The Flexner Report--100 years later

The Flexner Report of 1910 transformed the nature and process of medical education in America with a resulting elimination of proprietary schools and the establishment of the biomedical model as the gold standard of medical training. This transformation occurred in the aftermath of the report, which embraced scientific knowledge and its advancement as the defining ethos of a modern physician. Such an orientation had its origins in the enchantment with German medical education that was spurred by the exposure of American educators and physicians at the turn of the century to the university medical schools of Europe. American medicine profited immeasurably from the scientific advances that this system allowed, but the hyper-rational system of German science created an imbalance in the art and science of medicine. A catching-up is under way to realign the professional commitment of the physician with a revision of medical education to achieve that purpose.

Guidelines for Safe Surgery in Patients with Systemic Mastocytosis

Systemic mastocytosis (SM) is a rare disorder with important perioperative implications. The physiological stress of operative procedures and a variety of anesthetic and analgesic medications can be triggers of acute exacerbation of this condition. We present two patients with systemic mastocytosis. One underwent open left inguinal hernia and umbilical hernia repair and the other laparoscopic ventral hernia repair. The literature for perioperative management of patients with SM is extensively reviewed. Both patients were treated preoperatively with intravenous antihistamines and steroids to minimize SM reactions. The first patient underwent uneventful open left inguinal hernia repair and umbilical hernia repair under spinal anesthesia. The second patient underwent general anesthesia. A composite mesh was used to repair a 9 x 12-cm Swiss cheese incisional hernia at the site of previous surgery. After the administration of neostigmine and glycopyrrolate, she developed a generalized rash without any hemodynamic instability. The patient was treated with intravenous Solu-Medrol and Benadryl and was extubated successfully and had an unremarkable postoperative course. Patients with SM require careful perioperative management for surgery under spinal and general anesthesia. These patients can undergo surgical procedures safely and effectively without compromising the standard of care.

Guidelines for safe surgery in patients with systemic mastocytosis

Systemic mastocytosis (SM) is a rare disorder with important perioperative implications. The physiological stress of operative procedures and a variety of anesthetic and analgesic medications can be triggers of acute exacerbation of this condition. We present two patients with systemic mastocytosis. One underwent open left inguinal hernia and umbilical hernia repair and the other laparoscopic ventral hernia repair. The literature for perioperative management of patients with SM is extensively reviewed. Both patients were treated preoperatively with intravenous antihistamines and steroids to minimize SM reactions. The first patient underwent uneventful open left inguinal hernia repair and umbilical hernia repair under spinal anesthesia. The second patient underwent general anesthesia. A composite mesh was used to repair a 9 x 12-cm Swiss cheese incisional hernia at the site of previous surgery. After the administration of neostigmine and glycopyrrolate, she developed a generalized rash without any hemodynamic instability. The patient was treated with intravenous Solu-Medrol and Benadryl and was extubated successfully and had an unremarkable postoperative course. Patients with SM require careful perioperative management for surgery under spinal and general anesthesia. These patients can undergo surgical procedures safely and effectively without compromising the standard of care.

Portraits of an illness

Access to patients' inner lives can be expanded and enriched by incorporating the arts and humanities into the clinical encounter. A series of self-portraits created by an artist undergoing induction chemotherapy for leukemia afforded a unique opportunity to concentrate one's gaze upon the patient as a stimulus for reflection on suffering and isolation of patients. Poetry and theater were also invaluable in expanding the physician's awareness of the shared experience of illness. The process highlights the central role of the "New Humanities" in modern medicine, where science informs the arts and the arts inform science and medicine.

Oxaliplatin Induces a Delayed Immune-Mediated Hemolytic Anemia: A Case Report and Review of the Literature

We report a case of a 59-year-old woman with metastatic carcinoma of the ileocecal region who received FOLFOX(oxaliplatin/leucovorin/5-fluorouracil) and bevacizumab therapy and exhibited a partial remission with minimal side effects. She developed a mild self-limited episode of immune-mediated hemolytic anemia during her 16th cycle of chemotherapy, which precluded her from receiving further oxaliplatin. We review the literature on oxaliplatin-induced immune-mediated hemolysis, including its mechanism, presenting symptoms, laboratory features, management, and implications for future therapy.

Well Rounded

Team ward rounding is a time-honored practice. Trainees learn not only clinical aspects but also ethical values of patient care. Despite current emphases on the principles of professionalism and humanism in medicine, there remains little discussion about applying these principles to ward rounds. We believe that rounds can become classrooms for the intentional inculcation of professionalism and humanism as counterweights to unintentionally promulgated brusqueness, ambivalence, cynicism, and frustration. We gathered examples of "humanistic rounding" from various institutions that should stimulate discussion and illustrate that no specialized training is required to "humanize" rounds; rather, willingness and creativity are key ingredients.

