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American Journal of Clinical Medicine® Owned and Published by the American Association of Physician Specialists, Inc. Peer Reviewed. Listed in Google Scholar and BioMedLib

Fall 2012 • Volume Nine, Number Three

FEATURED IN THIS ISSUE 118 Johns Hopkins and the

Feminist Legacy: How a Group of Baltimore Women Shaped American Graduate Medical Education

128 Medical Information:

Females Bear the Burden and Are Not Prepared

134 The Art of Medicine:

Can You Recognize Aunt Minnie?

149 Breast Cancer in

the New Age – IMRT

154 Physicians’ Responsibility

with Prescription Drug Abuse

158 Medical Ethics

Without the Rhetoric


We’re Going Digital! American Journal of Clinical Medicine® Beginning with Volume 10 Number 1 – the Winter 2013 Issue –– the American Journal of Clinical Medicine® will be available in digital format only. You will receive an email announcement when the AJCM is posted on the AAPS website (www.aapsus.org) so BE SURE WE HAVE YOUR CORRECT EMAIL ADDRESS. The digital format will allow for •

Full color pages throughout the AJCM

More easily readable tables, charts, graphs, diagrams, x-rays, and photographs

Less cost to AAPS – no printing and no postage

We welcome submissions from our Diplomates, Members, and other Medical professionals. Continue to send your manuscripts electronically to editor@aapsus.org or contact Esther Berg at 813-433-2277 Ext 18 if you have any questions.


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See the American Journal of Clinical Medicine® for: •

Research and Review Articles – Your original research or your review of others’ research

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The American Journal of Clinical Medicine is peer reviewed and is listed in Google Scholar and BioMedLib.


CALL FOR PAPERS American Journal of Clinical Medicine

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Owned and Published by the American Association of Physician Specialists, Inc.

American American Journal of Jo A urn of can J Clinic® al M merial ou Clinical Medicine ed ® C liic niin cael M rnal of edici ® ne FEATURED Owned and Publishe d by the a merican assOciat Owned and Published by the american assOciatiOn Of Physician sPecialists, inc. iOn Of Physician Peer reviewed. sPecialists, inc listed in GOOGle . schOlar and b Owned iOmedlib and P Winter 2012 • Winter 2011 • Volume eight, number one ublished Volume

nine, number

FEATURED IN THIS ISSUE

6

11

IN THIS ISSU

E-

Review of Medical and Surgical Management of Postpartum Hemorrhage

8

Transfuse or Not to Transfuse: For Post-op Anemia

10 15

A Critical Appraisal of the Evolution of ST Elevation Myocardial Infarction (STEMI) Therapy and the Evidence Behind the Current Treatment Guidelines

40

Malignant and Benign Eyelid Lesions in San Francisco: Study of a Diverse Urban Population

47

Invasive Squamous Cell Carcinoma of the Cervix Following HPV Immunization in a Nineteen-Year-Old Woman

49

Impact of a Multi-Modality Intervention on Physician Knowledge and Practice in Managing Hepatitis C

57

Primary Mature Cystic Teratoma of the Liver: Report of a Rare Case

65

The Role of Physician Experience in Pelvic Examination Accuracy

11

14

22

30

FEATUR

ED IN

The Rural Health Landscape in Jeopardy

About Rural Health

70

in America

80

Medical Educa tion Cost & Debt Impacting Future Rural Physicians

Anaphylaxis: Diagn and Management osis in the Rural Emergency Department

Investigating a Rural Rotati on in the Mississippi Delta: A Qualitative Study in Medical Educa tion

88

92

102 104

Preconception Counseling to Prevent the Complications of Obesity during Pregnancy

one

THIS ISS

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by the

amer Peer revie ican assOciatiO wed. listed in n Of Physician GOOGle s schOlar Pecialists, inc. Summer and b iOmed 2012 lib

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Curricu lum Predicting Factors Specialty Family Medic ine An Exp Choice: lora Rural Me tory Study Am dical Sch ong olars

Urgent Car An Overv e Centers: iew Acute Infe ctious Monon ucl for Urg eosis: A Review ent Car e Physici ans

Review of ECG Fin Important dings in Patients with Syn cope Wellen s’ A Case Syndrome: Report

Medical Ethics Without the Rhe tor

ic

Quarterly Issues

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AJCM® – dedicated to improving the practice of clinical medicine by providing up-to-date information for today’s practitioners.

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• Interested physicians may submit manuscripts to editor@aapsus.org (See Manuscript Criteria and Information on pages 148-149).

The American Journal of Clinical Medicine® (AJCM®) is the official, peer-reviewed journal of the American Association of Physician Specialists, Inc. (AAPS), an organization dedicated to promoting the highest intellectual, moral, and ethical standards of its members. Its diversity incorporates physicians that represent a broad spectrum of specialties including anesthesiology, dermatology, diagnostic radiology, disaster medicine, emergency medicine, family medicine/OB, family practice, geriatric medicine, hospital medicine, internal medicine, obstetrics and gynecology, ophthalmology, orthopedic surgery, plastic and reconstructive surgery, psychiatry, radiation oncology, general surgery, and urgent care medicine.

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To further the goals of AAPS, which include providing education for its members and promoting the study, research, and improvement of its various specialties, the AJCM® invites submissions of high-quality review articles, clinical reports, case reports, or original research on any topic which has potential to impact the daily practice of medicine. Publication in the AJCM® is one of the criteria to qualify for the prestigious Degree of Fellow within the Academies of Medicine of the AAPS.


AJCM

®

144

Soft Tissue and Skin Infections in IVDA: Treatment, Complications, and Use of Imaging Nancy Lutwak, MD

147

In This Issue Johns Hopkins and the Feminist Legacy: How a Group of Baltimore Women Shaped American Graduate Medical Education

Medical Information: Females Bear the Burden and Are Not Prepared

149

151 134

Brian W. Harris, MD, PhD, FAAR Nicole F. De Simone, DO, MPH Jaime F. Slotkin, DO

Acute Diverticulitis: A Small Retrospective Study Leaving Many Questions Unanswered Nancy Lutwak, MD Curt Dill, MD

Breast Cancer in the New Age – IMRT Gary Shultz, DO, FAAR

128

Charles P. Davis, MD, PhD

The Art of Medicine: Can You Recognize Aunt Minnie?

Wudeneh Mulugeta, MD, MPH Lynn M. Steinbrenner, MD Deborah L. Farolino, MD

118

Leslie Mukau, MD, FAAEP, FACEP

Chylous Ascites from Transitional Cell Carcinoma of the Bladder

A Case Report and Discussion of Hibernomas: Pathology, Genetics, Diagnosis, and Treatment Jessica W. Grayson Joseph C. Wallace, MD

154

Physicians’ Responsibility with Prescription Drug Abuse Bradley T. Wajda, DO

138 158

Medical Ethics Without the Rhetoric Mark Pastin, PhD


American Association of Physician Specialists, Inc.® 5550 West Executive Drive Suite 400 Tampa, Florida 33609-1035 Phone: 813-433-2277 Fax: 813-830-6599 www.aapsus.org

AAPS Board of Directors William G. Anderson, DO Scott G. Barnes, DO Terrance Lee Baker, MD, MS A. Robert Cerrato, DO, JD Michael A. Cohen, DO Joseph M. Damiani, MD, FAAPRS Brian J. Feaver, MD, FAASFP Kenneth M. Flowe, MD, FAAEP Joseph C. Gallagher, DO, FAASOS William J. Garrity, DO, FAASFP Surinder K. Kad, MD, FAAIM, MPH, MBA Jerry R. Majers, DO, FAAIM, FAAGM Douglas L. Marciniak, D.O, FAAIM Stephen A. Montes, DO, FAASOS Thomas G. Pelz, DO, FAAIM Asaf R. Qadeer, MD Anthony P. Russo, Jr., DO Susan M. Sarracino, MD Craig S. Smith, MD Louis W. Sullivan, MD Martin E. Thornton, DO

AAPS Staff William J. Carbone Chief Executive Officer Nadine B. Simone Executive Assistant Andrea N. Balboa Assistant Director of Certification Christina Stebbins Manager of Test Development Susan LoBianco Certification Coordinator Marilyn D. Whitfield Certification Coordinator Esther L. Berg Director of CME, Meetings & Membership Keely M. Clarke CME, Meetings & Membership Coordinator Anthony J. Durante Director of Finance & Operations Debi S. Colmorgen Communications Coordinator Lauren E. Withrow Governmental Affairs Coordinator James G. Marzano Director of Public Relations & Marketing Jeffery L. Morris, Jr., JD Director of Communications & External Affairs

W

elcome to the American Journal of Clinical Medicine® (AJCM®). The Journal is dedicated to improving the practice of clinical medicine by providing up-to-date information for today’s practitioners. The AJCM is the official journal of the American Association of Physician Specialists, Inc. (AAPS), an organization dedicated to promoting the highest intellectual, moral, and ethical standards of its members, and whose diversity incorporates physicians that represent a broad spectrum of specialties including anesthesiology, dermatology, diagnostic radiology, disaster medicine, emergency medicine, family medicine obstetrics, family practice, geriatric medicine, hospital medicine, internal medicine, obstetrics and gynecology, ophthalmology, orthopedic surgery, plastic and reconstructive surgery, psychiatry, radiation oncology, general surgery, and urgent care medicine. Part of the mission of the AAPS is to provide education for its members and to promote study, research, and improvement of its various specialties. In order to further these goals, the AJCM invites submissions of high-quality review articles, clinical reports, case reports, or original research on any topic that has potential to impact the daily practice of medicine. Publication of a peer-reviewed article in the AJCM is one of the criteria needed to qualify for the prestigious Degree of Fellow in the Academies of Medicine of the AAPS. Articles that appear in the AJCM are peer reviewed by members with expertise in their respective specialties. Manuscripts submitted for publication should follow the guidelines in The International Committee of Medical Journal Editors: “Uniform requirements for manuscripts submitted to biomedical journals” (JAMA, 1997; 277:927-934). Studies involving human subjects must adhere to the ethical principals of the Declaration of Helsinki, developed by the World Medical Association. By AJCM policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of their article that might create any potential conflict of interest. More detailed information is included in the AJCM Manuscript Criteria and Information on pages 106 and 107. All articles published, including editorials, letters, and book reviews, represent the opinions of the authors and do not reflect the official policy of the American Association of Physician Specialists, Inc., or the institution with which the author is affiliated, unless this is clearly specified. ©2013 American Journal of Clinical Medicine® is published by the American Association of Physician Specialists, Inc. All rights reserved. Reproduction without permission is prohibited. Although all advertising material is expected to conform to ethical standards, acceptance does not imply endorsement by the American Journal of Clinical Medicine® and the American Association of Physician Specialists, Inc.

Editor-In-Chief

Wm. MacMillan Rodney, MD, FAAFP, FACEP

Senior Editor

Kenneth M. Flowe, MD, FAAEP

Managing Editor

Esther L. Berg, MEd

Editorial Board

Harold M. Bacchus, Jr., MD, FAAFP Gilbert Daniel, MD, FAAR Michael K. Garey, MD Surinder K. Kad, MD, FAAIM, MPH, MBA Leslie Mukau, MD, FAAEP, FACEP Thomas G. Pelz, DO, FAAIM

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AJCM is peer reviewed and listed in Google Scholar and BioMedLib


AJCM

®

Welcome to the American Journal of Clinical Medicine® (AJCM®)-

Since 1975, my goals have been to provide exemplary continuing health care for my patients and outstanding educational experiences for my students, residents, and colleagues. It is an honor to serve as editor of the American Journal of Clinical Medicine® (AJCM). As an author and/or editor for over 200 publications from 1977 to the present, my compliments to previous editors, authors, and staff for establishing and maintaining the ACJM. Thank you. Authors who produce quality manuscripts must be solicited, encouraged, nurtured, and published. Writing is a labor of love. The only thing more difficult than writing is rewriting. Welcome to the world of publication. All will benefit through the prosperity of the AJCM enterprise. In 2009, I proposed a circular hierarchy of seven activities. These activities are: patient care, education, scholarship, administration, ambassadorship, leadership, and legacy. The AJCM is now being cited as part of the international community of scholars. Our 2009-2012 editions are listed by Google Scholar and BioMedLib. These internet search engines are more extensive than PubMed. This gives published authors international recognition as achieving a universal academic standard of excellence. With this membership, AJCM joins the major leagues of science; published work will last as long as our civilization does AJCM was cited by the AAFP in 2012. WE must fund our efforts and make the transition to multimedia via the internet and explore a global outreach. Spanish translation should be explored, and, if reasonable, posted. In 2013, the journal will initiate electronic publishing. This will strengthen AAPS and ABPS recognition. The American Board of Physician Specialties (ABPS) was listed as one of the major certifying organizations for increased reimbursement in the Affordable Care Act final regulations for 2013. WE maintain an impeccable reputation for quality and integrity. WE should be part of a national campaign supporting recognition of the AJCM as a medical journal offering useful information for the practicing physician. There so many worthy causes, but the AJCM should be a journal which emphasizes the issues that make the AAPS important for physicians who have been challenged by training cartels and economic credentialing monopolies. Our research should demonstrate the role of privilege based on MERIT. The AAPS and the AJCM will develop a nationally recognized leadership position through recognition of its authors and their published research. In keeping with the 2011 link between the AAPS and the National Rural Health Association, the AJCM 2013 will focus its efforts on building ABPS – the logical solution for rural communities and Frontier Hospitals. These include mission hospitals. Two special groups in ABPS merit mention – BCEM and BC FMOB. In 1995, fellowship faculty recognized that the AAPS was the only organization with the vision for this innovation. Without grants or charity, these physicians fund teaching programs and clinical research encompassing almost all of the established specialties. AAPS, ABPS, and AJCM will strive for leadership in providing physicians for these underserved communities and developing countries.

To do in 2013: Continue application for membership in PubMed Propose Standing Features as a strategy for author recruitment Link some topics to the National Rural Health Association Feature materials at exhibits nationally and internationally – next July 26,2013, Kansas City, Mo.  Point-of-Care Ultrasonography Ecografia/Obstetricia/Trauma/Cirugia  Dermatology Quiz  iPad/iPhone Tips and Tricks    

 Mission/Rural Medicine a. Fractures to Manage b. Chest Radiograph Interpretation c. ECG Interpretation d. Competency Drills in Fetal Monitoring e. Office Surgery f. Anesthesia  Patient Centered Medical Home Spanish--Centro Diagnostico

“Medicos – where 10 percent of the information makes over 90 percent of the difference and where, through Grace, twice the service is provided at less than half of the cost.”

Wm. MacMillan Rodney MD, FAAFP, FACEP Editor, American Journal of Clinical Medicine® Member, American Board of Family Medicine Obstetrics


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American Journal of Clinical Medicine® • Fall 2012 • Volume Nine Number Three

Johns Hopkins and the Feminist Legacy: How a Group of Baltimore Women Shaped American Graduate Medical Education Leslie Mukau, MD, FAAEP, FACEP

Based on a Presentation at the 2012 AAPS Annual Scientific Meeting

The Johns Hopkins Hospital and School of Medicine are without a doubt one of the world’s greatest and premier medical establishments1 and historically the founding institutions of modern American medicine.2,3,4 Johns Hopkins is considered to be the first modern American research university; the birthplace of medical specialties such as neurosurgery, urology, pediatrics, endocrinology, cardiac surgery, and child psychiatry.4,5,6,7 Common medical traditions including wearing gloves during surgical procedures, “making rounds,” “bedside teaching,” “house staff,” “residents,” and “closed chest cardiac resuscitation” were all born at Hopkins. In a surprising twist of fate Johns Hopkins became ground zero and, initially, an unwilling partner in the late nineteenth century feminist battle for women’s equality. Perhaps the two most important Hopkins contributions to American medical education were the educational format and coeducation. Admission requirements for the first time included prerequisite college education, heavy on basic science; chemistry, physics, biology – and a tough entrance examination. The medical school curriculum itself underwent a complete transformation with emphasis on the scientific method with laboratory research as part of the instruction. The integration of the School of Medicine with the Hospital through joint appointments of the professors, who were first-rate full-time clinician-scientists, incorporated bedside teaching for the medical students. Satisfactory completion for graduation included four years of rigorous study, bedside learning, and extensive

laboratory training with mandatory student original research projects. The new model also created standardized advanced training in specialized fields of medicine with the creation of the first post-graduate internships and house staff fellowships. While most of the above developments were methodical and well planned, coeducation and admission requirements were not part of the original plan and came about as a result of a tenacious fight by a group of determined young late nineteenth century Baltimore feminists who were able to seize an opportune moment and confront powerful male hegemony and intransigence with “coercive philanthropy.”8,9 Recent preliminary data just released by the U.S. Department of Education on enrollments in all Title IV institutions in the United States for the 2010-11 academic year show that there were 29.5 million students enrolled at these Title IV institutions. Of these, nearly 17 million, or 57.5%, were women.10 Further analysis of the data also shows an interesting phenomenon – the “feminization” of higher education; among all major ethnic groups women are now more likely to enroll in, and graduate from, college than young men (Figure 1). Additionally, women comprised 60.2% of all students enrolled in graduate programs.10 In the United States for 2011women made up 47% of all new students at U.S. medical schools. In five of these U.S. medical schools, the University of California at San Francisco, the University of Missouri at Kansas City, the UMDNJ-Robert Wood Johnson Medical School, and Meharry Medical College

Johns Hopkins and the Feminist Legacy . . .


American Journal of Clinical Medicine® • Fall 2012 • Volume Nine Number Three

in Nashville, female students were more than 55% of the entering classes. At the Morehouse School of Medicine in Atlanta, 73.2% of the new students were women.11 Figure 1: The Feminization of AMerican Higher Education.

issued diplomas until finally sued by the Oklahoma territory Attorney General. In both Europe and the Americas the actual training for medicine was by apprenticeship. A student was indentured to a practitioner for an unspecified time of servitude. During this period the student “ . . . learnt to draw teeth, to cup, bleed and dress minor wounds, but he might also have to look after his preceptor’s horse and bring it around saddled and ready as necessary. He learnt his material medica in detail as his master’s drugs were obtained in crude form, and he had to pulverize bark and roots, make and spread plasters, and make up tinctures, ointments, extracts, blue mass, etc.13

Storming the Citadel: Gender Bias in Medicine – A Historical Perspective Source: Population Research Bureau analysis of data from U.S. Census Bureau.

Early American Medical Education In Colonial America, during the 1600s and 1700s, any enterprising person could practice medicine, since there were almost no medical schools. An aspiring healer generally did so by apprenticing to an already established physician. Those who had the means traveled to England or Europe to train with a famous physician at a school or hospital. Some entered the medical profession informally by establishing a reputation as a “physician” by nursing a sick acquaintance or selling curatives.12 In the mid-1700s, Americans began establishing their own medical schools. By 1810, there were seven medical schools: University of Pennsylvania (1765); King’s College, now Columbia (1767); Harvard (1782); Dartmouth (1797); College of Physicians and Surgeons of New York City (1807); University of Maryland (1807), and the short-lived Brown University program (1811). The total number of medical students in attendance was approximately 650, 406 of whom were at the University of Pennsylvania. Initially, these schools only offered a Bachelor of Medicine but soon began awarding a Doctor of Medicine degree. Medical education in that era included formal lectures for a semester or two and several years of apprenticeship. A degree was typically awarded after only two years of study, laboratory work, and dissection were not necessarily required. Many local doctors were the “instructors,” although their own training had left something to be desired. There was no formal tuition, no prerequisite academic preparation, and written exams were not mandatory. The regulation of the medical profession by state government was minimal or nonexistent. There were thousands of “proprietary” medical schools, actually commercial-for-profit operations that provided a minimum of easy, nonacademic courses for money. A “diploma mill,” called Twentieth Century Physio-Medical College, operated in Guthrie OK in 1900-1904, held no classes, but

These opportunities were primarily available only to men. At the outset of the 19th century, women were disenfranchised; they could not vote or hold office in any state, they had limited to no access to higher education, and were, therefore, excluded from professional occupations. Gradually social and economic changes, such as the development of a market economy and a decline in the birthrate, opened employment opportunities for women. Instead of bearing children at two-year intervals after marriage, as was the general custom throughout the colonial era, during the early 19th century reproduction was delayed and children became more spaced. However, at that time the American legal precept was that a wife had no legal identity separate from her husband. A woman, at that time, could not own nor enter into any contract. She could not be sued, nor could she bring a legal suit. If she happened to be employed and married, she was not permitted to control her own wages or obtain custody of her children in the event of separation or divorce. Merit Ptah (c. 2700 BCE) of early ancient Egypt, and whose picture is depicted on a tomb in the necropolis near the step pyramid of Saqqara, is believed to be the first woman known by name, as the first female physician.14 The high priest of the time, who happened to be her son, described Merit Ptah as “the Chief Physician.” According to Gaius Julius Hyginus (c. 64 BC – AD 17), a Roman author, Agnodice or Agnodike (Gr. ′Aγνοδίκη) was the earliest Greek female midwife, who dressed as a man in order to study with the famed ancient Greek doctor Herophilus. Agnodice reportedly continued the disguise so she could practice gynecology. Initially, women refused her service until she told them that she was a woman. After that her practice flourished, but fellow practitioners accused her of professional misconduct with her female patients. So as to escape execution, she was forced to reveal her deception but was charged with illegally practicing medicine, since women were not allowed to practice medicine. At the intervention of her satisfied patients the court in Athens acquitted Agnodice. However, the Agnodice story may be mythological, since Hyginus has no corroboration to this story. In the nineteenth century it was a common perception in the society at large that women were too “frivolous and delicate to

Johns Hopkins and the Feminist Legacy . . .

