexual Assault,” who declined to reply.

Sister (Mary?) Joseph’s Node

To the editor: We appreciated the thorough review of lymphadenopathy in Dr. Ferrer’s recent article.1 We would like to point out that the paraumbilical nodule (“Sister Joseph’s node”), cited by Dr. Ferrer as a sign of an abdominal or pelvic neoplasm, is not a lymph node but rather a direct metastatic lesion to the umbilicus.2,3 The nodule is most commonly associated with metastatic gastric or ovarian cancer.3 Less commonly, the nodule may be a metastatic lesion from colon or pancreatic cancer.3 The most important route for the spread of cancer to the umbilicus is considered to be direct extension from the anterior peritoneum.2

Whether the proper eponym for the nodule is Sister Mary Joseph’s node or Sister Joseph’s node has been debated. Sister (Mary?) Joseph was the daughter of Irish immigrants who settled in Minnesota.2 In the 1890s, she became the superintendent of Saint Mary’s Hospital (part of the early Mayo Clinic) in Rochester.2 Her responsibilities included preparing abdomens of patients for surgery, and during this task she pointed out a paraumbilical nodule that was associated with advanced intra-abdominal cancer.2 The nodule was first named Sister Joseph’s nodule by Sir Hamilton Bailey in 1949.2,3

In any event, the rare finding of a paraumbilical nodule suggests an intra-abdominal malignancy and warrants further evaluation. Fortunately, the accessibility of the nodule makes histologic diagnosis relatively simple.

Anthony J. Viera, M.D.

Timothy L. Clenney, M.D.

Naval Hospital Jacksonville

Family Practice Department

2080 Child St.

Jacksonville, FL 32214


1. Ferrer R. Lymphadenopathy: differential diagnosis and evaluation. Am Fam Physician 1998;58:1313-20.

2. Hill M, O’Leary JP. Vignettes in medical history. Sister Mary Joseph and her node. Am Surgeon 1996;62:328-9.

3. Skellchock LE, Goltz RW. Umbilical nodule: metastatic adenocarcinoma (Sister Mary Joseph nodule). Arch Derm 1992;128:551-2.

4. Schwartz IS. Sister (Mary?) Joseph’s nodule. N Engl J Med 1987;316:1348-9.

Editor’s note: This letter was sent to the author of “Lymphadenopathy: Differential Diagnosis and Evaluation,” who declined to reply.

Peripartum Emergencies

To the editor: I applaud Dr. Morrison’s effort to provide a complete review of common peripartum emergencies in her recent article.1 The breadth of the topic is certainly daunting, and her review of the applicable literature is well done.

I feel, however, that one omission in regard to the management of shoulder dystocia should be mentioned. Evidence in the medical literature indicates that a technique called the “all-fours” maneuver is a reasonable option to include in the treatment algorithm of this obstetric emergency.2

The all-fours maneuver has been reported, both anecdotally and in the midwifery literature, to be effective in resolving shoulder dystocia.3 The success of the maneuver depends on the patient’s ability to roll over into the “hands and knees” position. As mentioned in Dr. Morrison’s article, shoulder dystocia occurs when the anterior fetal shoulder becomes wedged behind the mother’s symphysis pubis and cannot be easily reduced. The all-fours maneuver takes advantage of the laxity of the sacroiliac joint at term, which may result in an increase of 1 to 2 cm in the sagittal diameter of the pelvic outlet.4 The dorsal lithotomy position restricts this posterior movement of the sacrum. The all-fours maneuver eases the delivery of the posterior fetal shoulder.

This procedure has recently been included in the curriculum for the American Academy of Family Physician’s course “Advanced Life Support in Obstetrics (ALSO)” as the additional “R” in the HELPERR mnemonic.5 Although the all-fours maneuver is not the standard of care, it is an alternative to the Zavanelli maneuver or the delivery of the infant’s posterior arm in the dorsal lithotomy position.

John M. Weigand, M.D.

Department of Family Practice

Mount Carmel Family Practice Residency Program

Columbus, Ohio 43215


1. Morrison EH. Common peripartum emergencies. Am Fam Physician 1998;58:1593-604.

2. Meenan AL, Gaskin IM, Hunt P, Ball CA. A new (old) maneuver for the management of shoulder dystocia. J Fam Pract 1991;32:625-9.

3. Gaskin IM. Shoulder dystocia: controversies in management. Birth Gazette 1988;5:14.

4. Borell U, Fernstrom I. A pelvimetric method for the assessment of pelvic ‘mouldability.’ Acta Radiol 1957a;47:365.

5. ALSO: advanced life support in obstetrics course syllabus. 3d ed. Kansas City, Mo.: American Academy of Family Physicians, 1996.

to the editor: I would like to commend Dr. Morrison for her article on common peripartum emergencies.1 She provides a thorough and logical discussion of some of the obstetric emergencies most frequently encountered during the peripartum period.

After reviewing the section on postpartum hemorrhage, however, I must mention some additional points from the American College of Obstetrics and Gynecology (ACOG) Educational Bulletin on postpartum hemorrhage.2 This bulletin was not referenced in Dr. Morrison’s article.

Although Dr. Morrison correctly describes the use of the prostaglandin derivative carboprost, or 15-methyl prostaglandin F2a, it should be noted that it is contraindicated in patients with “. . . active cardiac, pulmonary, renal, or hepatic disease.”2 The bulletin also recommends the use of another prostaglandin derivative, dinoprostone, or prostaglandin E2, for postpartum hemorrhage. Although carboprost is preferred over dinoprostone because of the latter drug’s potential to cause vasodilatation and hypotension, use of dinoprostone should be considered in patients for whom carboprost is contraindicated for the aforementioned medical conditions. Dinoprostone causes essentially the same side effects as carboprost (vomiting, diarrhea, nausea, fever, headache, chills or shivering), and it is administered as a 20-mg rectal dose once every two hours.

E. George Butler, II, M.D.

Department of Family Practice

United States Naval Hospital

2080 Child St.

Jacksonville, FL 32214-5227


1. Morrison EH. Common peripartum emergencies. Am Fam Physician 1998;58:1593-604.

2. American College of Obstetricians and Gynecologists. Postpartum hemorrhage. ACOG educational bulletin Number 243. Washington, D.C.: ACOG, 1998.

In reply: I would like to thank Drs. Weigand and Butler for pointing out useful additional techniques for handling peripartum emergencies- namely dinoprostone for postpartum hemorrhage and the all-fours maneuver for shoulder dystocia. Certainly, clinicians may find these options useful in certain situations. Given the space and reference constraints in American Family Physician, I had to omit many such helpful points. I am pleased that these tips have now been included through these letters from our colleagues. Like Dr. Weigand, I also recommend the “Advanced Life Support in Obstetrics” course from the AAFP as a wonderful resource for anyone who wishes to explore these topics in more depth.

Elizabeth Morrison, M.D. M.S.ED.

Department of Family Medicine

University of California, Irvine

101 City Dr. South

Bldg. 200, Suite 512, Rt. 81

Orange, CA 92868-3298

COPYRIGHT 1999 American Academy of Family Physicians

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