The Osler-Cushing covenant

In 1900 William Osler established a friendship with Harvey Cushing that encompassed the personal and professional aspects of their lives for over two decades. Their shared participation in the covenant of medicine shaped an intense friendship and mentoring relationship that profited both individuals immeasurably. The choice of Cushing as the recipient of Osler's mentoring had its origins in their rearing, avocations, and in the way of life that they shared. In Cushing, Osler identified a surrogate son who joined with him in defining the course of medicine and surgery over the next century.

Internists' attitudes towards terminal sedation in end of life care

OBJECTIVE

To describe the frequency of support for terminal sedation among internists, determine whether support for terminal sedation is accompanied by support for physician assisted suicide (PAS), and explore characteristics of internists who support terminal sedation but not assisted suicide.

DESIGN

A statewide, anonymous postal survey.

SETTING

Connecticut, USA.

PARTICIPANTS

677 Connecticut members of the American College of Physicians.

MEASUREMENTS

Attitudes toward terminal sedation and assisted suicide; experience providing primary care to terminally ill patients; demographic and religious characteristics.

RESULTS

78% of respondents believed that if a terminally ill patient has intractable pain despite aggressive analgesia, it is ethically appropriate to provide terminal sedation (diminish consciousness to halt the experience of pain). Of those who favoured terminal sedation, 38% also agreed that PAS is ethically appropriate in some circumstances. Along a three point spectrum of aggressiveness in end of life care, the plurality of respondents (47%) were in the middle, agreeing with terminal sedation but not with PAS. Compared with respondents who were less aggressive or more aggressive, physicians in this middle group were more likely to report having more experience providing primary care to terminally ill patients (p = 0.02) and attending religious services more frequently (p<0.001).

CONCLUSIONS

Support for terminal sedation was widespread in this population of physicians, and most who agreed with terminal sedation did not support PAS. Most internists who support aggressive palliation appear likely to draw an ethical line between terminal sedation and assisted suicide.

Diabetes prevalence among Puerto Rican adults in New York City, NY, 2000

This study assessed the prevalence of diagnosed diabetes and associated characteristics among Puerto Rican adults in New York City, NY, with a random-digit-dialed telephone survey with a dual-frame sampling design. Overall, 11.3% (95% confidence interval = 8.7%, 14.0%) had diagnosed diabetes; diabetes was significantly related to age, obesity, and family history; and the prevalence was high among those with the least education. This study showed the ability to obtain critically needed diabetes information from ethnic minorities at the local level.

Should disagreement about physician-assisted suicide discourage professional societies from engaging in public debate? A survey of 677 Connecticut internists

OBJECTIVE

To determine whether physicians within a state-level professional association who disagree about the ethics of physician-assisted suicide (PAS) also disagree about organized professional engagement in public discussions regarding PAS.

DESIGN

Anonymous mail questionnaire.

PARTICIPANTS

Connecticut members of the American College of Physicians-American Society of Internal Medicine as of February 1999.

MEASUREMENTS

Attitudes toward the legalization of PAS and organized participation in public discussions about PAS, and demographic and religious characteristics.

MAIN RESULTS

The mean age of 677 respondents was 51 years and 20% were women. The legalization of PAS was favored by 28% of respondents, and opposed by 53%, but 84% favored organized participation in appropriate public discussions regarding PAS. Differences in religious affiliation were strongly associated with disagreements about PAS: physicians with Jewish affiliation or no affiliation were more likely to favor legalizing PAS than those with Catholic or other Christian affiliations (45%, 38%, 14%, and 19%, respectively, P < .001). Religious affiliation was not associated with differences in attitude toward organized participation in public discussions about PAS. Statistically significant differences in attitude toward public participation were found between some subgroups according to differing attitudes toward PAS, but in each case at least 80% of physicians still supported participation.

CONCLUSIONS

Internists in this state-level organization widely supported organized participation in public discussions regarding PAS despite disagreements about its legalization, and support for organized participation was not affected by differences in religious affiliation nor substantially attenuated by differences in attitudes toward PAS.