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handle full-strength medical education, with its gory emphasis on human anatomy and disease.” Much of this sentiment, however, was due to pure misogyny and pure discrimination against women. Even the American Medical Association, founded in 1846, barred women from membership until 1915. A few women had surreptitiously and by sheer determination shown that they could compete. The intriguing case of Dr. James Barry (1797-1865), a medical officer in the British army, is illustrative of the former. Having graduated from the prestigious University of Edinburgh Barry worked at St Thomas Hospital, London, before joining the Army. As a military doctor he served in India and Cape Town, South Africa, where he performed the first successful caesarian section in 1826. After a tour of his military duties, during which he distinguished himself as a reformer by improving conditions for wounded soldiers, as well as that of the native inhabitants, he rose to the rank of Inspector General in charge of military hospitals.15 Although having lived his adult life as a man, Barry is now widely believed to have been female-assigned at birth as Margaret Ann Bulkley.16 It is speculated that he chose to live as a man in order to be accepted as a university student and become a physician.17 Perhaps because of an aggressive manner, skill as a surgeon, and a reputation as an accurate marksman the beardless, squeaky voiced rather effeminate looking Barry evidently was successful with this deception. Some have theorized that Barry may have been intersex.16 Elizabeth Blackwell’s (1821-1910) saga is one of sheer determination in the face of insurmountable odds, hostility, and downright gender discrimination. She was the first woman to receive a medical degree in the United States in 1849 and was also the first woman on the British Medical Register, primarily with the help of her mentor, Dr. James Paget at St. Bartholomew’s Hospital. It should be noted that before 1847, however, any women seeking medical training could go abroad to Europe where, at the University of Zurich and the University of Berlin, they could study the medical curriculum, although they were not granted a degree. Blackwell had applied to and was summarily rejected by 29 medical schools before being accepted in 1847 by a small school in upstate New York, The Geneva College of Medicine. Rather than reject her outright, since she was well qualified, the dean of the medical school, Dr Charles Lee, presented the application directly to his male students. Perhaps the real reason Lee was avoiding personal responsibility was fear of offending Miss Blackwell’s sponsor and mentor, Joseph Warrington, a well-respected and prominent physician in Philadelphia.18 Lee brought the matter of Blackwell’s admission before the student body. Should a woman be allowed to enroll in the medical school? Having stipulated a unanimous decision as a condition for admitting Blackwell, Lee was confident of a negative verdict. However, the students, thinking it a great practical joke, voted unanimously to admit her! According to an eye witness,19 there had been one lone dissent who soon had his mind changed for him!

“A meeting was . . . called for the evening and a more uproarious scene can scarcely be imagined. Fulsome speeches were made . . . the whole class voted ‘aye’ . . . a faint nay was heard in the corner of the room . . . and screams of ‘cuff him,’ ‘crack his skull.’ A young man was dragged to the platform screaming, ‘Aye, aye, I vote aye’.” A classmate, Stephen Smith, wrote years later about Blackwell’s first day19: “The Dean came into the classroom, evidently in a state of unusual agitation. The class took alarm, fearing that some great calamity was about to befall the College. . . . He stated, with a trembling voice, that . . . the female student . . . had arrived. With this introduction he opened the door to the reception room and a lady … entered, whom the Dean formally introduced as Miss Blackwell. She was plainly but neatly dressed in Quaker style, and carried the usual notebook of the medical student. A hush fell upon the class as if each member had been stricken with paralysis. A death-like stillness prevailed during the lecture, and only the newly arrived student took notes. She retired with the professor, and thereafter, came in with him and sat on the platform during the lecture.” She graduated two years later, January 23, 1849, at the head of her class. Upon her graduation multiple newspaper editorials had a field day commenting with the usual flippant slogans such as “the delicacy and shrinking sensibility that is the peculiar attribute of women” and that the “retirement and quietude of the family circle” are “more agreeable to the female disposition”.20 The New London Daily Chronicle (New London, Connecticut) on Feb. 1, 1849, noted “Miss Elizabeth Blackwell a few days since received the degree of M. D. from the medical college of Geneva, N.Y., and intends to enter upon the practice of the profession. She will probably be most successful in “diseases of the heart,” and if she is particularly pretty, it is to be feared, create quite as many cases as she prescribes for.” Immediately following Blackwell’s graduation, a spirited debate about women physicians arose in the Boston Medical and Surgical Journal (now the New England Journal of Medicine, which later would become the voice of opposition to the education of female physicians. There was quite a vigorous exchange between the pseudonymous “D.K.” who wrote a particularly venomous letter to the editor concerning Elizabeth Blackwell’s medical degree. Charles Lee, the dean of Geneva College, replied on the defensive.21 Surprisingly, Lee concluded that the inconveniences attending the admission of females to all the lectures in a medical school were so great that he felt compelled on all future occasions to oppose such a practice! A vanguard of other notable pioneer women soon followed despite these concerted efforts of protests from within the medical community and society at large. Chief among them were Elizabeth’s younger sister, Emily Blackwell, as well as Maria Zakrzewska, Mary Putnam Jacobi, and Ann Preston. The Women’s Medical College of Pennsylvania opened in 1850, the first of several institutions devoted primarily to the medical education of women. Even then, the Philadelphia County Medical Society denied membership admission to its graduates

Johns Hopkins and the Feminist Legacy . . .


American Journal of Clinical Medicine® • Fall 2012 • Volume Nine Number Three

and forbade the society’s members to meet with these female doctors or their school’s faculty until 1888, when the Society voted in Mary Willits, a graduate of 1881. In 1857, the Blackwell sisters, along with Zakrzewska, founded the New York Infirmary for Women and Children. By the end of the 19th century, 19 women’s medical colleges and nine women’s hospitals had been established. The struggle for coeducation, however, was initially successful only in a minority of institutions, hampered in large part by the theories of Harvard professor Edward H. Clarke22 who proclaimed that women seeking advanced education would develop “ . . . monstrous brains and puny bodies; abnormally active cerebration; and abnormally weak digestion; flowing thought and constipated bowels . . .” (page 41 of his popular book, Sex in education: or A fair chance for the girls (1873).

Johns Hopkins and the Baltimore and Ohio Railroad On December 24, 1873, a wealthy and influential Baltimore Quaker businessman named Johns Hopkins died unmarried and with no children of his own. Johns Hopkins’s unusual name was an amalgamation of his grandmother’s name, Margaret Johns, and his grandfather’s name, Gerard Hopkins.23 Johns Hopkins had been a shrewd and successful investor during the so-called gilded age at a time of no federal taxation. He seemed to have done very well indeed. Mr. Hopkins, the second eldest of eleven children of Samuel Hopkins and Hannah Janey, was born at Whitehall, his family’s slave-owning, 500-acre tobacco plantation in Anne Arundel County, Maryland, on land granted by the King of England to William Hopkins in the seventeenth century. In 1807, in accordance with their local Society of Friends decree which had begun to preach that human slavery was inconsistent with their faith, Samuel Hopkins, freed all his slaves. This development necessitated 12 year-old Johns to interrupt his formal education so as to work on the farm. However this lesson on racial tolerance and sympathy was well learned and would surface at various times of his life up to and including his bequests. Starting work at age 17 in his uncle’s wholesale grocery business in Baltimore, he soon branched off on his own. Taking three of his brothers as salesmen, he formed the wholesale house of Hopkins Brothers and was soon doing a profitable mercantile business in Maryland, Virginia, and North Carolina. By age 50 he retired from Hopkins Brothers, after 25 years, a very wealthy man. He then started using this wealth to finance very lucrative ventures. Johns Hopkins took to rehabilitating the Baltimore harbor area, which had outgrown its dingy facilities. He bought up old lots and replaced them with updated warehouses and office buildings. This urban renewal not only expanded the resources of the port but brought Mr. Hopkins substantial returns on his investment. His greatest venture, however, would be the Baltimore and Ohio Railroad (B&O). He was quick to see

the potential of the railroad, especially, since during his trader days, his merchandise had to be dragged in great Conestoga wagons over the mountains into the Shenandoah Valley and beyond. Moreover, in the 1820s the port of Baltimore was in danger of losing its preeminent trade position for the right of transit of goods to the West. The port of Baltimore was in fierce competition with New York and Philadelphia for trade with the Midwest. A new threat was coming from the newly opened Erie Canal and the proposed construction of the Chesapeake and Ohio Canal that would parallel the Potomac River from Washington, DC, to Cumberland, MD. These new water routes potentially threatened to bypass Baltimore’s thriving harbor.24 It quickly became apparent that a railroad would be a great asset in this competition, and Baltimore authorized construction of America’s first major railroad, the B&O, to connect the city with the Ohio River valley. While conservative investors refused to sponsor an untried futuristic venture like the B&O, Johns Hopkins gladly jumped in with his fortune. By quickly amassing and controlling between 15,000 and 17,000 shares he soon became the company’s largest stockholder. In 1847 he was made a director and by 1855 chairman of the company’s powerful finance committee, a position he held until his death. During the financial panics of 1857 and 1873, he floated the entire company by pledging his own personal fortune to the company, thereby rescuing his original investment while also averting financial disaster for the city. These actions also put Mr. Hopkins in a better position to influence the nomination of his best friend, John Work Garrett, as president of the B&O. The city of Baltimore and the state of Maryland provided much of the original capital of the Baltimore and Ohio railroad before it went public. Therefore, of the 30 railroad directors, eight were appointed by the Baltimore City Council, and 10 named by the state of Maryland, while 12 were elected by private stockholders. As to be expected, conflicting interests arose. Private investors preferred profits and dividend payments on their initial investments, while the public stockholders favored low transportation charges over profits and wanted improvements financed out of earnings. Specifically, the private investors led by Johns Hopkins wanted a 30% dividend in lieu of new construction. In 1858, Hopkins nominated John Work Garrett, a friend of his and another up-and-coming Baltimore financial titan, for the presidency of the railroad. In a hard-fought battle, Garrett was elected by a narrow margin but was able to hold the position until his death in 1884. The Civil War broke out during Mr. Garrett’s tenure as president of the B&O. Baltimore was on the Mason Dixon line with many of its citizens, including the rest of the Garrett family, sympathizing with the southern cause. However, John Work Garrett bucked this trend for economic reasons and cast his allegiance with Abraham Lincoln and the Union. As for Johns Hopkins he was a true abolitionist and progressive and way ahead of his time in matters of race and egalitarianism. As the nation’s first railroad, the B&O assumed a crucial if not decisive role in preserving the Union. It became a strategic link be-

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tween Washington, D.C., and the rest of the Union and allowed Union military elements to be positioned quickly into Virginia and the Confederate territory to the west. The B&O also facilitated transportation of equipment, supplies, and evacuation of the wounded. In fact during the War the B&O was known as “Mr. Lincoln’s Road.”8 After the war Garrett secured the most profitable contracts, restored the credit of the B&O, and extended the road until it became one of the largest and most prominent lines in the country. He made lots of money for himself and Mr. Hopkins.

A Paradigm Shift in American Medicine: Johns Hopkins’s Will and Letter to the Trustees It has been suggested that up to about 1866 or thereabout, six or so years before his death, Johns Hopkins had not yet drafted a will.8,25 That year his friend Garrett arranged a dinner meeting at the Garret mansion between Hopkins and George W. Peabody, a like-minded wealthy patron now residing in London but on a visit to Baltimore. It is widely assumed that on that fateful night Peabody prevailed upon Hopkins, who soon drafted a will and appointed two Boards of Trustees, consisting of his friends, his lawyers, and business associates. At the time of his death Mr. Hopkins’s estate was estimated at just over $8 million. Except for about $1 million left to his relatives, the bulk of his estate was left as a philanthropic bequest with specific apportionments and instructions, in fact so specific that this would cause a dilemma later on. At $7 million ($126 million in 2010 dollars), this bequest at that time was the largest endowment of any college in the United States. In the extensive obituary article on Johns Hopkins25 the Baltimore Sun pointed out that, at the time the endowment of Harvard University was less than two and a half million dollars; Princeton College, New Jersey, had received donations amounting to $470,000; and Cornell University in New York, $487,000. In the year that Hopkins died Commodore Cornelius Vanderbilt had been strong armed in his 79th year to make the gift that founded Vanderbilt University early in 1873. The $1 million that he gave to endow and build the university would be the Commodore’s only major philanthropy! By way of comparison Cornelius Vanderbilt, at the time of his death at age 82 in 1877, left a fortune that was estimated at over $100 million at the time. He left it all to his heirs. The Johns Hopkins bequest spelled out the formation of: 1. The Johns Hopkins Colored Children Orphan Asylum in 1875; 2. The Johns Hopkins University in 1876; 3. The Johns Hopkins Press, the longest continuously operating academic press in America, in 1878; 4. The Johns Hopkins Hospital and the Johns Hopkins School of Nursing in 1889; 5. The Johns Hopkins University School of Medicine in 1893.

The hospital and orphan asylum would each be overseen by the 12-member hospital board of trustees and the university by the 12-member university board of trustees. Many board members were represented on both boards. Johns Hopkins’s explicit views are formally spelled out in four documents: i.

The incorporation papers filed in 1867,

ii. His instruction letter to the hospital trustees dated March 12, 1873,26 iii. His will, which was quoted from extensively in his Baltimore Sun obituary,25 iv. And in his wills two codicils, one dated 1870 and the other dated 1873. Here are some interesting and revolutionary ideas that stand out in his letter addressed to the Hospital Trustees. “I have given you, in your capacity of Trustees, thirteen acres of land, situated in the city of Baltimore, and bounded by Wolfe, Monument, Broadway and Jefferson streets, upon which I desire you to erect a Hospital.-----which shall, in construction and arrangement, compare favorably with any other institution of like character in this country or in Europe. [The Hospital would admit] the indigent sick of this city and its environs, without regard to sex, age, or color, who may require surgical or medical treatment. ---------provide for the reception of a limited number of patients who are able to make compensation for the room and attention they may require. The money received from such persons will enable you to appropriate a larger sum for the relief of the sufferings of that class which I direct you to admit free of charge; ------It will be your special duty to secure for the service of the Hospital surgeons and physicians of the highest character and greatest skill. I desire you to establish in connection with the Hospital a training school for female nurses--- competent to care for the sick in the Hospital wards, and will enable you to benefit the whole community by supplying it with a class of trained and experienced nurses.------ It is my especial request that the influence of religion should be felt in and impressed upon the whole management of the Hospital; but I desire, nevertheless, that the administration of the charity shall be undisturbed by sectarian influence, discipline or control.26 It is still quite a puzzle as to how Johns Hopkins came up with such innovative ideas that were way ahead of his time. The intentional integration of the School of Medicine and the School of Nursing with the Hospital and emphasis on the scientific method was quite revolutionary. This was a deliberate nod to the German universities, where the scientific method and laboratory experiments were the basis of medical science. The Hopkins model would even outdo the German approach. During the American Reconstruction, when racism was rampant, Hopkins makes provisions for quality health services for the underserved, the poor, and the racial minorities without regard to their age, sex, and color. Curiously, he devised a plan for those with means to subsidize the care of the less fortunate, a notion the United States, the wealthiest nation in history is still grappling with more than a hundred years since Hopkins

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died. It is noteworthy that when the Hospital opened, the general wards were not segregated according to race but the faculty and staff soon protested, and this practice was quickly abandoned in rigidly segregated Baltimore. Such changes would not be revisited until 1964. Harvey Cushing, one of the first residents at Hopkins and an early surgical luminary, who would become a major force in American medicine, was opposed to the hiring of black nurses in municipal hospitals, and restricting the entry of blacks, Jews, and Italians into American medical schools.27 Decades later cardiac surgery would be born at Hopkins following the success of the Blalock-Taussig shunt (subclavian/pulmonary anastomosis for tetralogy of Fallot). Vivian Thomas, the black laboratory technician, who worked in Alfred Blalock’s experimental laboratory and who actually developed the animal model and devised and perfected the surgical technique remained unacknowledged for a long time, both by Blalock and by Hopkins.28 While Hopkins’s Quaker faith might have helped inform his egalitarian and philanthropic tendencies, it is remarkable that he yearned for an institution unencumbered by sectarian influence. However, such a progressive philosophy smacked of heresy in 19th century parochial Baltimore. Even when the University was dedicated in 1876, many hounded Daniel Gilman, the University’s first president, for what they considered a blasphemous oversight – conducting a dedication ceremony bereft of a benediction. Gilman may have attempted to quell this controversy by allowing “Christus Consolator” (Christ the Consoler), a 10½ foot Carrara marble Christ statue, an exact copy of one that Danish sculptor Bertel Thorwaldsen executed for Copenhagen’s Frue Kirke in 1821, to be erected under the octagonal historic dome of the new Hospital entrance. With its inscription from Matthew 11:28 -- “COME unto ME All Ye That Are Weary And Heavy Laden And I Will Give You REST”, the statue portrays the risen Christ, with open arms and deep nail marks in the hands and feet, and many regard it as a source of comfort and hope for afflicted patients and families.

The Four Founding Physicians The Hopkins revolution in medical education was spearheaded by an unusual and fortuitous combination of four impressive young physicians: William H. Welch, William Osler, William S. Halsted, and Howard Kelly – the so-called Big Four. They were recruited by offering them hitherto unprecedented research opportunities and a guaranteed full-time salary, a radical departure from the tradition of using part-time local practitioners to instruct medical students. All four of these doctors were idiosyncratic larger-than-life personalities who all had profound and long-lasting seismic influence on American medical education and research. Pathologist William Henry Welch was an inveterate bachelor whose favorite pastimes were swimming and carnival rides and who had a voracious appetite for five-dessert dinners; surgeon William Stewart Halsted, a rather shy taciturn reclusive and closet drug addict who could be very remote with students and had his laundry done in Paris, France; internist William Osler, quick witted renaissance man who always de-

lighted in practical pranks at the expense of his colleagues and patients; and gynecologist Howard Kelly, remarkable family man, fast and innovative with a scalpel, snake collector, and evangelical zealot intent on emptying Baltimore brothels and saving both body and soul. The individual accomplishments of each of these physicians to their individual disciplines in particular and medicine in general are numerous and well catalogued elsewhere.4,5,6,7,29 The opening of The Johns Hopkins Hospital was delayed for thirteen years after the opening of the University in 1876. This delay enabled William H. Welch, the new dean and first professor at the School of Medicine, time to recruit the other three professors and to get his pathology program up and running before the hospital wards and medical school opened. Likewise, the School of Medicine opened four years after the Hospital, and this unanticipated lag allowed the innovative residency system time to be properly rooted before the first medical students marched in. Yet another bonus of this delay was that William Osler was afforded ample time to write his classic textbook, The Principles and Practice of Medicine. These delays were caused by the slow progress of the physical plant construction. This in turn was due to the fact that Johns Hopkins had categorically specified in his will that the $2 million project would be funded solely by interest from half of the $7 million endowment. Simply put the trustees were prohibited from dipping into the principal. As a result the diligent trustees let construction proceed only as far as the interest from the preceding year would let them go. Construction was also hampered by the unexpected discovery of quicksand and an underground stream running through the property, complicating laying down stable foundations in a timely manner. At the completion of the Hospital buildings only half of the original trustees were still alive.

The Friday Evening Group Mary Elizabeth Garrett was born in Baltimore on March, 5, 1854. She was the youngest child and only daughter of John Work Garrett, president of the Baltimore & Ohio Railroad, friend, as well as trustee to Johns Hopkins’s endowment. She was brought up in an opulent mansion on Mount Vernon Place in Baltimore. By many accounts, Mary Elizabeth Garrett was the favored child. Her father often said, “I wish Mary had been born a boy!” While still a teenager, the father began including her in his travels and business meetings in the United States and abroad. Garrett greatly admired his daughter’s business sense and keen intellect but would not support her quest for a college education. In her role as “Papa’s secretary,” Mary Elizabeth Garrett met the titans of corporate America – Carnegie, Morgan, Vanderbilt, Fiske, and Gould, and, even at an early age, she learned and absorbed lessons that would guide her on how to use great wealth to advance women’s causes through effective strategy, perseverance, clarity of vision, and seizing opportunities at the right time.

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Mary Elizabeth Garrett grew up with a group of like-minded girlfriends. This group of friends included M. Carey Thomas, Mamie Gwinn, Elizabeth “Bessie” King, and Julia Rogers. Most of the women came from Quaker backgrounds. These five friends had been reared in privileged circumstances and their fathers, except that of Julia Rogers, served as trustees of the Johns Hopkins University, the Johns Hopkins Hospital, or both. In their late teens and early 20s this group of high-minded young Baltimore women started to meet regularly to discuss literature, philosophy, and social issues. They referred to themselves as the “Friday evening” group, since they met on the second Friday of each month.

kins. She was allowed private tutoring in Greek but no formal classes. Again with her father’s reluctant permission she took off for Europe, living with her close friend, Mamie Gwinn. Carey enrolled at the University of Leipzig. However, she had to transfer to the University of Zurich because the University of Leipzig would not award a Ph.D. to a woman. Moreover, in order not to “distract” male students the University of Leipzig had forced her to sit behind a screen during classes! Finally, she became both the first woman and foreigner graduating summa cum laude at Zurich. Coming back from Europe she successfully lobbied to become the dean, then president, of the of the newly created Quaker women’s college, Bryn Mawr.

The Friday Evening Group members all resolved never to get married. These somewhat “liberated” individuals felt that married women of their time were in bondage to their husbands, and this group of women preferred freedom rather than marriage. Mamie Gwinn would be the only one to break this vow, but only after she and Carey Thomas had lived in a “Boston marriage” for some 25 years. The term “Boston marriage” came to be used, apparently, after Henry James’ book, The Bostonians, (1886-87), which detailed an ambiguous marriage-like co-habiting relationship between two women. In the 19th century, this term was used for households where two women lived together in a romantic relationship, independent of any male support. It still continues to be debated whether these relationships were lesbian in the sexual sense or not.

M. Carey Thomas was an elitist and an advocate of the eugenics movement. She also had jingoistic and racist tendencies, endorsing strict immigration quotas, and subscribed to the “intellectual supremacy of the white race.” However, throughout her life she maintained an active role in women’s rights. She supported the Progressive Party in 1912 and did work for the National American Woman Suffrage Association. She continued to believe that, if possible, women ought not to get married, but if married they should continue with their careers. During her tenure at Bryn Mawr she worked hard to make the institution a center of educational excellence for women.

Mamie Gwinn married Alfred Hodder, a fellow English professor at Bryn Mawr, who had to divorce his (common-law) wife to marry Mamie. This caused a mini-scandal from which Gertrude Stein, who had flunked out of the Hopkins medical school and knew the Friday Evening Group characters, is believed to have based her early unpublished work, Fernhurst (1904). This novella fictionalizes the ménage à trois among M. Carey Thomas, then dean of Bryn Mawr College, Mamie Gwinn, and Alfred Hodder, a longtime friend of Stein’s. The presence or absence of sexual activity in the Mamie-Carey relationship, or later in the Garrett-Carey combination, may never be known, but the emotional intensity of these women and their attachment to one another is clearly evident in the multiple letters and personal correspondence among themselves.30 Martha Carey Thomas (1857–1935) was born to a Quaker family in Baltimore and educated in Quaker schools. Her father, James Carey Thomas, was a physician and one the original Johns Hopkins trustees. Her mother, Mary Whitall Thomas, and her mother’s sister, Hannah Whitall Smith, were very active in the Women’s Christian Temperance Union (WCTU). As a result M. Carey’s interest in women’s rights began early and was encouraged by her mother and aunt to the dismay of her father. The father also opposed her wish to enroll at Cornell University, one of the few coeducational colleges at that time. Again supported by her mother, she prevailed and graduated with a bachelor’s degree in 1877. She pleaded with Daniel Coit Gilman, university president, to pursue post-graduate studies at the then all-male Johns Hop-

One Wealthy Woman When John W. Garrett died in 1884, Mary Elizabeth Garrett had reason to be worried and apprehensive. While she had played an active role in her father’s business while alive, she now passively watched her brothers carve out the family business. All of sudden reality sank in. She was a woman with no college degree, no career, and no husband in a man’s world. However, the father who had discouraged her in education and never forced a suitor on her was generous to her in his will. He left his daughter a sizable fortune. She inherited one-third of his estate, acquiring $2 million and three of his lavish estates. She immediately was transformed to become one of the wealthiest women in the United States as well as one of the largest female landowners in the country. She immediately put this fortune to work. The first project of that philanthropy was the Bryn Mawr School. Shortly after assuming her inheritance, the Friday Evening Group embarked on establishing a school for the education of girls in Baltimore. It was decided to name the new school after the Philadelphia College with the anticipation that the school would steer many of its students to the college. To that end matriculation from the Bryn Mawr School consisted of passing the entrance examinations to the Bryn Mawr College. Mary Garrett personally bankrolled and oversaw the construction of the buildings, spending over a half million dollars on the school.8 She saw to the decoration of the new school with selected statuary, lithographs of well-known European paintings, and even a copy of the Parthenon frieze. She was personally involved in the selection of exercise equipment for the new gymnasium. She was responsible for all of the school’s bills. She was the president of the committee running the school while the Friday Evening Group was the defacto governing body of the new school.

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Mary Elizabeth Garrett and the Hopkins Board of Trustees: A Lesson in Coercive Philanthropy As noted above it was not the intention of Johns Hopkins University to admit women to its new medical school. Additionally, no one had addressed the admission criteria for these incoming medical students. We have also noted that the Hospital opening was delayed because of the construction finances tied to the B&O railroad stock interests. It has been the plan for the School of Medicine to open at the same time as the Hospital in 1889. This was not to be. There was no money. The railroad stock which had been paying out a decent annual dividend of 8% to 10% first lowered the dividend in the late 1880s and then stopped dividend payments completely. This loss of stock dividend decreased the University’s annual income by 75%, slashing more than $155,000 from an operating budget of $200,000. Additionally, the Trustees were anticipating a deficit of $98,000 for the coming year. These were indeed hard times and the Trustees considered disregarding the founder’s directive of keeping the stock and using the interest. However, they were warned that such a move would give control of the B&O to the Richmond and West Point Terminal Company and bring financial havoc to the city of Baltimore. In 1888 Gilman confided to the Hospital Trustees that they needed to look for an outside source to fund the medical school, since its special earmark had dwindled to $67,480.42 before anything was built. In the meantime, Harvard, McGill, and the University of Pennsylvania were trying hard to woo away the priceless four professors. Since their fathers were on the Hopkins board, the Friday Evening Group were privy to the inside information about this crisis as well as the Board’s deliberations. Mary Elizabeth Garrett realized that this financial crisis offered a unique opportunity to advance the cause of women’s education while at the same time rescuing Hopkins from its financial dilemma. The Friday Evening Group decided to launch a Women’s Medical Fund Campaign. The purpose of the campaign was to raise a sum of money sufficient to offer to the Trustees of the University in order to open the School of Medicine on condition that women are admitted to the school on the same basis as men. The Women’s Medical School Fund committee would ultimately encompass 15 chapters across the country and enlisted a number of nationally prominent women. The list of female volunteers making donations and/or joining the efforts of the committee included Caroline Harrison, wife of the sitting president, Benjamin Harrison; Jane Stanford, wife of Leland Stanford, a U.S. senator and founder of Stanford University; and Bertha Palmer, prominent in Chicago society circles and married to Potter Palmer, who had built the Palmer House Hotel; Louisa Adams, wife of President John Quincy Adams; Julia Ward Howe, the abolitionist who wrote “The Battle Hymn of the Republic;” Alice Longfellow, daughter of poet Henry Wadsworth Longfellow; and Sarah Orne Jewett, who featured strong and

independent women in her novels. Among the recruited female physicians was Emily Blackwell, who, with her sister Elizabeth Blackwell and Marie Zakrzewska, had opened in New York the first American hospital for and staffed by women and Mary Putnam Jacobi, organizer of the Association for the Advancement of Medical Education for Women. They also put their trustee fathers to work. Charles J. M. Gwinn, Mamie Gwinn’s father, a lawyer with strong sympathies for women’s issues, became a liaison between the Women’s Medical Fund Committee and the Board of Trustees. He would in fact end up drafting the stipulations of the gift and would provide legal counsel to Mary Garrett in her final negotiations with the trustees. Initially, M. Carey Thomas took the lead in negotiating with President Gilman and the Hopkins trustees. However, things did not go well. In her own words she felt that “many of the trustees, and Gilman above all, seemed to prefer not to open the school at all if it meant that women were to be admitted.” Nevertheless by October 1890, within six months of its inauguration, the committee had raised $111,300, which included a donation of $47,787.50 from Mary Elizabeth. On Oct. 28, 1890, the trustees formally accepted both the money and the stipulation about admitting women on an equal basis with men. The trustees accepted but threw down another gauntlet. Prices had gone up, and the medical school could not open until it had $500,000. Miss Garrett again stepped in with an offer the University could not refuse. She offered an additional $100,000 with other conditions. To get the money, the trustees themselves would need to raise the balance to meet the $500,000 endowment by the following February, and the medical school would open by October 1892. Gilman, the university president was secretly looking for and hoping that a male donor would step forward to the rescue. He proposed that the medical school would be named in honor of such a donor. Such a donor did not materialize, and neither the university nor the Women’s Medical Fund Committee was able to meet the new target. Mary Elizabeth Garrett met with Charles Mayer, a co-executor of her father’s estate, to discuss her new plan. They enlisted Mr. Gwinn to draft the proposals and present them before the Trustees. Mary offered to give the university $306,977 and not one penny more than the precise amount needed. She would pay annual installments of $50,000 each, beginning in January 1894, the year after the school opened, until the final payment of $6,977, to be paid on January 1, 1899. Since the payment was in installments the university would get 5% interest each year. She also demanded that $50,000 of the $500,000 endowment be “expended on a building or buildings . . . in memory of the contributions of the Committees of the Women’s Medical School Fund . . . [and it] shall be known as the Women’s Fund Memorial Building.” However, this particular new offer came in with quite astounding and very revolutionary stringent conditions.

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The new stipulations included the following: 1. That women be admitted to the school on equal terms as men and “enjoy all its advantages on the same terms as men” and be “admitted on the same terms as men to all prizes, dignities or honors that are awarded by competitive examination, or regarded as rewards of merit”; 2. “That the Medical School of the university shall be exclusively a graduate school” and “that it shall provide a four years’ course, leading to the degree of Doctor of Medicine”; 3. That requirements for admission specify that applicants have a bachelor’s degree and proof that they have satisfactorily completed courses in physics, chemistry and biology, and have a “good reading knowledge of French and German.” Furthermore, she concluded by adding an escape clause “That in the event of any violation of any of the aforesaid stipulations the said sum of $306,977 shall revert to me, or such person or persons, institution or institutions, as I by testament or otherwise may hereafter appoint”.31 On Christmas Eve 1892, the trustees voted to accept Mary Garrett’s proposals. These new stipulations by the Women’s Medical Fund Committee were quite revolutionary and more radical than the initial proposal to admit women. The medical faculty, particularly Welch and Osler, were very concerned that the admission criteria were being set too high and that few applicants could qualify. This discomfort generated Osler’s now legendary quip to Welch, “We were fortunate to get in as professors; we would never have made it as students.” Gilman had another concern with Garrett’s proposals. He was afraid that these stipulations could hamstring the university’s prerogative in making future changes. After the trustees’ vote, the medical faculty dispatched Welch as intermediary to negotiate with Mary Garrett, but to no avail. In a letter Miss Garrett pointed out that the terms of her gift would not interfere with university operations. Finally, everyone was satisfied, and the long-awaited medical school would open that October. Abraham Flexner was a high school principal who had reported on the status of Colleges in the United States. Based on this report and the recommendation of his brother, a Hopkins trained physician and pathologist, Flexner was chosen by the Carnegie Foundation to do a study of American Medical Education. After visiting all of the 155 American medical schools then in existence in 1910 Abraham Flexner generated his now famous report.2 Using the Johns Hopkins University School of Medicine as the ideal, Flexner issued his bold recommendations: Admission to a medical school should require, at minimum, a high school diploma and at least two years of college or university study, primarily devoted to basic science. The length of medical education should be four years, and its content should be what the Council of Medical Education (CME) agreed to in 1905. Proprietary medical schools should either close or be incorporated into existing universities. Medical

schools should be part of a larger university, because a proper stand-alone medical school would have to charge too much in order to break even. With amazing speed all state medical boards gradually adopted and enforced the Flexner Report’s recommendations. In 1904 before the report, there had been about 160 medical-granting institutions with more than 28,000 students. After the Flexner report, there were only 85 medical schools in 1920 educating only about 13,800 students. Only 66 medical schools were left by 1935 and, of these, 57 were part of a university. Mary Elizabeth Garrett and the Friday Evening Group had won and changed the face of American medicine.

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Flexner A. Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching, Bulletin No. 4. New York City: The Carnegie Foundation for the Advancement of Teaching. 1910.

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McGehee HA, McKusick VA. A Model of Its Kind: Volume 1 - A Centennial History of Medicine at Johns Hopkins. Baltimore: Johns Hopkins University Press. 1989.

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Osler W. The inner history of the Johns Hopkins Hospital. Johns Hopkins Med J. 1969;125(4):184-94.

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Grauer NA. Leading the Way: A History of Johns Hopkins Medicine. The Johns Hopkins University Press; 2012.

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Cameron J. Williams Stewart Halsted: Our Surgical Heritage. Annals of Surgery. 1997;225(5):445–58.

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Imber G. Genius on the Edge. New York: Kaplan Publishing; 2011.

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Waters SK. Mary Elizabeth Garrett: Society and Philanthropy in the Gilded Age. The Johns Hopkins University Press; 2008.

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Lefkowitz HH. The Power and Passion of M. Carey Thomas. Knopf; 1st edition; August 23, 1994.

10. U.S. Census Bureau Statistics. 11. WIA Report: Tracking women in Academia. http://www.wiareport.com/ category/enrollments/ Accessed August 13,2012. 14;37. 12. Rothstein WG. American Medical Schools and the Practice of Medicine: A History. Oxford University Press; First Edition; October 29, 1987. 13. MacDermot HC. Early Medical Education in North America. Canadian Medical Association Journal. 1952; 67:370-375. 14. Kampp F. Die Thebanische Nekropole. Mainz: Zabern, 1996, Vol. I, p. 262. 15. Kubba AK. The Life Work and Gender of Dr. James Barry MD (17951865). (PDF). Proc R Coll Physicians Edinb. 2001;31(4):352–356. PMID 11833588. Archived from the original August 14, 2012. 16. Five British heroes overlooked by history. BBC News. 17 November 2009. http://news.bbc.co.uk/2/hi/uk_news/magazine/8364465.stm. Retrieved August 14, 2012. 17. Pain S. The male military surgeon who wasn’t. NewScientist.com (2008). http://www.newscientist.com/article/mg19726462.000-histories-themale-military-surgeon-who-wasnt.html. Retrieved August 14, 2012. 18. Justin MS. The Entry of Women into Medicine in America: Education and Obstacles 1847-1910. http://www.hws.edu/about/blackwell/articles/ womenmedicine.aspx.

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19. Smith S. Speech at a Memorial Service for Elizabeth Blackwell and Dr. Emily Blackwell (New York: Academy of Medicine, 1911, p. 7. 20. Pettinato T. Elizabeth Blackwell: First Woman Doctor in the U.S. http:// www.newsinhistory.com/blog/elizabeth-blackwell-first-woman-doctorus. Accessed August 16, 2012. 21. Editorials and Medical Intelligence. Boston Med Surg J. 1849;40:84-88. February 28, 1849. 22. Clarke EH. Sex in education: or, A fair chance for the girls. Boston: James R. Osgood and Co; 1873. onlinebooks.library.upenn.edu/webbin/book// lookupid?key=olbp41506. 23. Jacob KA. Mr. Johns Hopkins. The Johns Hopkins Magazine. 1974;vol.25, no.1, pp.13-17. 24. Stover JF. History of the Baltimore and Ohio Railroad. Purdue University Press; 1987. 25. Death of Johns Hopkins. His Last illness Life and Character His Career as a Merchant and Banker His Benevolent Enterprises Monuments of Learning and Charity, &c. Baltimore Sun. Dec.25, 1873. 26. Letter of Johns Hopkins to the Trustees. http://www.snowden-warfield. com/Stories/Letter-Johns-Hopkins-Trustees.htm.

html. Accessed August 22, 2012. 28. Ayd MA. Like Something the Lord Made; The Vivien Thomas Story. The Dome. Feb 2003;54:1. http://www.hopkinsmedicine.org/dome/0301/ close_up.cfm. Accessed August 22, 2012. 29. Cushing H. The Life of Sir William Osler. 2 Volumes. Oxford University Press; 1956. 30. Jarrett WH. Raising the bar: Mary Elizabeth Garrett, M. Carey Thomas, and The Johns Hopkins Medical School. Proc (Bayl Univ Med Cent). 2011 Jan;24(1):21-6. 31. Letter from Miss Garrett to the Trustees of the University, December 22, 1892, Daniel Coit Gilman Papers, ms. 1, Sheridan Libraries, JHU. 32. Chesney AM. The Johns Hopkins Hospital and The Johns Hopkins University School of Medicine: A Chronicle. Vol. 1: Early Years. Baltimore: The Johns Hopkins Press, 1943, 42. 33. Welch WH. An Address by Professor William H. Welch, M.D. Delivered at the Graduating Exercises of the Johns Hopkins University, June 13, 1893. Mary Elizabeth Garrett Papers. Bryn Mawr College Archives, Bryn Mawr.

27. Agin D. Bigotry and Racism in America: What Harvey Left Us. http://www. huffingtonpost.com/dan-agin/bigotry-and-racism-in-ame_b_241080.

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Medical Information:

Females Bear the Burden and Are Not Prepared Charles P. Davis, MD, PhD

Based on a Presentation at the 2012 AAPS Annual Scientific Meeting

Abstract Emergency department personnel seem constantly complaining that many patients arrive unprepared to provide important medical information that may have an impact on their care. This manuscript reviews in detail some interesting findings from a study done to assess the completeness of information provided to emergency department personnel. The results reviewed suggest that, although both men and women are poorly prepared with information, the bulk of responsibility has men deferring to female relatives to provide information, regardless of race. The poorest responses were to questions about medical history and advance directives. The reasons for and potential approaches to remedy the information-based problems are reviewed.