Pulmonary hypertension in type 1 Gaucher's disease: genetic and epigenetic determinants of phenotype and response to therapy

Type 1 Gaucher's disease (GD) is recognized for striking but unexplained phenotypic diversity. Rarely, severe pulmonary hypertension (PH) may occur in GD but its clinical spectrum, determinants or its response to enzyme replacement therapy (ERT)+/-vasodilators is not known. One hundred and thirty-four consecutive patients with Type 1 GD were screened to estimate right ventricular systolic pressure (RVSP) by Doppler echocardiography. Ninety-four patients were on ERT and 40 were untreated. Eight additional GD patients were studied that represented consecutive tertiary referrals with severe PH. Angiotensin converting enzyme (ACE) gene polymorphisms and acid beta-glucosidase gene (GBA) mutations were determined by DNA analysis. Mild, asymptomatic PH (RVSP>35<50 mmHg) was prevalent in Type 1 GD: 30% in untreated patients and 7.4% among patients receiving ERT (P<0.001). Splenectomy was strongly associated with severe, life-threatening PH: all patients with severe PH (RVSP 50-130 mmHg) were asplenic compared to only 31% of patients with RVSP<50 mmHg (Odds ratio [OR] 28.8, 95% CI 1.6-531.6, P<0.001). Other characteristics of patients presenting with severe PH were poor compliance to ERT (4/9 patients) or no ERT (5/9 patients), a family history of a sib with GD and PH (2/2 patients), an excess of ACE I allele (OR 2.3, 95% CI 1.1-4.9, P=0.034) and an excess of non-N370S GBA mutation (OR 6.0, 95% CI 1.1-33, P=0.003). Severe PH was ameliorated by ERT+/-vasodilators during 4.6+/-4.0 yr (range 1-12 yr) follow-up; three patients were initially considered for lung transplantation but improved such that they are no longer active transplant candidates. Our study reveals a remarkable predisposition for PH in type 1 GD. Progression to severe, life-threatening PH occurs in the presence of additional genetic factors (non-N370S GBA mutation, positive family history, and ACE I gene polymorphism) and epigenetic modifiers (i.e., asplenia and female sex). Splenectomy should be avoided and in high-risk patients, ERT+/-vasodilators/coumadin should be initiated.

Lymphomas of mucosal-associated lymphoid tissue in common variable immunodeficiency

Common variable immunodeficiency (CVID) is a primary immunodeficiency disease characterized by low serum immunoglobulins IgG, IgA, and usually IgM. The central immune deficiency is impaired secretion of immunoglobulins and lack of antibody production; however, T cell dysfunction and a variety of inflammatory complications suggest global immune dysregulation. A number of reports have documented the association of primary immunodeficiency diseases with the development of non-Hodgkin's lymphoma (NHL). In CVID, the risk has been estimated to lie between 1.4% and 7%. As for NHL arising in other immunodeficiency states, the lymphomas in CVID are extranodal and are usually B cell in type. Of 22 B cell lymphomas that have appeared over a period of 25 years in a cohort of subjects with CVID, five lymphomas, appearing in more recently studied subjects, that arose in mucosal sites would be classified as mucosa-associated lymphoid tissue (MALT) lymphomas. MALT lymphomas are low-grade B cell lymphomas that result from a proliferation of neoplastic marginal-zone related cells of lymphoid tissue and tend to occur in organs that have acquired lymphoid tissue due to long-term infectious or autoimmune stimulation. Lymphomas of this kind have not been described in patients with congenital immunodeficiency, although chronic mucosal antigen stimulation is an integral part of these immune deficiency states.

Anemia of pregnancy

A general work-up for anemia during pregnancy could follow a simplified flow diagram, such as the one shown in Figure 1. More specific laboratory tests should be selected as needed.

The mast cell and mast cell disease

Mast cell disease or mastocytosis is a heterogeneous group of clinical disorders characterized by the proliferation and accumulation of mast cells in a variety of tissues, most often the skin. The signs and symptoms of mast cell disease are varied, dependent on the localization of mast cells in different organs and the local and systemic effects of mediators released from these cells. Although mast cell disease is most commonly identified in the skin, involvement of the skeletal, hematopoietic, gastrointestinal, cardiopulmonary, and central nervous systems may be seen. Clinical management of mastocytosis depends most heavily on knowledge of the diverse effects of mast cell mediators on various tissues and organs, the stimuli that can cause their release, and the different methods available for blocking the effects of these mediators.

Pericardial tamponade in chronic myelomonocytic leukemia

We report four cases of malignant pleuropericardial effusions in patients with chronic phase myelomonocytic leukemia (CMML). Based on current literature, this event is rare and very poorly understood. Our cases shed light on three important clinical characteristics: (1) patients with CMML develop effusions during uncontrolled leukocytosis; (2) these effusions are very responsive to conventional chemotherapy; and (3) effusions may develop without clinical forms of disease in other sites of extramedullary hematopoiesis.