Introduction Most people do not wish to make a visit to an emergency room (ER) or go to the doctor’s office. However, statistics indicate that about 117 million times per year in the US, people will visit an ER as a patient.1 This number indicates that for every 100 people in the US, there will be about 40 ER visits per year. When repeat patient visits per year are factored into these numbers of yearly visits, the data still indicate that about one person in every four (about 25% of the US population) visits an ER once per year. These data indicate that ER visits are common in the US and that for everyone in the US, there is about a one in four chance that they will, during any given year, visit an ER as a patient.1 Office visits are far more numerous, about 1.1 billion, excluding ER visits. At each visit, medical information is requested from either the patient or their caretaker(s). During a study of how well people were prepared for an ER visit, data indicated that females carry the largest burden for emergency

medical information. The purpose of this paper is to review recent data2 that give evidence for the dependence on females for medical information, to review recent evidence that shows that poor medical information is provided to ER staff by most patients, and to discuss methods that may help both men and women address this serious gap in medical information.2,3

Material and Methods All patient data were garnered by a single physician over six months. Patients were interviewed, diagnosed, treated, and given a disposition by this same physician during their ER stay; the only patients excluded were those that began, finished their workup, or were given a disposition by another physician before this doctor began or ended his ER shift. All other patients were seen from their initial workup to disposition by this physician and were included in this study. All patients were seen during day shifts (7AM – 7PM) at one small (five-bed) hospital ER, Texsan Heart Hospital, in San Antonio, TX. This hospital was a specialty hospital that has mainly cardiac patients as inpatients during the study. It recently changed its name to Methodist Texsan Hospital and changed its focus of being a specialty hospital to more general care.2 Data were collected by the verbal response of the patient to questions asked by the physician, nursing staff, and registration clerk, and documented for each patient at the time of patient disposition. In addition, after the patient interview, family members, friends, home health care givers, and the patient’s physician(s) were also interviewed to help confirm or correct the data collected by the patient’s verbal response. Occasionally, the patient produced written documentation as an answer to questions. For the written documentation to be considered

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a patient response, the patient had to have the document on his or her person while undergoing an interview, not a document provided at a later time by someone else. The data then were recorded as either yes (+) or no (-) for some questions or complete (+) or incomplete (-). A few questions garnered responses that led to follow-up questions. These follow-up questions allowed additional information to be gained but were only asked when a specific question was answered as “no” or “ask” or “check with” (see questions below). When the patient produced written documentation to answer a question, this written documentation was then determined to be complete or incomplete by checking with family members, friends, home health care givers, patient records (charts), and the patient’s physician(s) to the best of our ER staff’s ability, depending on the availability of access to these sources. The questions that were asked and evaluated or followed-up with additional questions are as follows: •

Allergies – Do you have any allergies to medicine, foods, or other things? Answer + if list is complete (verbal or written); answer – if patient does not remember allergies or has to refer the staff to another person or their previous medical record. If the allergy list is later revised or is found to be incomplete, this fact was noted.

Medications – Do you have a list of your medications, including strength and time(s) of day taken? Answer is + if patient produces an up-to-date list of medications, including strength and time(s) of day taken, either written or verbal format; answer is – or incomplete if the verbal or written list is not current or is revised during the ER stay. A – response to the medication question generated a secondary question: where or who can we contact to get this medical information? Patient responses to this question were documented. For example, if the patient said to ask his wife or to check his medical records or call his doctor, the first “contact or source for information” suggested by the patient was documented.

Medical history – Could you describe your current and past medical history. A + response was a verbal or written medical history that was complete. A – or incomplete history occurred when the patient said they do not remember, check my medical records, revised their history during the ER stay, or if other sources (for example, relatives, old charts, or the patient’s doctor) are consulted to complete the medical history. Surgical history – Could you describe any surgical procedures done at any time during your life? A + response was a verbal or written medical history that was complete. A – or incomplete history occurred when the patient said they do not remember, check my medical records, revised their history during the ER stay, or if other sources (for example, relatives, old charts, or the patient’s doctor) are consulted to complete the medical history. Name of patient’s doctor(s) – Who is your primary care doctor and who are any other doctors that treat you? A

+ answer is the name(s) of at least one doctor that potentially can be contacted by the ER staff; a – answer was the equivalent of “I do not have a doctor” or patient provided a doctor’s name but there was no way for the ER staff to contact the doctor (for example, Dr. Jones at an out-of-state hospital whose hospital name the patient cannot recall). •

Person(s) to contact in case of an “emergency” – Who can we contact in case of an emergency? A + response is a person’s name and their phone number; a – response is no named person or a named person with an incorrect or no phone number, unless that person accompanied the patient to the ER and provided the information to the ER staff. Unfortunately, verification of the contact person’s information was not routinely recorded.

Prior ER visits – Have you ever been a patient in this ER? A + response is a yes answer and is confirmed by checking the ER records; a – response is either a no answer or a yes that is not confirmed by the hospital ER records.

Advance directive(s) – A + response is a yes answer; a – answer is a no answer to the first question. If the patient’s answer was that they had a directive, a follow-up question was asked: do you have a copy of the directive with you? The answer to the follow-up question was recorded.

Insurance information – Do you have health insurance? A + response is yes and verified by the ER clerk; a – response is either a yes answer but the clerk cannot verify the insurance or simply a no answer. This question was asked after initial ER assessment of the patient.

Patients comprised a convenience sample; all patients (or their guardians) were interviewed, treated, and either released, admitted, transferred to another hospital, or decided to leave against medical advice (AMA). None died during the ER shifts when the examining ER physician was on duty. All patients that arrived at the ER were seen regardless of their complaint or condition.2 Table 1: Patient Population (309 patients)*. Table 1. Patient Population (309 patients)*

Race

%

Anglo male

26

Hispanic male

24

Anglo female

22

Hispanic female

21

Black male

4

Black female

2

Asian male

0

Asian female

1

* Males = 53% and Females = 47%

Results Over a six-month period a total of 309 patients were seen from arrival to disposition in the hospital ER by a single physician who recorded patient responses to questions. Table 1 shows the

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demographics in percentages of the sex and race of the 309 patients included in the study. The majority of patients were Anglo and Hispanic males and females (total = 93%). When compared to the population of people in San Antonio, Texas, our patient population was considerably older with a median age of 60, 28 years older than the mean age of the city’s population. Also, the hospital had a disproportionate share (higher) of white versus Hispanic patients as compared to the city’s population, but both white and Hispanic patients had the same percent of insured and uninsured patients arrive at the hospital (93% insured versus 7% uninsured). When all patients’ insurance statistics were calculated and compared to the national average of insured patients seen in ERs across the US, the hospital clearly showed a higher percentage of insured patients that visited its ER (91.5% insured versus 84.7% nationally in the US). Every patient had a contact person listed (100%), but the accuracy of this contact person information was not confirmed. Most of the patients (96%) initially said they knew their allergies, but during their stay, 13% that were initially “positive” that they gave an accurate allergy history had it changed or modified during their ER stay. The majority of the 13% of altered allergy history that was corrected was corrected by women (Figure 1).

was the primary one for individual patients. “Check my chart for my medications” is the paraphrased answer of 23.5% of patients, while 19.1% corrected, completed, or updated their own list in the ER. The majority of other sources was closely related to the patient and was female (51.3%), mainly a daughter or wife. The few other sources were documented as mother, sister, parents, husband, niece, or son (Figure 3). Combined, all of these ten sources comprised about 40% of the responses related to medications, with males and females both deferring the questions to a female relative. Those questions deferred to females comprised about 20% of all responses related to medications with the majority of men deferring to their female relatives. When this 20% of responses deferred most often by male patients is added to the approximate 54% of all visits to the ER being females,4 it results in the burden for females to provide for about three-fourths of all medical information, especially medications, to emergency personnel (Figure 4). Figure 2: Response of patients to Figure 2: Responses of patientsquestions to medical questions. medical 100%

80%

Figure 1: Responses to allergy questions

Figure 1: Responses to allergy questions. 8%

5%

17.9

90%

43.1

26.7

14.1

70%

4%

% of patients

130

19.3

60% 50% 40%

23.9

68

30%

83%

20%

54 33

10%

Gray = % patients that knew allergies Black= % patients that did not know allergies White= % male patients that changed allergy list Pattern= % female patients that changed allergy list

Figure 2 shows the response of patients to three common and important medical questions. Column 1 shows the low percentage of patients (33%) that knew their medical history. Men were exceptionally poor at knowing their medical history (43.1% did not know all of their history) as compared to women (23.4%). Males and females did know their surgical history better (68%) than their medical history; more males (17.9%) than females (14.1%) did not know their surgical history (Figure 2). The third medical question asked was to have the patient identify the medication(s) they currently take. The numbers of men and women that knew their medications were not very high (54%); males were worse than females (27% and 19%, respectively) in identifying their medications. Because preliminary study suggested that revision of the medication lists might be high, in addition to documenting the revision, the source(s) for the revision in medications was also documented. Although occasionally more than one source was listed per patient, Figure 3 shows the ten listed sources patients used or requested in the ER to correct or complete their medication documents. The sources are listed in order of frequency beginning with the source that

0%

1

2

3

Gray bars represent % complete answers, gray textured bars represent % female incomplete answers, white bars represent male incomplete answers. Column 1 represents Medical History, column 2 represents Surgical History , Column 3 represents Medication History (current medications).

Other answers to questions were documented; prior visit to study ER (57% had prior visits) and identity of a treating physician (80% could identify a treating doctor, although only 43% of female in this 80% could). Only 7% of the study patients were uninsured, but 57% of those were males. One question asked in this study population that was answered by both males and females that elicited a poor percentage of positive or complete responses was whether the patient had an effective (signed) advance directive of any type with them in the ER. Figure 5a shows that only 10% of females and 11% of males responded that they had an advance directive, and, when asked if they had a signed directive with them, an overwhelming 99% responded they did not (Figure 5b). Significant differences between Anglo and Hispanic males and females in answering the study questions were not found.

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Figure 3: % of people who modified their original medication list and who or what the patient said Figure 3: % of people who modified their original medication list and who or what the patient said supposedly had a correct list of their medications. supposedly had a correct list of their medications 25

23.5

22.6

21.7 19.1

20

% of people

15

10

5

49%m 59%m 100%m 57%m

3.5

2.6

2.6

1.7

0.9

0.9

0

1

2 3 4 5 6 7 8 9 10 Categories of who or what had to correct the original list of their medications; 1 = medical chart, 2 = daughter, 3 = wife, 4 = patient who just remembered changes, 5 = mother, 6 = sister, 7 = parents, 8 = husband, 9 = niece and 10 = son; total % <100%

Figure 4: % ofwho people who provide (or expected to Figure 4: % of people provide (or expected to provide) provide) medical information to ER Staff medical information to ER Staff. 20%

54% 26%

Gray = % of females seen nationwide in ER’s White and Textured = % of males seen nationwide in ER’s White= % of males who provide their medical information Textured= % of males who expect females (mainly female relatives) to provide their medical information

Discussion The data in Table 1 clearly show that the patient population in this study was composed of similar numbers of males and females that represented an older population. However, the study population had about the same number of Anglo and Hispanic patients that comprised the large majority of patients, although the city of San Antonio has a predominant Hispanic population (61%). One reason for this may be because the hospital was well known to be a private hospital that mainly designed to care for patients with a cardiac history or complaint; another reason may be due to the high median age of the patients (60 years old) so that a high percentage of patients could be eligible for Medicare coverage. The patient response to commonly asked questions was surprising in several ways. First was the revisionism exhibited by a

large number of patients and their caregivers about allergies and medications along with the lack of completeness of surgical and especially medical histories found while they were being examined, treated or admitted (Figures 1-2). Second was the large number of patients and caregivers that expected sources other than themselves to provide essential information to the ER staff and the additional finding that female relatives were considered to be one of the main repositories of such information (Figures 3-4). The third surprise was the high number of patients that had no directives (Figure 5a) and fourth was the high number or patients with doctors and previous ER visits to the study-centered hospital that arrived without an effective directive (Figure 5b). Figure 5: % of that Patients have an directive Figure 5: % of Patients said that they said havethey an advance advance directivewith (Fig.an5a) and % of* patients (Fig. 5a) and % of patients effective advacnce directive (Fig. 5b). with an effective * advance directive (Fig. 5b) 10%

Fig. 5a

11%

79% 1%

Fig. 5b

99%

Figure 5a: Large gray area in both figures represent % of patients without an advance directive ; patterned represent % of females and white represent % of males claim they have one ,while Fig. 5b shows the vast majority (grey, 99%) do not possess an effective (signed*) copy in the ER.

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Although some ER clinicians, especially those that have worked in charity hospitals, may not be surprised at the data, the specialty hospital ER staff was concerned because at least 57% of patients had at least one prior visit to the hospital and the majority (80%) of patients had doctors who likely had asked them similar questions in an office setting. Thus, they had experienced most or all of the questions and likely had been given advise about what to bring with them if a future ER visit happened. This study suggests that either a large number of patients cannot or will not take the advice to prepare for a future ER visit or the ER staff is failing to get their message to prepare for future visits across to patients and caregivers. The poor preparation could also be due to a combination of all three situations. The data from previous studies that examined only a few aspects about the accuracy of patient health information support the conclusion that patient recall of their personal medical information is poor.5-7 The data reviewed here show greater details, document the depths in percentages of the various areas where patients lack information, and agree with the decades of experiences that many healthcare providers have had and with the few that are documented.5-7 Two major points are derived from the studies presented in review; first, the majority of the study population was poorly prepared to provide accurate and complete medical information in several categories to emergency health care providers, and, second, the bulk of medical information was either expected to be provided or is provided by females. The latter finding occurred because the majority of males in the study were poor medical information providers and often deferred to their female relatives to provide medical information. How are these information problems solved? Understanding that males (regardless of race) are very poor at knowing and providing medical information and defer to females to provide such information may make people aware that cultural changes are needed. Change in behavior seems unlikely to occur rapidly, although perhaps some males will make some efforts to become more responsible for their own medical information. More immediate results may be to emphasize the importance of keeping accurate medical information available to men and women when discharged from the hospital or clinic. Since this study and others strongly suggest that patients routinely are missing important information on arrival at ERs and clinics, developing ways to help both males and females assimilate, mod-

ify, and easily carry it 7/24/365 days per year seems a priority. Although the Electronic Medical Record would help solve this problem, there are so many problems to develop this nationwide; no one expects this to happen quickly or inexpensively.8 However, developing a complete, private, easily accessible, and portable method to help females (and males) have good to excellent medical information has been recently accomplished. The methods involve templates that can be filled out by the person, are password protected, and portable. Some are available as phone applications; others are available as pre-programmed flash (thumb) drives. These are relatively inexpensive (about 20 – 30 dollars), small, durable, and easy to transport. We urge doctors, insurance companies, lawyers, and caregivers to encourage their patients and clients to carry one at all times. Charles P. Davis, MD, PhD, Professor (Retired), University of Texas Health Science Center, San Antonio, currently serves on the staff of the South Texas Spine and Surgical Hospital, San Antonio, TX. He is the CEO of CPD Health Consultants, LLC. Potential Financial Conflicts of Interest: By AJCM policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The author has stated that no such relationships exist. ®

References 1.

Niska R, Bhuiya F, Xu J. National Hospital Ambulatory Medical Care Survey: 2007 Emergency Department Summary. Nat Health Stat Reports. 2007;26:1-32.

2.

Davis C. Emergency department visits: we are not prepared. Amer. J. Emerg. Med. 2012;30:1364-1370. doi:10.1016/j.ajem.22011.09.026.

3.

Kellermann AL, Martinez R. The ER, 50 Years On. N Eng J Med. 364:2278-2279, 2011.

4.

Centers for Disease Control. Source: National Hospital Ambulatory Medical Care Survey: 2009 Emergency Department Summary Tables, Table 2, p3, http://www.cdc.gov/nchs/fastats/ervisits.htm, published 2012.

5.

Neugut A, Neugut R. How accurate are patient histories? J. Community Health. 1984;9(4):294-301.

6.

Cohen G, Java R. Memory for medical history: accuracy of recall. Appl Cogn Psychol. 1995;9:273-288.

7.

Mai P, Garceau A, Goraubord, et al. Confirmation of family cancer history reported in a population-based survey. J. Natl Cancer Inst. 2011;103(10):788-797.

8.

Blumenthal D, Taynner M. The “Meaningful Use” Regulation for Electronic Health Records. N Engl J Med. 2010;363:501-504.

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The Art of Medicine: Can You Recognize Aunt Minnie? Brian W. Harris, MD, PhD, FAAR Nicole F. De Simone, DO, MPH Jaime F. Slotkin, DO

Abstract Aunt Minnie, the pseudonym most often used by radiologists, describes pattern recognition that is pathognomonic of a disease. Debate exists in medical training as to whether a lengthy workup for symptoms affects diagnostic accuracy, as the Aunt Minnie method usually yields the correct diagnosis rapidly. After training, many unknowingly adopt this method of pattern recognition for symptoms or imaging based off initial impressions. However, this can lead even the most experienced clinician down the wrong path. Classic Aunt Minnie scenarios may resemble very different pathologies and confuse the clinician. At times, recognizing what appears ordinary as extraordinary is achieved by embracing a more Socratic method of discussion among colleagues. Here, we present three cases that appear to be Aunt Minnie from afar but are not. Our objective is to encourage direct dialogue with radiologists to aid in diagnostic accuracy in an age when technologic advances and outside pressures have limited the personal interactions of the past. The clinical and radiographic criteria for each diagnosis are also reviewed.

Introduction As much as 80-90% of diagnoses can be made from history alone, and, yet, imaging has become mainstay to support diagnoses.1 However, our clinical course for a patient may alter dramatically based on the radiographic interpretation and in particular for those who lack confidence in certain findings. Understanding that a potential disconnect exists between history,

clinical examinations, and the radiographic picture, especially when interpreted as separate entities, can have dramatic effects on patient care and their future outcomes. With varying degrees of enthusiasm, traditional medical education has embraced the Socratic Method for trainees.2 This very thorough and time-consuming discussion of all the known diagnostic possibilities tends to slowly dissolve through the years due to outside pressures, advancements in technology and imaging, and the development of focused super subspecialties.3 For an experienced clinician, most correct diagnoses do come through pattern recognition and not problem solving.1 As medical training ensues, most have been told the medical adage, “When you hear hoof beats don’t look for zebras” implying that one should look for the obvious answer, not the exotic one. Among all disciplines, clinical reasoning and diagnostic accuracy are improved with acquisition of knowledge and experience, and, through time, we begin to rapidly identify the hoofbeats or, more appropriately said, we have embraced Aunt Minnie. Aunt Minnie is the fictitious name given by Sackett et al. and others to describe pattern recognition in medicine. If a lady walks and looks like your Aunt Minnie, then she probably is.4 Often we see her somewhere, radiologically or in history and physical examination, and proceed to make critical medical and surgical interventions based off this that are most of the time correct. Presumptive diagnosis based on radiographic or symptomatic pattern recognition can be fraught with complications, as Aunt Minnie often changes her appearance when more dynamic clinical information is provided among

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disciplines. Recognizing when Aunt Minnie is not who she appears to be can often be disclosed by dialogue with radiologists who can help attribute clinical features to radiographic findings that could be interpreted more than one way. The three cases described will show how a classic Aunt Minnie diagnosis can change with additional information and how dialogue could have changed the patient’s course. The first case describes what appears to be constipation by history and physical examination. Aunt Minnie is recognized as constipation, initially treated as such, and later proven wrong by imaging. The second case describes vague chest complaints and possible partial bowel obstruction in an otherwise healthy individual. Aunt Minnie is recognized on chest radiograph as pulmonary edema by the radiologist and is later proven to be wrong with additional information. The third case describes what appears to be acute appendicitis on history and physical examination. Aunt Minnie is recognized as acute appendicitis; however, imaging and pathology prove it to be wrong. The clinical and radiographic findings for each diagnosis are reviewed for each different entity that can mimic another benign condition based off of historical or radiographic information that is interpreted separately.

the kidneys, ureters, bladder (KUB) radiograph ordered. This image confirmed the working diagnosis of constipation by the ER physician, and the patient was discharged home with instructions for a bowel regimen. The patient returned to the ER two days later with progressively worsening symptoms and localization of pain to the right lower quadrant. Computed Tomography (CT) scan of the abdomen and pelvis was ordered, and demonstrated acute appendicitis. Histological evaluation of the specimen after appendectomy was also consistent with acute appendicitis. The initial report on Image 1 noted a psoas shadow was absent on the right, raising the possibility of acute appendicitis on the radiograph. Clinically, at the time this was not recognized as pertinent. Image 2: Diffuse bilateral interstitial alveolar opacities.