Isolated amyloidosis of the penile urethra and corpus spongiosum: a case report

Localized amyloidosis of the penile urethra and corpus spongiosum is rare. The pathogenesis is obscure and optimal management of such patients has not been defined. We report a case that was treated with transurethral removal of amyloid tissue, which was obstructing the urethral outlet. Previously, the patient had been treated with dilation with temporary relief of the symptoms. He was disease-free 1 1/2 years postoperatively.

Sickle myonecrosis revisited

This review focuses on the classification of sickle myonecrosis in the context of sickle cell vaso-occlusive crisis. Further, the potential and novel use of magnetic resonance imaging to further clarify the nature of sickle crisis is discussed.

Successful childbirth by a patient with congenital factor XI deficiency and an acquired inhibitor

Acquired inhibitors in factor XI deficiency (FXI) are rare. The presence of an inhibitor during pregnancy poses a potential haemorrhagic risk to the fetus. We report an uncomplicated pregnancy and successful childbirth by a woman with congenital FXI deficiency and an acquired inhibitor, and discuss the persistence of residual FXI activity in the presence of an inhibitor.

Disseminated intravascular coagulation and excessive fibrinolysis in a patient with metastatic prostate cancer. Response to epsilon-aminocaproic acid

BACKGROUND

Disseminated intravascular coagulation (DIC) and primary fibrinolysis have both been reported in association with prostate carcinoma. The correct diagnosis of the coagulopathy can be difficult and the appropriate management controversial.

METHODS

A case is presented of a man in whom DIC and soft tissue hemorrhage developed after prostatic biopsy. The results of therapy and a review of the literature are discussed.

RESULTS

Fibrinogen levels continued to decrease despite high-dose estrogen therapy, but they rapidly returned to normal after therapy with epsilon-aminocaproic acid. Although routine coagulation tests were suggestive of primary fibrinolysis, the results of the D-dimer assay confirmed that the patient had DIC associated with excessive fibrinolysis.

CONCLUSION

A review of the literature suggests that most cases of primary fibrinolysis are probably DIC with excessive secondary fibrinolysis. In cases in which bleeding is the primary manifestation of DIC and there is a significant reduction in alpha-2-plasmin inhibitor activity, a trial of epsilon-aminocaproic acid and low-dose heparin should be considered. The failure in this case of estrogen therapy to correct the coagulopathy, despite a later good tumor response, is consistent with the delay in which anorchid testosterone levels are obtained after initiating treatment.

Rationing health care: its impact and implications for hematology-oncology

Rationing of health care in the United States currently exists via the covert mechanism of restricting significant segments of medical care for many of those who cannot afford it. Provision of universal health care would necessitate explicit rationing of certain interventions and technologies, even though an individual could afford them. The British and Canadian experiences provide lessons from which America can profit, and the Oregon health plan is an experiment in this direction. The progressive "graying" of America has raised the question of the need for intergenerational charity as a form of rationing. The implications of these rationing plans would result in a major restructuring of the practice of hematology-oncology.

Development of leukemia after doxorubicin and cisplatin treatment for ovarian cancer

Alkylating agents have been the major group of chemotherapeutic agents associated with an increased incidence of secondary leukemias. In ovarian cancer alkylating agents have resulted in a lesser, although still increased, risk of secondary malignancies. This paper reports two cases of ovarian cancer treated with cisplatin and doxorubicin (Adriamycin, Adria Laboratories, Columbus, OH), and the subsequent development of an acute nonlymphocytic leukemia and a preleukemia syndrome. This regimen does not contain alkylating agents, and has not been associated with leukemia in patients with ovarian cancer. In these two cases, abnormalities of chromosomes 5, 7, 11, and 17 are reported which have been shown to occur in therapy-related leukemia.

Beta-thromboglobulin during normal pregnancy, labor, and puerperium

Platelet activation has been implicated in the pathogenesis of several obstetrical conditions such as preeclampsia and intrauterine growth retardation. Plasma beta-thromboglobulin (BTG) concentration is an index of in vivo platelet activation. The purpose of this study was to establish normal values of plasma BTG during pregnancy, labor and puerperium. Plasma BTG concentrations were determined from 121 uncomplicated pregnant women, 20 women in labor, 20 puerperal women, and a control group of 28 healthy non-pregnant volunteers. There was no significant difference in plasma BTG concentrations between non-pregnant and pregnant women. Gestational age, labor, and puerperium did not affect plasma BTG concentrations.