Image 1: KUB demonstrating psoas shadow on right.

Cases A 12-year-old male presented to the emergency room (ER) complaining of diffuse abdominal pain for three days. Prior to this presentation, he felt constipated and was unable to move his bowels after enema administration at home. He complained of anorexia but was tolerating a diet. He denied fevers, chills, nausea, or vomiting. His past medical and surgical history was unremarkable. On physical examination he was afebrile with normal vital signs. His abdomen was soft, mildly distended, but diffusely tender without guarding, rebound, or rigidity. All laboratory results were normal. Image 1 shows

A 68-year-old male presented to the ER complaining of two days of worsening nausea, vomiting, chest pain, and shortness of breath at rest. He also complained of mild abdominal bloating and recent loose stools. His history was remarkable for six months of worsening joint aches, nausea, and unintentional weight loss. His past surgical history was significant for gastric banding and prostate biopsy for an elevated Prostate-Specific Antigen (PSA) level obtained as an outpatient. Multiple biopsies demonstrated chronic inflammation. His past medical history was significant for benign prostatic hyperplasia. On physical examination he was afebrile, slightly tachycardic, and oxygen saturation was 95% on room air. His heart and lung sounds were unremarkable. He was tender in the epigastric region, right lower quadrant, and demonstrated peritoneal signs. A chest radiograph, seen in Image 2, was ordered and performed prior to CT scan. This was read as diffuse interstitial alveolar opacities suggestive of pulmonary edema. CT scan of the abdomen and pelvis demonstrated mechanical small bowel obstruction at the level of the distal ileum, diffuse sclerotic lesions within the axial skeleton compatible with diffuse metastatic disease. Later that evening he underwent laparotomy and right hemicolectomy for an obstructing

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mass in this area. Pathology from surgery came back poorly differentiated adenocarcinoma with signet ring features with extensive angiolymphatic invasion. Retrospectively, Image 2 was consistent with pulmonary lymphangitic metastases from prostate cancer and not pulmonary edema. A 53-year-old male presented to the ER with a four-day history of worsening abdominal pain, now localized to the right lower quadrant. He complained of fevers and chills, anorexia, diarrhea, and emesis. His past medical and surgical history was unremarkable. On physical examination he was afebrile with a heart rate of 110. He had diffuse abdominal tenderness, greatest in the right lower quadrant, with mild peritoneal signs. He had a normal white count with a slight left shift and a C-reactive protein level elevated at 5.3. Urinalysis was positive for trace blood. Image 3 shows the CT scan of the abdomen and pelvis ordered. This was read as significant phlegmon formation in the right lower quadrant suspicious for Crohn’s disease versus acute appendicitis. He was admitted for observation that evening. The following morning his laboratory results remained unchanged, and his pain was more localized to the right lower quadrant. He underwent surgery later that morning. In the operating room a significant amount of phlegmon was evacuated from the right lower quadrant. The appendix was identified, removed, and did appear inflamed as did some mesentery in the cecal region. The cecum and the remainder of large and small bowel appeared normal. Pathology from the appendix came back consistent with active Crohn’s disease. Image 3: Axial view demonstrating phlegmon formation on the right and thickening of the cecum and terminal ileum.

Discussion The first case presented appeared to be constipation based on history and physical examination. The plain abdominal film (PAX) obtained appeared to support this benign suspicion. This looked virtually normal to the untrained eye; however, the radiologist identified something much different. This patient did not fit the classic description of acute appendicitis which he ultimately had. The imaging abnormality identified should

have prompted further investigation from the ER physician. Likely, a different outcome would have occurred if dialogue between specialties was present. Appendicitis is the most common surgical emergency in children in the United States, with more than 75,000 appendectomies performed each year.5 It remains difficult to diagnose, and much debate exists regarding the optimal diagnostic approach in children with abdominal pain.5,6 Many studies highlight the variability in eliciting history and physical examination findings in children. This may reflect the fluid nature of the physical examination, the maturity of the child, and the need to perform multiple examinations to gain a better perspective of clinical status.5 In one study examining this, the inter-rater reliability of patient history and physical examination findings was generally considered fair to moderate and should be accounted for when developing prediction rules and clinical pathways that guide clinical management. The duration of pain, history of emesis, presence of abdominal tenderness, and pain with walking, jumping or coughing were the variables with the highest degree of inter-rater reliability in children with possible appendicitis.5 CT scan remains the most sensitive imaging modality for appendicitis, although protocols vary among institutions to its use in children where ultrasound or magnetic resonance imaging may be the first study of choice.6,7 Reported accuracy rates of spiral CT for diagnosis of appendicitis are as high as 98%, with a diameter >6mm being the most specific finding.8,9 Uncommonly, PAX is used to aid in the diagnosis of appendicitis but does not remain among the recommended imaging modalities. The utility of ordering such a study is debated in the literature with different numbers supporting or negating its use.10 PAX can frequently be misleading but may raise suspicion when an abnormality is identified. One study showed that the negative predictive value of PAX in diagnosing acute appendicitis was 32.5%, and the positive predictive value was 89%,11 whereas another study showed abnormal finding in 51% of patients with appendicitis, 47% of those without, and normal in 50% of those with appendicitis.12 PAX findings of appendicitis can demonstrate an appendicolith, right lower quadrant soft tissue mass or extraluminal air, psoas margin obstruction, and levoconvex lumbar spine scoliosis.11,12 As demonstrated in Image 2, a classic Aunt Minnie picture of pulmonary edema is seen. However, it is pulmonary lymphangitic carcinomatosis (LC), a much different pathology that looks similar radiographically. This was appreciated retrospectively when a more complete history and pathology was obtained. Pulmonary LC is a rare manifestation of metastatic cancer, and radiographic imaging can mimic other pulmonary entities.13 Clinical awareness of this is important to help guide appropriate therapy in these patients, as it signifies very poor prognosis and advanced metastatic disease. The diffuse infiltration and obstruction of lymphatic channels by tumor causes a beaded chain appearance on chest radiograph due to uneven thickening in the interlobular septa. This reticulonodular pattern can easily be seen in Image 2 and resembles Kerley B lines, the hallmark sign for congestive

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heart failure.13-15 Manifestations of LC, such as dyspnea, the most common reported symptom, or non-productive cough, can lead to an incorrect diagnosis of pneumonia, pneumonitis, pulmonary embolism, congestive heart failure, asthma, or sarcoidosis.13 In LC, tumor spread through the lymphatic system is hypothesized to occur in one of two ways, either through hematogenous spread to the interstitial space or in a retrograde manner from the lymph node to the periphery.13 The incidence of LC accounts for 6-8% of all metastatic disease to the thorax, and 80% arise from adenocarcinomas. The most common are from breast, larynx, prostate, thyroid, gallbladder, stomach, and pancreas.13-15 In the third case, Crohn’s disease versus appendicitis was read on CT scan. Based off imaging it was unclear as to which process was occurring in this patient. The admitting team diagnosed appendicitis due to the unlikelihood of a new Crohn’s presentation at this age and the classic physical examination findings. Crohn’s disease can occur at any age but is more prevalent among adolescents and young adults between the ages of 15 and 35. It is a transmural process that may extend to the surrounding perienteric fat and mesentery. The most specific findings on CT scan for Crohn’s disease are a mean wall thickening of 11-13mm and involvement of the right colon.8 In some patients with appendicitis a distended appendix cannot always be visualized and changes such as focal cecal apical thickening, the arrowhead sign, or a cecal bar may be present instead and are noted in up to 30% of cases.8 These findings are suspicious for acute appendicitis but not diagnostic because other conditions such as Crohn’s or cecal diverticulitis may demonstrate similar inflammatory changes.8 One study demonstrated that the most significant predictors of acute appendicitis in patients more than 50 years old were tenderness, rigidity, pain at diagnosis, and body temperatures.16 In conclusion, embracing the Aunt Minnie method can occasionally lead to snap judgments and the wrong diagnosis in even the most experienced hands. Initial impressions may be incorrect; we must not always see the ordinary as such and develop a more open discussion with our radiology colleagues to improve patient care and outcomes. Recognizing our beloved Aunt Minnie and having Socrates question her may prove to be the most efficient and effective way to improve the rapidly evolving field of medicine. Brian W. Harris, MD, PhD, FAAR, Radiologist, Department of Radiology, Pinnacle Health Hospital System, Community General Hospital, Harrisburg, PA, and Quantum Imaging and Therapeutic Associates. He is the principal investigator.

Potential Financial Conflicts of Interest: By AJCM policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The author has stated that no such relationships exist. ®

References 1.

Greenberg LW. Aunt Minne: Will Inexperienced Trainees Recognize Her? Arch Pediatr Adolesc Med. 1999;153(2):893-894.

2.

Zou L, King A, Soman S, et al. Medical students preferences in radiology education a comparison between the Socratic and didactic methods utilizing PowerPoint features in radiology education. Acad Radiol. 2011;18(2):253-256.

3.

Cayley WE. Effective clinical education: strategies for teaching medical students and residents in the office. WMJ. 2011;110(4):178-181.

4.

Cunningham AS, Blatt SD, Fuller PG, et al. The Art of Precepting Socrates or Aunt Minnie? Arch Pediatr Adolesc Med. 1999;153(2):114-116.

5.

Kharbanda AB, Stevenson MD, Macias CG, et al. Interrater Reliability of Clinical Findings in Children With Possible Appendicitis. Pediatrics. 2012;129(4):695-700.

6.

Bachur RG, Dayan PS, Bajaj L, et al. The Effect of Abdominal Pain Duration on the Accuracy of Diagnostic Imaging for Pediatric Appendicitis. Ann Emerg Med. 2012;[Epub ahead of print].

7.

Linam LE, Munden M. Sonography as the first line of evaluation in children with suspected acute appendicitis. J Ultrasound Med. 2012;31(8):1153-1157.

8.

Horton, KM, Corl FM, Fishman EK. CT Evaluation of the Colon: Inflammatory Disease. RadioGraphics. 2000;20:399-418.

9.

Lai V, Chan WC, Lau HY, et al. Diagnostic power of various computed tomography signs in diagnosing acute appendicitis. Clin Imaging. 2012;36(1):29-34.

10. Gans SL, Stoker J, Boermeester MA. Plain abdominal radiography in acute abdominal pain; past, present, and future. Int J Gen Med. 2012;5:525-533. 11. Turkyilmaz Z, Sonmez , Konus O, et al. Diagnostic value of plain abdominal radiographs in acute appendicitis in children. East Afr Med J. 2004;81(2):104-107. 12. Rao PM, Rhea JT, Rao JA, et al. Plain Abdominal Radiography in Clinically Suspected Appendicitis: Diagnostic Yield, Resource Use, and Comparison With CT. Am J Emerg Med. 1999;17(4):325-329. 13. Kanthan R, Senger JB, Diudea D. Pulmonary lymphangitic carcinomatosis from squamous cell carcinoma of the cervix. World J Surg Oncol. 2010;8:107-110. 14. Guddati AK, Marak CP. Pulmonary Lymphangitic Carcinomatosis due to Renal Cell Carcinoma. Case Rep Oncol. 2012;5(2):246-252. 15. Babu S, Satheeshan B, Geetha M, et al. A rare presentation of Pulmonary Lymphangitic Carcinomatosis in cancer of lip: case report. World J Surg Oncol. 2011;9:77. 16. Eskelinen M, Ikonen J, Lipponen P. The value of history-taking, physical examination, and computer assistance in the diagnosis of acute appendicitis in patients more than 50 years old. Scand J Gastroenterol. 1995;30(4):349-355.

Nicole F. De Simone, DO, MPH, Department of General Surgery, Pinnacle Health Hospital System, Community General Hospital, Harrisburg, PA, Assistant Principal Investigator, General Surgery Resident, PGY4. Jaime F. Slotkin, DO, Department of General Surgery, Pinnacle Health Hospital System, Community General Hospital, Harrisburg, PA, Assistant Principal Investigator, Chief General Surgery Resident, PGY5.

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Acute Diverticulitis: A Small Retrospective Study Leaving Many Questions Unanswered Nancy Lutwak, MD Curt Dill, MD

Abstract

Study Design

Diverticulitis is a common cause of abdominal pain in patients presenting to emergency departments. The incidence increases with age. Guidelines for its diagnosis and treatment are evolving. Computerized axial tomography (CT) scanning has been the most commonly used diagnostic tool. There are concerns for the increasing number of CT scans routinely ordered, with the resultant radiation exposure. We discuss this controversy as well as those regarding medical and surgical treatment. In addition, we have reviewed cases of patients who presented with abdominal pain and were diagnosed with uncomplicated diverticulitis based on clinical parameters and CT findings. We analyzed outcomes and presented a number of issues being questioned about this frequent illness. The study, which was retrospective and small, did not allow for definitive conclusions but highlights that randomized investigations need to be performed in the future to further clarify ongoing questions about diverticulitis.

This was a retrospective study based on an administrative database search audit to identify emergency department (ED) patients diagnosed with diverticulitis during a 15-month period of January 1, 2010, to March 31, 2011. The study was exempted by the Institutional Review Board.

Introduction Diverticulitis is most often uncomplicated – without perforation, obstruction, abscess, or fistula. Current standards of care in diagnosis and treatment of this disease are being revised.1-4 We wished to explore this controversial topic and analyze presentation, progression of care, and outcomes of patients diagnosed and treated with diverticulitis in our institution over a 15-month period. The patients considered did not require surgical intervention.

Study Setting and Population The emergency department is a division of a large metropolitan Veterans Administration Healthcare Center, federally run, which predominantly serves a male population. The Healthcare Center provides emergency services as well primary care. Patients receive medical, surgical, mental health, and dental care at the Center. The computerized patient record system allows access to notes from all visits, whether in the emergency department or in the clinic setting. It also provides complete records of all laboratory data, results of radiological examinations, as well as communication with patients via telephone conversations. This computerized system ensures accurate information regarding follow-up of patients.

Study Protocol The focus of the study was to determine the effectiveness of treatment of patients presenting to the emergency department who were diagnosed with diverticulitis, not requiring surgical intervention, based on clinical parameters and CT findings.

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The cases included in the study were captured from the Hospital’s data base using the International Classification of Diseases Ninth Revision (ICD-9) diagnosis codes. The charts of the patients with ICD-9-CM 562.11 code (diverticulitis) were reviewed and analyzed for clinical findings, CT scan findings, prescribed therapy, admission decisions, and clinical outcomes, as well as initial physical examination. We also evaluated treatment strategies for clinical complications, resolution of disease, and change in management strategy. Patients in septic shock or those hemodynamically compromised were excluded from the study. Patients with generalized peritonitis were likewise excluded, since the goal of the study was to evaluate conservative therapy of patients not requiring aggressive surgical treatment.

Data Analysis Chart reviews of the patient population yielded descriptive statistics allowing for analysis of multiple variables. These included length of hospital stay, findings of CT scans, prescribed therapy with outcome, initial treatment success, age range, most common presenting symptoms, clinical assessment of emergency medicine attending physicians, and ultimate outcome of patients with initial treatment failure.

Results A total of 50 case records were identified in the hospital data base indicating eligibility for the study. All but one patient were male; the ages ranged from 28-89 years old, with median age of 62. The emergency department complaints were: isolated left lower quadrant pain 40%; generalized abdominal pain (with history of diverticular disease) 35%; non-localized abdominal pain with multiple episodes of soft stool 25%. On physical examination, all of the patients in the study exhibited left lower quadrant tenderness without peritonitis. All of the patients underwent CT scans of the abdomen and pelvis with oral and intravenous contrast during their index Emergency Department visit. The physicians wished to document the diagnosis definitively before disposition was determined. Of all, 42 patients were diagnosed with diverticulitis without abscess, and eight patients had diverticulitis with abscesses ranging in size from 1.5cm to 5cm. Of the 42 patients with diverticulitis without abscess, 21 were admitted and treated with intravenous antibiotics, and 21 were treated with oral antibiotics as outpatients. Patients treated with oral antibiotics were considered reliable, able to tolerate the PO medication, lacked significant co-morbidities, and had adequate social support. The decision was made by experienced emergency attending physicians who weighed the clinical picture and were certain of rapid follow-up. These factors were documented in the chart notes of the attending physicians. Of the 21 patients diagnosed with diverticulitis on CT scan and treated as outpatients, three required subsequent admission for persistent pain. Each of these patients improved within two days once intravenous antibiotics were started and required no

intervention. Of the patients who failed outpatient treatment, none had leukocytosis, significant tenderness, or a high fever on the initial visit. Of the 21 patients admitted to the hospital with diverticulitis without abscess, all improved within two days of inpatient treatment, at which time they were tolerating food and had very mild or no abdominal pain. Of the eight patients with diverticulitis and abscess, three declined admission and were discharged with oral antibiotics. There were no treatment failures in the group. The other five patients with abscesses were admitted for intravenous antibiotics. None of the abscesses were drained by interventional radiology or surgically. One patient who initially had a 3 cm abscess was re-scanned after 16 days of intravenous antibiotics, and his abscess had decreased to 1.5 cm. The patient with the largest abscess of 5 cm did not have percutaneous drainage because of past hernia repair with mesh placement thought to be problematic by interventional radiologists. He improved rapidly and was discharged after four days of intravenous antibiotics. Chart documentation of clinical improvement consisted of lack of fever, lack of abdominal pain, and ability to tolerate diet. The patients treated with intravenous antibiotics received metronidazole and ampicillin/sulbactam for ten days. The percentage of treatment failures of those treated with oral antibiotics, including those with Abscesses, was 12.4%. Oral antibiotics consisted of ten days of treatment with metronidazole and ampicillin/sulbactam. None of the patients in this cohort with abscesses and treated with antibiotics failed treatment, despite no drainage. All of the patients were followed post-discharge in out-patient clinics or by telephone to confirm resolution of symptoms and no recurrence. None returned to the emergency department.

Discussion Although diverticulitis is common, multiple questions remain about its diagnosis, treatment, and prevention. Diverticulitis is a common illness and incidence will increase as the population ages.4,5 There are multiple aspects of this disease requiring further study and clarification. Our small, retrospective study did not provide conclusive evidence and only highlighted some of the questions that need to be clarified with prospective, randomized trials. The most effective medical as well as surgical treatment of uncomplicated diverticulitis, for example, is being reviewed by experts. The use of antimicrobials, type of antimicrobials, and route of required antibiotics are also being questioned. Furthermore, the need for drainage of small-to-moderate abscesses by interventional radiologists or with traditional open surgery is currently controversial, as is the most effective manner to prevent recurrence.

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Diagnostic Testing There are those who feel that clinical acumen is sufficient to make accurate diagnoses of some causes of abdominal pain, such as renal colic or recurrent acute diverticulitis, without obtaining an immediate Computerized Axial Tomographic Scan. This would decrease exposure of patients to harmful radiation and increase costs.6 This commonly occurs in clinic settings, where patients are diagnosed clinically with recurrent diverticulitis and discharged home to start bowel rest and antimicrobials.7 A recent study was performed suggesting some parameters may be helpful to accurately diagnosis uncomplicated diverticulitis, and use of these parameters may reduce the need for CT imaging in some cases. These parameters included localized left lower quadrant tenderness, no vomiting, and elevated CRP.8 Some agree that patients with localized left lower quadrant tenderness without peritoneal signs, who are able to tolerate oral antibiotics, have no significant co-morbidities, and are reliable to return if their symptoms worsen, can be safely discharged with presumptive diagnosis of mild diverticulitis. They would be instructed to follow bowel rest and take antimicrobials. This is advocated particularly in patients who have previous history of documented diverticulitis.9 There are advocates who support the notion that, if patients have rapid follow-up or will return for CT scan within 48 hours if their condition worsens, foregoing an immediate scan from the emergency department may be considered. If a patient presents with localized leftsided abdominal pain and has no peritoneal signs and is presumptively diagnosed with uncomplicated diverticulitis, but there are subsequent questions about the accuracy of the diagnosis, the CT scan can be performed after a short interval of treatment and observation.3 This approach might be possible under selected circumstances with very reliable patients who have family support and understanding. In case of possible underlying malignancy, patients would undergo a colonoscopy after the acute symptoms improve and the patient is clinically stable. Certainly a colonoscopy would be recommended if the patient improved clinically and did not have a colonoscopy within the previous five years. Treatment without immediate CT scan on presentation, however, is reasonable only under select circumstances. In obese, elderly, or immunosuppressed patients with abdominal pain who may present atypically, CT scan of the abdomen and pelvis would be the appropriate immediate diagnostic tool in the emergency department. Likewise, patients with diffuse abdominal pain of unknown etiology, septic patients, or those demonstrating peritoneal signs on examination would require this test emergently.3 Older patients who may not reveal peritonitis despite having perforations should also undergo CT scans upon presentation. Such patients would also certainly require rapid assessment by surgeons. D.J. Brenner, at the Center for Radiological Research Columbia University Medical Center, New York, has written of the increasing numbers of CT scans being done which may not be necessary. Dr. Brenner suggests scans may be reasonably

replaced with other radiological imaging tests. He feels that developing and using new guidelines for patient disposition and treatment would decrease unneeded CT scans.10 His approach should be used cautiously under limited circumstances. It is true, however, that emergency physicians commonly underestimate radiation doses from CT scans of the abdomen and pelvis, which is 15.0 mSv, while the dose from one chest x-ray is 0.1 mSv. In addition, estimates that 1.5% to 2.0% of all cancers in the United States are attributable to radiation exposure from CT scans have been published.11 It is imperative, therefore, that when CT scans are ordered by emergency physicians, the risks and benefits are weighed carefully. The cost effectiveness of CT scans has only been demonstrated in patients clinically suspected of acute appendicitis. It has been suggested that ultrasound may serve well as an initial diagnostic test in patients with abdominal pain to decrease cost and avoid radiation exposure.12 There is evidence that ultrasound can be quite useful for making accurate diagnosis of uncomplicated diverticulitis and is also an effective tool to monitor response to treatment. The sensitivity in diagnosing acute colonic diverticulitis for ultrasound is 92% versus 94% for CT scan. Specificity for ultrasound is 90% as opposed to 99% for CT scan. Its use should be considered with caution, however, since its reliability is somewhat dependent on technical skill.13

Use, Choice, and Duration of Antibiotics Also Uncertain Some recent publications have demonstrated that uncomplicated diverticulitis may be treated successfully with a short course of antibiotics, and others, in fact, demonstrate that antibiotics are not needed at all.14,15,16 There are ongoing studies to reassess these notions. Uppsala University is sponsoring ClinicalTrials.gov Identifier NCT01008488 to evaluate if antimicrobial treatment is necessary to treat uncomplicated colonic diverticulitis and to test if not treating with antibiotics will result in complications. A second study sponsored by University of Amsterdam, Clinical Trials.gov Identifier NCT01111253, is investigating whether using antimicrobials lessens time to full recovery from an attack of mild diverticulitis compared to supportive therapy only. Which antibiotics are best is also being questioned. Most current recommendations for the appropriate selection of antimicrobials for treatment of diverticulitis are based on studies of severe intra-abdominal infections, tradition, clinical consensus, and indirect evidence. They are not based on careful prospective trials. The optimum duration antimicrobials should be administered is also unclear.9,17,18 A recent study compared the efficacy of four days therapy with ertapenem and seven days therapy with standard antibiotics in treatment of uncomplicated sigmoid diverticulitis. The overall success rate at one month following treatment was 94% versus 96.2%.14 Furthermore, multiple studies have been published concluding that ambulatory treatment of simple diverticulitis is effective and safe provided patients can tolerate PO medication and have adequate support of families.18,19,20,21

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Effective Treatment of Abscesses in Dispute There is on-going dispute regarding the size of abscesses that can be treated effectively with only antibiotics, oral or intravenous, and those which need drainage.22-24 Recent publications have reported patients with abscesses less than 3 cm responding well to oral antibiotics, with a success rate of almost 95%.25 One publication compared two groups with abscesses, the first with median size 6 cm, treated with percutaneous drainage, and the second with median size 4 cm treated with antimicrobials alone. The failure rate in the first group was 33%, and the failure rate in the second was 19%, despite more aggressive treatment of the first.26 Another recent study demonstrated an overall success rate over 90% in treating patients non-operatively with complicated diverticulitis, some with abscesses greater than 4 cm or with free air distant from the site of perforation.27 This issue needs clarification.

Role of Surgical Intervention to Prevent Recurrence Unclear The role of surgical resection to prevent recurrence is unclear. The indications for elective sigmoid resection in patients with multiple attacks of acute diverticulitis are being challenged, as stated by The Society for Surgery of the Alimentary Tract. Several publications discuss this uncertainty.1-3,18,22,23,28

Pathophysiology Under Investigation The pathophysiology of the disease is under investigation with the goal of prevention. Increased fiber in the diet has been espoused in the past as a tool for prevention of recurrence. As diverticular disease is better understood, however, and appears to have common overlapping clinical findings with inflammatory bowel disease, the use of 5-aminosalicylic acid and probiotics may also prove effective. The inflammation of diverticulum seems to be the result of greater production of pro-inflammatory cytokines, greater intramucosal nitric oxide production, and less anti-inflammatory cytokine synthesis. There is evidence that diet which is fiber deficient results in changes in colonic microflora leading to an increase in pathogenic bacteria. The combination of rifaximin, a broad spectrum antibiotic, and mesalamine seem to prevent disease recurrence by de-activating the inflammatory cascade caused by alterations in the colonic micro-ecology. Probiotics, rifaximin, and mesalamine seem to down-regulate the inflammatory cascade caused by bacterial overgrowth with resultant increased mucosal levels of interleukin-1 and tumor necrosis factor alpha.1,3,18,23 This therapy may demonstrate effectiveness in the future. On the other hand, the traditional recommendation to avoid corn, nuts, and seeds in the diet was not based on clinical trials. Antispasmodic and anticholinergic agents have been used in treatment, but, again, there have been no well controlled studies to prove their clinical efficacy.9 Thus, the approach for

effective treatment and prevention of recurrence is evolving as the pathophysiology is becoming clearer and the concept of diverticular disease changes.1,3,18,23

Recommendations Are in Transition The diagnostic strategies and treatment recommendations for diverticulitis are in transition. The routine ordering of immediate CT scans for emergency department and primary care clinic patients may be increasing radiation exposure without clear benefits.29 There are physicians who treat patients with signs of uncomplicated diverticulitis empirically without obtaining immediate imaging studies, particularly if there is a history of diverticulosis.30 Clinical judgment with presence of specific parameters or use of sonogram may be reasonable, safe alternatives to immediate CT scanning in selected patients. This group would not include, however, the elderly, obese, or immunosuppressed. Further investigations are certainly required to answer this controversy more definitively. Shorter duration of antibiotic administration for simple diverticulitis may be curative. The absolute need for antimicrobials in addition to bowel rest to effectively treat simple diverticulitis is also being questioned. Entities such as micro-perforations and localized abscesses have been treated medically with success. The need for drainage of abscesses of moderate size remains unclear. This question is under scrutiny. Indications for elective resection also warrant further investigation. Some surgeons advocate treating non-feculent perforated diverticulitis with laparoscopy, copious lavage, and antibiotic therapy. The need for open surgery as performed in the past is another aspect of this illness that is being debated. As the pathophysiology of the disease becomes clearer, probiotics, rifaximin, and 5-ASA may become part of the armamentarium to prevent recurrences. The effectiveness of using these adjuncts in addition to recommending high fiber diet will hopefully be revealed in the future. The other questions under investigation include employing the most effective diagnostic tools with the least risks to the patient, the best medical treatment, the need to drain small- to moderate-size abscesses, as well as the surgical approach with most benefit, and will be demonstrated by future randomized trials. 1-28,31 Our small retrospective study demonstrated effective treatment with antibiotics and bowel rest of 50 patients diagnosed with uncomplicated diverticulitis without and with abscesses up to 5 cm. This study merely highlights one of the on-going controversies currently being debated about this common illness, and there is no doubt that future, randomized trials must be performed to provide evidence to answer the many questions that remain.

Limitations The first limitation of our small study is its retrospective nature. We did not study those who required immediate surgical intervention. Patients with generalized peritonitis were also

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not part of the study cohort. In addition, patients who were seriously ill or septic were not included, and there was only one female in the study. We did not include patients who were thought clinically to have diverticulitis but whose CT scans revealed other diagnoses. Finally, patients with diverticulosis were not part of the study cohort. We analyzed the outcomes of patients known to have uncomplicated diverticulitis with and without abscesses, all treated with either oral or intravenous antibiotics alone. None of the patients with abscesses had surgical drainage or drainage performed by interventional radiologists. Nancy Lutwak, MD, is Attending Physician and Clinical Assistant Professor, Department of Emergency Medicine, VA New York Harbor Healthcare System, New York City. Curt Dill, MD, is Chief of Service, Department of Emergency Medicine, VA New York Harbor Healthcare System, and Assistant Professor, NYU School of Medicine. Potential Financial Conflicts of Interest: By AJCM policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The author has stated that no such relationships exist. ®

Conclusion There are many on-going studies to determine the most reliable and safe diagnostic tools and treatment for uncomplicated diverticulitis. The patients in our study were diagnosed based on clinical parameters and CT findings and were found to have simple diverticulitis with or without abscess. They were all effectively treated with medication and bowel rest only, and none required abscess drainage for full recovery. It is clear that diverticulitis is being more conservatively treated over time. Prospective studies are warranted to determine the best strategy for evaluation of simple, clinicallyevident diverticulitis, keeping in mind the risks of intravenous nephrotoxic contrast, the radiation exposure from CT scans, and the financial burden which occurs from excessive testing. The safety of administering intravenous or oral antimicrobials in treatment of this illness complicated by small to moderate abscesses without drainage is still uncertain. Randomized trials are needed to ascertain which patients may be effectively treated without hospitalization, what antimicrobials are most appropriate, and the duration antibiotics should be administered for full recovery. There are ongoing studies to determine whether patients with uncomplicated diverticulitis require antibiotics at all or if supportive care alone is sufficient. As the physiology of diverticulitis is unfolded, the benefit of probiotics, rifaximin, and mesalamine to reduce bacterial overgrowth, inflammation, and reduce recurrences will hopefully be clarified. The most effective surgical approach for diverticulitis is also being questioned. It has become clear that this disease may range in severity from mild to life-threatening. The dogma requiring aggressive medical treatment, percutaneous drainage, and extensive surgical resection electively or emergently needs to be re-assessed with this revised view of diverticulitis.1-31

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9.

Stollman NH, Raskin JB. Diagnosis and Management of Diverticular Disease of the Colon in Adults. Amer J of Gastroenterol. 1999;94:31103121.

10. Brenner DJ. Should we be concerned about the rapid increase in CT usage? Rev Environ Health. 2010;25(1):63-68. 11. Brenner DJ, Hall EJ. Computed Tomography-An Increasing Source of Radiation Exposure. N Engl J Med. 2007;357:2277-2284. 12. Stoker J, Van Randen A, Lameris W, Boermeester MA. Imaging Patients with Acute Abdominal Pain. Radiology. 2009;253(1):31-46. 13. Mizuki A, Nagata H, Tatemichi M, Kaneda S, et al. The out-patient management of patients with acute mild-to-moderate colonic diverticulitis. Aliment Pharmacol Ther. 2005;21:889-897. 14. Schug-Pass C, Geers P, Hugel O, Lippert H. Prospective randomized trial comparing short-term antibiotic therapy versus standard therapy for acute uncomplicated sigmoid diverticulitis. Int J Colorectal Dis. 2010;25(6):751-9. 15. De Korte N, Unlu C, Boermeester MA, Cuesta MA. Use of antibiotics in uncomplicated diverticulitis. British J of Surgery. 2011;98:761-767. 16. Hjern F, Josephson T, Altman D, Holmstrom B, et al. Conservative treatment of acute colonic diverticulitis: Are antibiotics always mandatory? Scan J of Gastro. 2007;42:41-47. 17. Byrnes MC, Mazuski JE. Antimicrobial therapy for acute colonic diverticulitis. Surg Infect. 2009;10(2):143-54. 18. Szojda MM, Cuesta MA, Mulder CM, Felt-Bersma RJF. Review Article: management of diverticulitis. Aliment Pharmacol Ther. 2007;26 S2:6176. 19. Pelaez N, Pera M, Courtier R, Sanchez J, et al. Applicability, safety and efficacy of an ambulatory treatment protocol in patients with uncomplicated acute diverticulitis. Cir Esp. 2006;80(6):369-72. 20. Ridgway PF, Latif A, Shabbir J, Ofriokuma F, et al. Randomized controlled trial of oral vs. intravenous therapy for the clinically diagnosed acute uncomplicated diverticulitis. Colorectal Dis. 2009;11(9):941-6. 21. Alonso S, Pera M, Peres D, Pascual M, et al. Outpatient treatment of patients with uncomplicated acute diverticulitis. Colorectal Dis.2009;2:e278-282. 22. Stocchi L. Current indications and role of surgery in the management of sigmoid diverticulitis. World J Gastroenterol. 2010;16(7):804-817. 23. Beckham H, Whitlow CB. The Medical and Nonoperative Treatment of Diverticulitis. Clin Colon Rectal Surg. 2009;22:156-60.

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24. Vermeulen J, Lange JF. Treatment of Perforated Diverticulitis with Generalized Peritonitis: Past , Present and Future. World J Surg. 2010;34(3):587-593. 25. Martin GJ, Serralta DeColsa D, Garcia MA, Vaquero Rodriguez A, et al. Safety and efficiency of ambulatory treatment of acute diverticulitis. Gastroenterol Hepatol. 2009;32(2):83-7. 26. Brandt D, Gervaz P, Durmishi Y, et al. Percutaneous CT scan guided drainage vs. antibiotherapy alone for Hinchey II diverticulitis: a case control study. Dis Colon Rectum. 2006;49(10):1533-8. 27. Dharmarajan S, Hunt SR, Birnbaum EH, Fleshman JW, et al. The efficacy of nonoperative management of acute complicated diverticulitis. Dis Colon Rectum. 2011;54(6):663-71. 28. Ibele A, Heise CP. Diverticular disease: update. Curr Treat Options Gastroenterol. 2007;10(3):248-56. 29. Smith-Bindman R, Miglioretti DL, Larson EB. Rising Use of Diagnostic Medical Imaging in a Large Integrated Health System. Health Aff.2008;27(6):1491-1502. 30. DeStigter KK, Keating DP. Imaging Update: Acute Colonic Diverticulitis. Clin Colon Rectal Surg. 2009;22(3):147-155. 31. Hogan A, Winter D. Management of Acute Diverticulitis: Is Less More? Dis Colon Rectum. 2011;54:126-128.

Our MISSION The American Board of Physician Specialties® (ABPS) sets rigorous standards of certification, at all times furthering patient care, not only in the major cities but in rural areas that are sometimes forgotten— always focusing on communities’ needs. Our allopathic (MD) & osteopathic (DO) physicians place patients first and abide by the highest ethical standards.

Our vAlueS Integrity, Trust & Respect Our organization and its Diplomates conduct themselves with the highest level of integrity ensuring patient safety while providing for the highest level of care. Open & Honest Communications It is only through open and honest communications that we can build unity and strength. Advocating for the Highest Level of Patient Care The rigorous standards that we set ensure that our Physician Diplomates will provide the highest level of patient care.

Acute Diverticulitis: A Small Retrospective . . .

Sharing Knowledge & Best Practices Together our board certified physicians strive to share experiences, learnings and best practices in order to advance the level and quality of patient care. Compassion Our physicians demonstrate compassion in every aspect of their practice.

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Soft Tissue and Skin Infections in IVDA:

Treatment, Complications, and Use of Imaging Nancy Lutwak, MD

Abstract The patient is a 56-year old male presenting to the emergency department complaining of redness, swelling, and pain of his right forearm. One week prior to arrival, he was injecting cocaine when the needle tip broke off under his skin. He developed cellulitis secondary to a methicillin-resistant Staphlococcus aureus (MRSA) infection. The patient was hospitalized, treated with intravenous vancomycin, and the needle was surgically extracted using ultrasound guidance. The patient did well. Treatment was successful because of appropriate antibiotics, extraction of the foreign body, and adequate tissue penetration of the vancomycin. He was discharged on hospital day nine. IV drug abusers commonly develop skin and soft tissue infections. Cellulitis may progress to more serious illness if left untreated. Pyogenic myositis, necrotizing fasciitis, osteomyelitis, septic arthritis, abscesses, and bacterial endocarditis could develop. Patients sometimes present subacutely with retained needles. Use of imaging techniques to detect and treat complications is imperative. Ultrasound-guided removal of foreign bodies is effective. MRI and CT scans are invaluable for detecting deep complications progressing from cellulitis. MRSA infections require aggressive treatment with appropriate antimicrobials for improvement, particularly in patients with human immunodeficiency virus (HIV). Other infective agents should be considered when osteomyelitis is one of the complications.

Case Presentation The patient was a 56-year-old male, HIV positive, who chronically used cocaine. He presented to the emergency department

one week after a needle tip broke off in his right forearm while injecting cocaine. He complained of worsening redness, swelling, and pain at the site. Past medical history was significant for hepatitis C, myocardial infarction, chronic obstructive pulmonary disease, cardiomyopathy, and depression. The patient lived in a shelter, smoked one pack of cigarettes per day, and drank one beer daily. He used cocaine and marijuana. Medications included aripiprazole, bupropion hydrochloride, carvedilol, ipratropium inhaler, lisinopril, simvastatin, and trazodone hydrochloride. However, he was not taking the medications prescribed. Physical examination revealed pulse of 61, temperature of 97.8°F, respiratory rate of 16, and blood pressure of 121/80. The right dorsal forearm from one centimeter proximal to right antecubital crease was erythematous, edematous, and tender. There was warmth but no areas of drainage or fluctuance. Range of motion was normal at the elbow and wrist. No open wound was evident. The remainder of the examination was negative. Laboratory data were unremarkable. Wrist radiographs revealed a linear, needlelike, opaque foreign body in the soft tissues at the dorsal aspect, distal radius (Figure 1).

Treatment The patient was hospitalized, treated with intravenous vancomycin, and the needle was surgically extracted using ultrasound guidance.

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American Journal of Clinical Medicine® • Fall 2012 • Volume Nine Number Three

Figure 1: Soft Tissue and Skin Infections in IVDA.

Ultrasound guidance is excellent for removal of foreign bodies and prevents damage to tissue from attempted blind extraction.3 Ultrasounds may also detect fluid collections in the soft tissues and muscle.1 In addition, the sonogram is an effective tool to guide aspiration of intramuscular fluid and fluid collections in infected joints.1 CT scans are invaluable for determining depth of infection4 but detect change in soft tissue density, thus demonstrating the extent of infection. Gadolinium-enhanced MRI also demonstrates inflammatory changes in soft tissues. CT with contrast and MRI imaging are both helpful in detecting abscesses and fasciitis, an opposed to cellulitis.1 In patients suspected of osteomyelitis, CT detects subtle osteolysis of the cortex or sequestra. MR imaging is also key in making this diagnosis. Both of these imaging techniques pick up joint effusions indicative of septic arthritis, leading to joint aspiration with definitive identification of the causative infective agent.

Outcome The patient did well. Treatment was successful because of appropriate antibiotics, extraction of the foreign body, and adequate tissue penetration of the vancomycin. He was discharged on hospital day nine.