Acquired factor XI inhibitors in congenitally deficient patients

Four factor XI (F XI)-deficient patients are described, all of whom formed circulating anticoagulants against F X1. In the three most severely affected patients (F XI 0%-6% activity), the anticoagulant appeared to have been stimulated by plasma infusion. However, in the milder case (25% F XI activity), no infusion had been documented. The findings in these cases emphasize the diversity of F XI inhibitors in congenitally deficient patients. Awareness of the potential development of these inhibitors will be helpful in both daily management and perioperative care of such patients.

Acute fatty liver of pregnancy. A reassessment based on observations in nine patients

Acute fatty liver of pregnancy was diagnosed in nine patients over a 10-year period. Eight patients had severe hepatic dysfunction typical for this syndrome and one had subclinical disease but typical hepatic histologic findings. All patients survived with little fetal wastage; all had preeclampsia. Histologic findings included cholestasis, hepatocellular necrosis, and inflammation, as well as microvesicular fat. Histologic findings from biopsy specimens of four of seven patients were initially misinterpreted as hepatitis. This disorder may have both a broad clinical and histologic spectrum; it is probably not rare but often misdiagnosed, perhaps as viral hepatitis. The concurrence of this disorder with toxemia of pregnancy suggests that these entities may be pathophysiologically related.

Normal arterial oxygen saturation with the ear oximeter in patients with leukemia and leukocytosis

Leukemic patients with severe leukocytosis experience a spurious lowering of the arterial oxygen tension if the arterial blood samples are not immediately analyzed. Arterial oxygen tensions were measured in three patients with acute leukemia; actual oxygen saturation was simultaneously measured with an ear oximeter. Blood gases demonstrated significant arterial hypoxemia even with immediate blood gas analysis in all patients. The ear oximeter in two patients revealed a relatively normal oxygen saturation while there was a simultaneous decrease in the calculated oxygen saturation. With reduction of the leukocyte count following chemotherapy in one patient, the calculated arterial oxygen saturation and the ear oximetry reading approximated one another. The ear oximeter is of value in the assessment of the true oxygenation status of patients who have leukemia and severe leukocytosis.

Isoniazid-induced pure red cell aplasia

The clinical courses of four individuals with pure red cell aplasia associated with isoniazid use are described. Erythroblastopenia in these individuals resolved following cessation of this antituberculous therapy. A clonal assay system that quantitates erythroid precursor cells was used to investigate the pathogenesis of the red cell aplasia in three of the patients. Using this technique, however, we were unsuccessful in demonstrating an inhibitory effect of acute phase serum, isoniazid or a combination of the two on erythroid colony formation. We conclude that isoniazid usage alone appears to be associated with a readily reversible form of acquired pure red cell aplasia. In addition, the results of our in vitro studies emphasize the limitations of bone marrow culture systems when used to implicate offending drugs in the production of drug related cytopenias.

Sir William Osler revisited

The basis of Sir William Osler's fame is elusive to almost all and the appropriateness of such recognition is questioned by many. His many contributions as a practitioner, teacher, writer, and scientist in medicine do not adequately explain his prominence 60 years following his death. It was his participation in the covenant of medicine and the special components of that relationship that may account for his hold on his followers today.

Idiopathic thrombocytopenic purpura occurring in a subject previously splenectomized for traumatic splenic rupture. Role of splenosis in the pathogenesis of thrombocytopenia

A 25 year old woman presented with idiopathic thrombocytopenic purpura. She had undergon splenectomy 12 years previously for traumatic splenic rupture. Thrombocytopenia was ultimately resistant to steroid therapy. Howell-Jolly bodies were absent from the peripheral smear and 99mTC-spleen scan demonstrated foci of increased uptake thought consistent with accessory spleens. However, splenosis alone was demonstrated at laparotomy, and all visible splenotic tissue was surgically removed. The patient responded and adequate platelet counts were maintained after discontinuation of steroid therapy. The functional capacity of splenic implants has been previously demonstrated both in animal and man. However, reports linking splenosis to hematologic disease are rare. In the present case, characteristic splenic function was demonstrated by both the the -9mTc-spleen scan and the absence of the typical peripheral blood findings of asplenia. The hematologic response to the removal of the splenotic tissue attests to its importance in maintaining the thrombocytopenic state. In the setting of prior splenectomy for splenic trauma, splenosis may contribute to hematologic disease. Removal of this splenotic tissue may result in hematologic remission.