Discussion Intravenous drug users commonly develop skin and soft tissue infections ranging from mild to life threatening. Complications from infection result in 60-80% of total hospital admissions for this group. If not adequately treated, cellulitis may progress to pyogenic myositis, necrotizing fasciitis, osteomyelitis, septic arthritis, abscesses, bacterial endocarditis, and sepsis. Severe infections can result in high fatality rates and may not earlier be detected clinically. Imaging is an important diagnostic tool to differentiate between superficial and deep-seated involvement of the infection.1,2 Imaging leads to aggressive and necessary surgical intervention in cases of deep infection, such as abscesses, necrotizing fasciitis, or pyomyositis.1,2 IVDA patients present with varied complication. Foreign bodies, such as embedded needles, may complicate the presentation.2 Sub-optimal nutritional status and poor compliance with medication often lead to serious and deeper infections in patients with intravenous drug abuse.2 Soft tissue infections in this group are caused by inoculation of pathogens from the skin, most commonly Staphylococcus aureus or Streptococcus pyogenes. Delayed presentation results in spread of infection to subcutaneous tissue, muscle, fascia, tendons, as well as adjacent bones and joints. There also may be vascular complications, such as hematomas, aneurysms, septic thrombophlebitis, and arterial emboli. Other sequelae include lymphatic obstruction and emboli leading to endocarditis.1 Imaging is helpful in determining extent and location of infection and is also useful in detecting foreign bodies, such as embedded needles.1

Missed foreign bodies that remain undetected are problematic in substance abuse patients. Delayed migration of foreign bodies may occur and lead to morbidity. Needle fragments from peripheral veins can lead to pulmonary embolization. Blind attempts at extraction are unwarranted. This often causes tissue damage as well as unsuccessful removal. Imaging should be used liberally for localization if presence of foreign body is suspected.5,6 In this IVDA patient population, which may be HIV positive, skin and soft tissue infections are frequently caused by MRSA. Intravenous vancomycin or oral linezolid treat MRSA effectively provided there is adequate dosing and tissue penetration. Osteomyelitis, however, may involve other bacteria: likely, salmonella, mycobacteria, pseudomonas, nocardia, and klebsiella.1

Learning Points •

Skin and soft tissue infection is common in IV drug abusers. It must be treated aggressively to prevent serious complications.

MRSA infections are effectively treated with IV vancomycin or oral linezolid as long as there is adequate dosing and tissue penetration.

Blind attempts at foreign body extraction without accurate localization may result in tissue, neural, and vascular damage.

Imaging tools are invaluable in determining depth and extent of skin and soft tissue infection.

Ultrasound, CT scan, and MRI are excellent tools for foreign body localization.

Nancy Lutwak, MD, is Attending Physician and Clinical Assistant Professor, Department of Emergency Medicine, VA New York Harbor Healthcare System, New York City.

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Potential Financial Conflicts of Interest: By AJCM policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The author has stated that no such relationships exist.

5.

Ozsarac M, Demircan A, Sener S. Glass Foreign Body in Soft Tissue: Possibility of High Morbidity Due To Delayed Migration. The J of Emerg Med. 2011;41(6):e125-e128.

6.

Brunette DD, Plummer DW. Pulmonary Embolization of Needle Fragments Resulting from Intravenous Drug Abuse. Am J Emerg Med. 1988;6:124-127.

References

7.

Weigelt J, Itani K, Stevens D, Lau W, et al. Linezolid versus Vancomycin in Treatment of Complicated Skin and Soft Tissue Infections. Antimicrob Agents Chemother. 2005;49(6):2260-2266.

8.

Stein GE, Wells EM. The importance of tissue penetration in achieving successful antimicrobial treatment of nosocomial pneumonia and complicated skin and soft-tissue infections caused by methicillin-resistant Staphylococcus aureus: vancomycin and linezolid. Curr Med Research and Opinion. 26(3):571-588(18).

®

1.

Theodorou SJ, Theodorou DJ, Resnick D. Imaging Findings of complications affecting the upper extremity in intravenous drug users: featured cases. Emerg Radiol. 2008;15:227-239.

2.

Warner RM, Srinivasan JR. Protean manifestations of intravenous drug use. Surg J R Coll Surg Edinb Irel. 2004;3:137-140.

3.

Callegari L, Leonardi A, Bini A, Sabato C, et al. Ultrasound-guided removal of foreign bodies: personal experience. Eur Radiol. 2009;19:1273-1279.

4.

Fayad LM, Carrino JA, Fishman EK. Musculoskeletal Infection: Role of CT in the Emergency Department. Radiographics. 2007;27(6):1723-36.

Soft Tissue and Skin Infections in IVDA . . .


American Journal of Clinical Medicine® • Fall 2012 • Volume Nine Number Three

Chylous Ascites from Transitional Cell Carcinoma of the Bladder Wudeneh Mulugeta, MD, MPH Lynn M. Steinbrenner, MD Deborah L. Farolino, MD

Abstract

Case

The majority of atraumatic chylous ascites in adults is caused by malignancies. Among the different malignancies, lymphomas are by far the most common causes of chylous ascites. Other reported causes include neoplasms arising from the breast, endometrium, ovary, testis, pancreas, esophagus, stomach, colon, prostate, carcinoid, and lung. However, atraumatic chylous ascites secondary to bladder cancer is extremely rare. We report here the case of a 74-year-old male with stage IV bladder cancer who was found to have chylous ascites.

A 74-year-old male, who was undergoing initial staging workup for a newly diagnosed transitional cell carcinoma (TCC) of the bladder, presented with a one-month history of non-specific abdominal pain. Initial abdominal computer tomography (CT) scan revealed mesenteric and retroperitoneal lymphadenopathy along with small peri-hepatic and peri-splenic ascites not amenable to paracentesis. Subsequent biopsy confirmed metastasis of TCC of the bladder to the retroperitoneal lymph nodes. Further workups of his abdominal pain with esophagogastroduodenoscopy (EGD) and mesenteric angiogram were unremarkable. After adequate pain control, he was discharged home with outpatient oncology appointment. The patient returned one week later with continuation of his abdominal discomfort along with anorexia, abdominal distension, and leg swelling. He did not have fever or chills. Upon presentation, his blood pressure was 140/66, pulse rate 82, and temperature 97.4°F. On physical examination, bowel sounds were audible. The abdomen was mildly distended and diffusely tender without guarding or rebound tenderness. There was significant pitting edema of the lower extremities. Blood analysis revealed the following results: white blood cell 4.4 k/mm3; hemoglobin 11.0 g/dl; platelets 305 k/mm3; neutrophils 73%; and lymphocytes 15.5%. Repeat CT scan of the abdomen at the time showed increased ascites as well as increased mesenteric and retroperitoneal lymphadenopathy. Paracentesis was performed with removal of 1.7L milky-appearing peritoneal fluid. Fluid analysis confirmed chylous ascites with triglyceride level of 893 mg/dl. Gram stain, bacterial, and fungal cultures of the peritoneal fluid were unremarkable. Cytology of the peritoneal fluid was consistent with metastatic TCC of the bladder. The patient was started on high-protein, low-fat, and medium-chain triglycerides (MCTs) diets along with octreotide. He was also initiated on chemotherapy with Carboplatin and Gemcitabine,

Introduction Chylous ascites, or chyloperitoneum, is a rare form of ascites that is caused by the leakage of lymphatic fluid in the abdominal cavity. The reported incidence ranges from 1 per 187,000 to 1 per 20,000 admissions over a 20-year period at large tertiary referral hospitals.1 Although trauma as well as congenital lymphatic abnormalities can lead to chyloperitoneum, malignancies are the most common causes, with malignant lymphomas accounting for as much as 54% of chylous ascites among adults.2 The prognosis in these patients is usually very poor with a one-year mortality rate of 90%.2 In addition to lymphomas, several cancers and sarcomas have been reported as the underlying causes for atraumatic chyloperitoneum. However, there is very little report of atraumatic chylous ascites secondary to bladder cancer in the literature. We discuss here a case of chyloperitoneum secondary to bladder cancer with review of the relevant literature.

Keywords Chylous ascites, chyloperitoneum, atraumatic, transitional cell carcinoma of the bladder.

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eventually completing five cycles. Repeat CT scan following five cycles of chemotherapy showed some improvement of the lymphadenopathy. Subsequent paracentesis also revealed substantial reduction in triglyceride level of the peritoneal fluid from 893 mg/dl to 240 mg/dl. Repeat cytology of the peritoneal fluid was found to be negative for malignancy. Unfortunately, our patient had multiple and prolonged hospitalizations complicated by urinary tract infection and recurrent Clostridium difficile colitis. The patient progressively deteriorated, and he died eight months later.

Discussion The lymphatic system was discovered by the Italian physician Gasparo Aselli in 1622.3 Although the first case of chylothorax was reported by Bartholin in 1651, it wasn’t until 1694, when Morton described the first case of chylous ascites.3 Chylous ascites refers to the presence of milky chyle in the peritoneal cavity. Previous studies have reported incidence of chylous ascites ranging from 1:187,000 to 1:20,000 admissions over a 20-year period at major hospitals.1 However, the incidence is believed to be increasing because of more aggressive thoracic and retroperitoneal surgery along with prolonged survival of cancer patients. Some investigators have roughly categorized the causes of chylous ascites into traumatic and atraumatic.4 In traumatic cases, blunt abdominal trauma or direct injuries from surgical procedures can rupture lymphatic vessels, creating lymphoperitoneal fistula and chyloperitoneum. On the other hand, atraumatic chylous ascites manifests when the lymph flow is obstructed by non-traumatic causes, such as malignancies, infections, or congenital abnormalities. The most common causes of atraumatic chylous ascites among adults are malignancies. Malignancies can cause lymph flow obstruction by extrinsic compression or direct invasion. The majority (as much as 54%) of the malignancies causing chylous ascites are lymphomas.1,2 Carcinomas of the breast, endometrium, ovary, testis, pancreas, esophagus, stomach, colon, prostate, carcinoid, and lung have also been reported as causes of chyloperitoneum.1,2,4 However, atraumatic chylous ascites secondary to bladder cancer is extremely uncommon. In our Medline search (using PubMed) of the literature, we found very few reports of chylous ascites associated with bladder cancer. This is consistent with other large case series and meta-analysis studies, which did not find atraumatic chylous ascites caused by bladder cancer.2,4,5 A possible explanation for this observation is the fact that the vast majority of patients with bladder cancer tend to present at early stages of the disease. According to data released by the National Cancer Institute (NCI) in 2012, nearly 86% of bladder cancers are either in situ or localized to the primary site at the time of their diagnosis.6 Unfortunately, our patient had advanced bladder cancer with metastasis to the mesenteric and retroperitoneal lymph nodes leading to chyloperitoneum. Patients with chylous ascites can present with abdominal distension, non-specific abdominal pain, anorexia, weakness, and edema. To make a definitive diagnosis of chylous ascites, paracentesis should be performed for peritoneal fluid analysis. Some of the main characteristics of chyle include milky appearance, alkaline chemical

property, specific gravity greater than 1.012, and staining of fat globules with Sudan Red stain.1 Although there is no set criteria to make the diagnosis of chyloperitoneum, measuring the triglyceride level is critical. The triglyceride levels are typically > 200 mg/dl, and some authors have used 110 mg/dl as a cut off value.1,7 Management of chylous ascites includes high-protein and low-fat diets with MCTs to improve nutritional status and reduce chyle formation. Although no treatment guidelines exist, several case reports have demonstrated benefits from using octreotide.8 Ultimately, the treatment as well as the prognosis of chylous ascites depends on the underlying disease process. For patients with chylous ascites caused by malignancies, the prognosis is usually very poor with the three-month and one-year mortality of 52% and 90%, respectively.2 Unfortunately, our patient had advanced bladder cancer with multiple complications and partial response to treatment. Wudeneh Mulugeta, MD, MPH, is a second year Internal Medicine/Social and Preventive Medicine Resident at the State University of New York (SUNY) at Buffalo. Lynn M. Steinbrenner, MD, is Clinical Associate Professor of Hematology/Oncology, Department of Medicine at the State University of New York (SUNY), Buffalo, and Chief of Hematology and Oncology at the Veterans Administration (VA) Western New York Healthcare System at Buffalo. Deborah L. Farolino, MD, is Clinical Assistant Professor of Hematology/Oncology, Department of Medicine at the State University of New York (SUNY) at Buffalo. Potential Financial Conflicts of Interest: By AJCM policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The author has stated that no such relationships exist. ®

References 1.

Aalami OO, Allen DB, Organ CH Jr. Chylous ascites: a collective review. Surgery. 2000;128:761–778.

2.

Press OW, Press NO, Kaufman SD. Evaluation and management of chylous ascites. Ann Intern Med. 1982;96:358–364.

3.

McCarthy H, Organ CJ. Chyloperitoneum. Arch Surg. 1958;77:421-32.

4.

Steinemann DC, Dindo D, Clavien PA, Nocito A. Atraumatic chylous ascites: systemic review on symptoms and causes. J Am Coll Surg. 2011;212(5):899-905.

5.

Vasko J, Tapper R. The surgical significance of chylous ascites. Arch Surg. 1967;95:355-68.

6.

Howlader N, Noone AM, Krapcho M, Neyman N, Aminou R, Altekruse SF, Kosary CL, Ruhl J, Tatalovich Z, Cho H, Mariotto A, Eisner MP, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975-2009 (Vintage 2009 Populations), National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2009_pops09/, based on November 2011 SEER data submission, posted to the SEER web site, 2012.

7.

Almakdisi T, Massoud S, Makdisi G. Lymphomas and chylous ascites: Review of the literature. The Oncologist. 2005;10:632-635.

8.

Mincher L, Evans J, Jenner MW, Varney VA. The successful treatment of chylous effusions in malignant disease with octreotide. Clin Oncol (R Coll Radiol). 2005;17:118.

Chylous Ascites from Transitional Cell Carcinoma of the Bladder


American Journal of Clinical Medicine® • Fall 2012 • Volume Nine Number Three

Breast Cancer in the New Age – IMRT Gary Shultz, DO, FAAR

Based on a Presentation at the 2012 AAPS Annual Scientific Meeting

Abstract Since its introduction into clinical use, IMRT (Intensity Modulated Radiation Therapy) has revolutionized the ability to deliver radiation to the breast. The ability to optimally manipulate the intensities of individual rays within each beam allows for potential improved tumor control with normal tissue toxicity reduction.1

Introduction Breast cancer statistics show 213,000 new cases per year with 40,000 deaths. It is the leading cancer among women and is the second leading cause of cancer death in women. Breast cancer risk factors include the following: gender – male: female 1:100; age – 1 in 50 women by the age of 50 and 1 in 8 over a lifetime. The environment and physical risks include: early menarche, late menopause, nulliparity, late first pregnancy, high-fat diet, alcohol- and tobacco-use, and decreased physical activity. Related risks are exogenous hormones with replacement therapy being particularly problematic. The inherited factors are: family history, major inherited susceptibility, and DNA repair defects. Cases can be sporadic (70%), family clusters (20%), or hereditary (10%). The cause of hereditary susceptibility is BRCA1 – 20 to 40%; BRCA2 – 10 to 30%; TP53 <1%; PTEN <1%; and undiscovered genes 30 to 70%. The most common are the BRCA mutations, which occur in multiple cases of early-onset cancer. A family history of ovarian cancer shows an increased incidence in breast cancer. The patients who have bilateral breast cancer are most likely to Ashkenazi Jewish heritage and/or are male. The types of BRCA are

usually found in tumor suppressor gene on chromosome 17 and have autosomal dominant transmission.

Diagnosis of Breast Cancer Recommendations for women ages 20-30: monthly breast selfexamination and clinical breast examination every three years. The baseline mammogram for high-risk patients (as defined above) starts at 35 years old. Low-risk patients should have monthly self- and yearly clinical breast examinations and occasional mammograms starting at age 40, though these recommendations are being reviewed intensely as the radiation risks are balanced and new technologies become available. The highrisk patient or one who has dense breasts should have a consultation with a high-risk specialist, possibly using ultrasound and/or MRI of the breast. The treatment is based on genetic, axillary lymph node status usually by sentical node dissection, tumor size, histological grade, stage, hormonal receptors status, HER@/neu status, age, and margin status. The criteria were established by the NIH Consensus Conference 2003. Staging consists of history and physical, chest, abdomen, and pelvis CT scan, MRI of the breasts, CBC, and blood chemistry. The standard treatment for early breast cancer is surgery with lumpectomy or partial mastectomy followed by chemotherapy and/or hormonal therapy. The chemotherapy and/or hormone therapy are dependent on the tumor size, DNA studies, and lymph node status. We follow with radiation to the breast. In advanced cancers we may use a modified radical mastectomy instead of the lumpectomy or partial mastectomy. New hori-

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zons have brought new treatments with partial breast radiation and genetic and protein inhibitors.

Gary Shultz, DO, FAAR, is Department Chairman at the Christie Clinic Cancer Center, and Assistant Professor at the University of Illinois.

Radiation Discussion

Potential Financial Conflicts of Interest: By AJCM policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The author has stated that no such relationships exist. ®

IMRT has improved on delivery with sparing of healthy tissues and places more radiation in the tumor bed region. We have developed components to improve tumor control by using a prescription method, structure definition, setup aids and immobilization devices, positioning strategy, new delivery techniques, and quality assurance checks. The recommendation for the dose is to be delivered over the course of treatment with each session. We use several modes of operation to achieve the best course of treatment with radiography, cone beam CT, and fluoroscopy. Many randomized trials are showing the benefit of IMRT and the reduction of long-term side effects, such as coronary artery disease. We continue to work through the clinical challenges ahead to eliminate this disease.

References 1.

Clifford Chao KS. Chapter 9 in Practical Essentials of Radiation Therapy. Lippincott Williams and Wilkins; 2004.

2.

Herring DF, Compton DMJ. The degree of precision required in the radiation dose delivered in cancer radiotherapy. Brit. J. Radiol. 1970;5:1112-1118.

3.

Zagar TM, Marks LB. Breast Cancer Radiotherapy and Coronary Artery Stenosis: Location, Location, Location. JCO. February 1, 2012;30(4):350352.

4.

Shultz G. Re-Radiation and Casodex in Locally Advanced, Radiation Recurrent, Locally Progressing Prostate Cancer. American Journal of Clinical Medicine. 2011;8(3):170-171.

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Sounding Board and Letters to the Editor are your opportunities to share your thoughts, concerns, or suggestions to the AJCM readers. Publication in the AJCM is one of the criteria to qualify for the prestigious Degree of Fellow within the AAPS Academies of Medicine.

Breast Cancer in the New Age – IMRT


American Journal of Clinical MedicineÂŽ â&#x20AC;˘ Fall 2012 â&#x20AC;˘ Volume Nine Number Three

Case Report A Case Report and Discussion of Hibernomas: Pathology, Genetics, Diagnosis, and Treatment Jessica W. Grayson Joseph C. Wallace, MD

Abstract A hibernoma is a rare benign tumor found in brown fat, compared to white fat, where most tumors arise. Hibernomas can usually be surgically removed without complication. Some genetic markers may exist for development of hibernomas, particularly genetic deformities occurring in genes situated on chromosome 11. In addition, different types of hibernomas tend to present based on the area of the body in which they form. Hibernomas are often undiagnosed unless they pose a particular problem to the patient, i.e. pain or pressure. Hibernomas can be surgically removed in order to relieve these symptoms, as seen in the case study for this report.

Introduction Hibernomas are rare benign soft tissue tumors that arise from brown fat that persists beyond fetal life. The most common soft tissue tumors arise from white fat.1,2,3 These tumors were initially described in the early 1900s by Merkl as being composed of brown fat. In 1914, the term hibernoma was proposed by Gery due to the morphological similarities of this tumor to the brown fat present in hibernating animals.4 There are four subtypes of hibernomas that have been described previously and were recently added to the WHO Classification of tumors.9 These tumors occur more commonly in adults and are seen in the interscapular-periscapular area, neck, axilla, thigh, brain,

intrathoracic, and retroperitoneal area, as these are some of the places that brown fat will persist into adult life.5 These tumors usually present as slow, painless growths, most common in the third and fourth decades of life.2,6,7 There is some debate over gender predominance, and it has been noted previously that hibernomas are more common in one gender or another, although in previous reporting these numbers are very close to each other.2,8

Case Report A 30-year-old man was referred to Surgical Specialists of Alabama because of a mass in the right shoulder. He had previously presented to the Northport DCH Emergency Room complaining of pain and limited range of motion. The mass had been present in the right shoulder, proximal deltoid area for years and over the last two to three months had been increasing in size rapidly. The patient stated that he smokes one pack of cigarettes per day and was otherwise healthy. MRI of the shoulder and chest was obtained, pre- and post-contrast. On imaging, there was a large fatty mass seen in the anterior right chest/shoulder measuring 18 X 7.8 X 4.5cm. It contained multiple thin internal septations and a thin well-defined capsule. STIR images showed mild scattered edema around and within the mass. Post-contrast, the capsule and septa enhanced. The mass was noted to abut the pectoralis muscle with pos-

A Case Report and Discussion of Hibernomas . . .

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sibility of invasion. The mass also abutted the right shoulder and upper arm musculature. These findings were found to be consistent with lipomatous neoplasm, specifically benign fibrolipoma and liposarcoma. Suspicion for liposarcoma was high due to significant recent enlargement and associated pain. The mass was completely excised down to the fascia. It was found to involve the right deltoid muscle and extend onto the area of the pectoralis muscle. A portion of the pectoralis muscle was excised with the specimen. The specimen was encapsulated and not infiltrating and was completely excised and sent for pathology and inking of margins. The patient had an uneventful operative course and was discharged home the same day with follow-up appointment in one week. Macroscopically, the mass was tan-pink to tan-yellow, lobular, soft, irregularly surfaced, encapsulated, and vascular. The mass measured 21 X 11 X 6cm. After fixation there was no color, texture, or architectural change noted. It was composed of abundant brown fat, and no lipoblasts were seen. The specimen was determined to be a hibernoma.

Discussion The human body contains two types of fat: brown fat and white fat. Brown fat participates in thermogenesis and regulation of metabolism. While it is commonly found in animals that hibernate, the theory that it is involved in hibernation has been disproved. Brown fat also exists in animals that do not hibernate and in humans during gestation.8 It becomes recognizable in humans after the 21st week of gestation and is slowly replaced with white fat as maturation occurs.2 However, it does persist in humans in specific areas of the body, particularly the neck, axilla, mediastinum, periaortic area, and perirenal area. Brown fat constitutes 1% of body mass in adults.8,11 Furlong et al. completed a review of 170 hibernoma cases and found that hibernomas are more common in men than women, though that distinction is debated. The average age of diagnosis for the four histological subtypes of hibernomas occurs at 38.8 years.11 The study found that this tumor is most common in the lower extremities, followed by the upper extremities, head and neck, abdomen, and retroperitoneal.9 The overlying skin can be warm to the touch due to the extensive vascularity of the tumor.11 Typically, these masses present as painless, progressive, slow growth, and only become symptomatic when they compress adjacent structures.2 On imaging, they should clearly light up on contrast CT due to their fatty solid structure. Angiography can also be used, as these tumors are vascular. Blood flow through and within the mass can confuse the picture and cause it to look similar to a malignant process.2,6 On T1 weighted MRI they show up as hypointense to fat, and on T2 images they are usually found to be isointense to subcutaneous fat.11 These tumors can mimic the appearance of other lipomatous tumors, such as liposarcoma, increasing the need for index of suspicion and knowledge of the tumor type prior to surgery.1,11 Gross specimen is well defined, encapsulated, soft, and a tan to red-

dish brown color depending the amount of intracellular lipids present.2,7 Microscopically, it has large multivacuolated cells with eosinophilic cytoplasm and eccentric nuclei, univacuolated cells with peripheral nuclei, and smaller round cells with a granular cytoplasm.5,6

Diagnosis There tumors are generally painless and are often found incidentally during routine physical exams or following an injury.8 There has been some association to weight loss due to the excessive thermogenesis produced by the brown fat. In some cases a fever and elevated inflammatory markers such as sedimentation rate, leukocytes, and C-reactive protein can be elevated.8 At the time of diagnosis the tumor is usually ≥ 10 cm.3 On radiography, the hibernoma is seen as a soft tissue swelling, with few other characteristics.8 Ultrasound studies will show a hyperechoic mass with hypervascularity noted on Doppler studies.5,8 Angiography will also show the hypervascularity of the hibernoma along with possible arteriovenous shunts.8 The non-lipoma subtype is always heterogeneous, hypo- or isointense with hypervascularity on MRI.3 On T1 weight MRI they show up as hypointense to fat, and on T2 images they are usually found to be isointense to subcutaneous fat.11 On PET scanning these lesions typically light up due to an increased number of mitochondria and high rate of metabolism occurring in the brown fat.8 This is not the only benign lesion that lights up on PET scan; other examples include: benign follicular thyroid adenomas, colonic adenomas, renal oncocytomas, and benign plexiform neurofibromas.8 Typically, lipomas do not show uptake on PET scan, and liposarcomas show moderate uptake; however, there is some overlap in the definition of uptake values with little standardization so uptake potential does not accurately predict malignant potential.8 Some have suggested CT guided biopsy, but due to the hypervascularity of the tumor, this has been controversial due to risk of hematoma or bleeding.3 Therefore, core or percutaneous biopsies should be avoided to prevent these negative side-effects.5 However, it has been noted that fine needle or percutaneous biopsy has a specificity of 100% and a sensitivity of 99% for diagnosis of this pathology.8 Differential diagnosis of these tumors should include atypical lipoma, well differentiated liposarcoma, rhabdomyoma, fibroma, neurofibroma, angiolipoma, and granular cell tumor.8

Pathology In 2001, four morphological subtypes of hibernomas were described by Furlong: typical, myxoid, lipoma-like, and spindle cell, and in 2002 they were added to the WHO Tumor Classification.9,11 These four subtypes are determined based on ratio of multivacuolate adipocytes that are commonly seen in brown fat and univacuolate adipocytes that are commonly seen in white fat. Tumors with ≥ 70% multivaculoate adipocytes are considered to be non-lipoma hibernomas (typical), while < 70% multivacuolate adipocytes are considered lipoma-like hibernomas.3,8,9,10,11 The non-lipoma or typical subtype is considered the

A Case Report and Discussion of Hibernomas . . .


American Journal of Clinical Medicine® • Fall 2012 • Volume Nine Number Three

most common (82%) and has three histological appearances: the eosinophilic variant, the pale variant, and the mixed variant. The eosinophilic variant is the classic presentation.3 The myxoid subtype (9%) contains a basophilic matrix.8 Spindle cell hibernomas (2%) contain features of spindle cell lipomas and hibernomas.8 The lipomas variant (7%) only contains lipomatous cells in a scattered arrangement.8 Certain variants are more common in specific anatomical locations. For example, the thigh is most common for the typical hibernoma, while the myxoid type is most common in the head and neck, and the spindle cell variant is most common in the posterior neck and scalp.8 Approximately 85% of all hibernomas were found to contain S100 protein on immunohistochemical staining.11

Genetics Recent studies in Sweden suggest that there may be a genetic component to propensity to form hibernomas. Based on their research with 15 hibernomas, they found that these tumors typically present with a balanced translocation between the 11q13 chromosome and a variety of other chromosomes.12 These translocations have been found to be associated with MEN1 and AIP genes. These two genes sit close to each other on chromosome 11. They found in all except for one of their tumors that one or both of the alleles were deleted. The translocations of chromosome 11 occur between many different partner chromosomes, unlike other translocations that typically occur between alternating chromosomal partners. The target genes involved in the translocation are well known tumor-suppressor genes that are involved in hereditary tumor syndromes. AIP mutations area associated with a predisposition to familial pituitary adenoma syndrome. MEN1 protein product menin is associated with transcription and genomic stability and involved in the MENI, multiple endocrine neoplasia type I. These patients have displayed some lipomatous tumors in addition to the endocrine neoplasias typical of the disorder.12 MENI and AIP have been found to be connected to the formation of brown fat and its development. AIP is thought to repress peroxisome proliferator-activated receptor - alpha (PPAR alpha), and menin has been shown to have the same effect on peroxisome proliferator-activated receptorgamma. PPAR-alpha and PPAR-gamma have been shown to be involved in the rate-limiting reaction for brown fat lipogenesis. Therefore, the loss of MENI and AIP’s regulatory effect has been associated with overactivity of these enzymes leading to overproduction and development of brown fat.12

Treatment Hibernomas are typically removed surgically because histology and pathology cannot be confirmed by imaging and can even mimic more ominous tumors on imaging studies. These tumors do not infiltrate surrounding structures but can grow to a large size and lead to compressive effects.8 At the time of surgery, these tumors are found encapsulated and can be adhered to muscle or growing intramuscularly.8 Hibernomas are considered benign tumors, and, therefore, marginal excision is considered curative. There have been no metastasis or deaths

reported from these tumors, although there have been a few cases of nuclear atypic identified.9,11 There has been evidence of recurrence in some cases, but that has been attributed to incomplete resection of the primary hibernoma.8 Jessica W. Grayson is a fourth-year medical student at the University of Alabama School of Medicine, Tuscaloosa. Joseph C. Wallace, M.D., is Associate Professor and Chair, Department of Surgery, University of Alabama School of Medicine, Tuscaloosa. Potential Financial Conflicts of Interest: By AJCM policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The author has stated that no such relationships exist. ®

References 1.

Chitoku S, Kawa S, Watabe Y, Nishitani M, Fujimoto K, Otsuka H, Fushimi H, Kotoh K, Fuji T. Intradural spinal hibernoma: Case report. Surg Neurol. 49:509-13,1998.

2.

Kosem M, Karakok M, Hibernoma: A Case Report and Discussion of Rare Tumor. Turk J Med Sci. 25:175-76,2001.

3.

Peycr T, Tardat E, Schwartz A, Dufau J, Benois A, Durand-Dastes F. Hibernoma of the neck: a rare benign tumour. Can J Surg. 52: E52-53, 2009.

4.

Ahn C, Harvey JC. Mediastinal hibernoma, a rare tumor. Ann Torac Surg. 50: 828-30,1990.

5.

Dursun M, Agayev A, Bakir B, Ozger H, Eralp L, Sirvanci M, Guven K, Tunaci M. CT and MR characteristics of hibernoma: six cases Clin Imag. 32:42-47,2008.

6.

Rigor VU, Goldstone SE, Jones J, Bernstein R, Gold MS, Weiner S. Hibernoma: A case report and discussion of a rare tumor. Cancer. 57:2207-11,1986.

7.

Enzinger FM, Weiss SW. Soft tissue tumors. Mosby-Year Book, Inc. 4203,1995.

8.

Balaguera J, Fernandez i, Aquiriano L, Gonzalez M, Orellana J, Cerquella H. Axillary Hibernoma: An Unusual Benign Soft-Tissue Tumor. Int Jour of Surg. 22:11,2010.

9.

Furlong MA, Fanburg-Smith JC, Mittinen M. The morphologic spectrum of hibernoma: a clinicopathologic study of 170 cases. Am J Surg Pathol. 25:809-14,2001.

10. Miettinen MM, Fanburg-Smith JC, Mandahl N. Hibernoma. WHO Classification of tumors pathology and genetics of tumors of soft tissue and bone. 33-4,2002. 11. Moretti V, Brooks J, Lackman R. Spindle-Cell Hibernoma: A Clinicopathologic Comparison of This New Variant. 33, 2010. 12. Nord K, Magnusson L, Isaksson M, Nilsson J, Lilljebjorn H, Domanski H, Kindblom L, Mandahl N, Mertens F. Concomitant deletions of tumor suppressor genes MEN1 and AIP are essential for the pathogenesis of the brown fat tumor hibernoma. PNAS. 107:21122-27,2010.

A Case Report and Discussion of Hibernomas . . .

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Physicians’ Responsibility with Prescription Drug Abuse Bradley T. Wajda, DO

Abstract The discharge of a patient found to be abusing their prescription represents a tragic outcome – that of a missed opportunity to provide appropriate continuity of care for a newly discovered (and recognized) medical problem of the substance use disorder. As physicians we need to realize (as with the acetaminophen case) that we have just as much medicine to practice to help our patients solve their substance use disorder as we practiced while accompanying them to that point of developing a substance use disorder. Recently, I had the good fortune to be on a rather long flight to the Caribbean. Among the reading selections was the December 2011 issue of Discover magazine,1 which had a brief summary of a Journal of Pediatrics September 2011 article2 documenting a 101% increase in ER visits for accidental ingestions of medications by children under the age of five between 2001 and 2008, and which coincides with a near doubling of oxycodone prescriptions and a 559% rise in methadone prescriptions between 2000 and 2007. It struck me that, as physicians, we are expected to get our patients to say “yes” to drugs ... at least to prescription drugs when appropriate. The pace of today’s medical practice can be a challenge for us to do all the right things we learned in our last risk management seminar – such as getting an informed consent for medication. When prescribing a medication I typically tell the patient: 1) Take their medication as directed. 2) Let me know if they believe the dosage is insufficient to manage their problem. 3) Do not attempt to enhance the potency of their medica-

tion by “borrowing” the medication of a friend or family member (or by using alcohol and/or illicit drugs). 4) Tell each doctor they see which medications they are taking (including over-the-counter medications). 5) When using analgesics, they are not to use the medication to dull the pain enough to engage in physical activities that will only aggravate their condition. Furthermore, I monitor for use beyond the expected duration of the pain, the use of ever-larger amounts of medication, and reports of potential withdrawal symptoms when they try to stop taking their medication. However, reality is very different. Every day I have patients react to my pursuit of informed consent for medications with surprise and suspicion because “I’ve never had any other doctor do this.” How often do we see non-compliance or find out that our patient believed “if a little is good, then more is better?” Even so, we generally trust our patients. We recognize them as a partner in their own health care – someone who has far more to lose than we do if they are not both forthcoming and compliant. If we tell a patient to use acetaminophen for pain, how often do we tell them about the potential consequences of taking more than four grams per day?3 When they show up in the clinic with elevated liver enzymes, what do we do? We treat them and we educate them. In other words, we recognized that there was more medicine to be practiced when we discovered the problem. Why then do so many of us feel betrayed by the patient when we discover that they took a prescription for a scheduled drug and are now found to be abusing it? Granted, their presentation can be more devious (doctor shopping, lying, and manipulative behavior). Yet I see many patients who are denied any further prescription for scheduled medication or they are simply ter-

Physicians’ Responsibility with Prescription Drug Abuse


American Journal of Clinical Medicine® • Fall 2012 • Volume Nine Number Three

Table 1: Three Risk-Reduction Strategies.

Patient category

Urine drug tested

Made regular office visits

Restricted early refills

All patients

8.0%

49.8%

76.7%

Patients with drug use disorder

29.3%

52.9%

66.7%

minated from treatment altogether. Without exception, every physician I have ever spoken to about this regarding a mutual patient has cited liability concerns. I will be the first to say that I am not an attorney; however, it certainly seems to me that liability was an issue in the above described acetaminophen scenario as well. It is my opinion that to abruptly deny the refill of a scheduled medication or to terminate the doctor-patient relationship may well incur a greater liability. As physicians we need to realize (as with the acetaminophen case) that we have just as much medicine to practice to help our patient solve their substance use disorder as we practiced while accompanying them to that point of developing a substance use disorder. The real reason for this article is to remind us to maintain the delivery of good patient care AFTER we find out that our patient now has a prescription substance abuse problem. In my experience, the majority of the time the patient is discharged from care without a specific referral. They are often left without prescriptions, treatment recommendations, or even an explanation of what to expect (such as what withdrawal symptoms may occur). This scenario often leads to the first illicit use of drugs and where they will buy it from other (as-of-yet undiscovered) abusing patients or they will find the street equivalent.4 The discharge of a patient found to be abusing their prescription represents a tragic outcome – that of a missed opportunity to provide appropriate continuity of care for a newly discovered (and recognized) medical problem of the substance use disorder. Furthermore, this tragic outcome (in my opinion) could be construed as patient abandonment in the face of the aforementioned newly discovered medical problem. As medical professionals we strive to provide the best care possible, and the reality is that the best care is often only as good as our documentation in the event of a poor outcome. For this reason, we all practice some degree of defensive medicine. This should not be overlooked in cases of prescription abuse. Obvious areas of potential liability in the event that the patient is simply “cut off” from treatment or their prescription would be when withdrawal can be life threatening (such as benzodiazepine withdrawal).6 “An ounce of prevention is worth a pound of cure.” Preventing prescription abuse is the goal, and three risk-reduction strategies identified by Joanna Starrels, M.D., at the Albert Einstein College of Medicine11 as successful for prevention are: 1) Urine drug testing. 2) Regular face-to-face office visits at least every six months (and within 30 days of modifying treatment). 3) Restricted early refills. 4) The study included 1,612 patients which revealed the results in Table 1.

Apart from the urine testing, which was done more often in those patients with a substance use disorder, there was little difference in how often primary care clinicians saw the patient. Random urine testing is recommended along with faceto-face visits at least every six months (and within 30 days of a modification in the drug regimen). Of interest is that those with a substance abuse disorder were given early refills 10% more often. Early refills should require an explanation by the patient and be limited (e.g., once every two years). I also educate the patient about the abuse potential of the drug and how tolerance can manifest itself with specific prescriptions. If there is suspicion of prescription abuse, any consideration of treatment options begins with defining the extent of the problem. The following table is used extensively on different sites on the internet, including the site for the California Society of Addiction Medicine. This simply and sufficiently summarizes the DSM IV criteria for dependence vs. abuse without the excessive detail included in the more recent DSM IV-TR: DEPENDENCE (3 or more in a 12-month period) • Tolerance (marked increase in amount; marked decrease in effect) • Characteristic withdrawal symptoms; substance taken to relieve withdrawal • Substance taken in larger amount and for longer period than intended • Persistent desire or repeated unsuccessful attempt to quit • Much time/activity to obtain, use, recover • Important social, occupational, or recreational activities given up or reduced • Use continues despite knowledge of adverse consequences (e.g., failure to fulfill role obligation, use when physically hazardous) • Recurrent use resulting in failure to fulfill major role obligation at work, home, or school

Physicians’ Responsibility with Prescription Drug Abuse

ABUSE (1 or more in a 12-month period) • Symptoms must never have met criteria for substance dependence for this class of substance • Recurrent use in physically hazardous situations • Recurrent substance related legal problems • Continued use despite persistent or recurrent social oar interpersonal problems caused or exacerbated by substance

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Certain medications, which are prone to abuse, create more complex clinical issues. One popular medication is Soma (carisoprodol). It is a non-controlled skeletal muscle relaxant whose active metabolite is meprobamate, a Schedule IV controlled substance.7 Although several case reports have shown that carisoprodol has abuse potential, it continues to be widely prescribed. Biopsychiatry.com reports that a significant percentage of the physician population is unaware of the potential of carisoprodol for abuse and of its metabolism to meprobamate, a controlled substance. Another popular medication is Ultram (tramadol). Withdrawal from tramadol includes both opiate withdrawal and SSRI (selective serotonin reuptake inhibitor) withdrawal.8,9,10

Bradley T. Wajda, DO, is a Diplomate in Psychiatry certified by ABPS and in private practice in central California. He recently opened Esano Corporation offering adult and child psychiatry and substance abuse treatment.

1.

Once you have defined the substance use disorder, then it is necessary to determine treatment. Begin with a contract between you and the patient. Any controlled medications should be monitored by one physician (preferably with access to a Bureau of Narcotics Enforcement database, such as the California Prescription Drug Monitoring Program). The three riskprevention strategies discussed earlier should be applied, and appropriate laboratory studies should be obtained (e.g., LFTs). Patient accountability is paramount. Make specific referrals. Involve the family whenever possible. Depending on your area of expertise, you might elect to treat the problem on your own, but don’t hesitate to refer at the first sign of a treatment failure. There are many treatment possibilities including (but certainly not limited to): Buprenorphine, Methadone, Naltrexone, benzodiazepine taper, barbiturate taper, non-narcotic detoxification, Cognitive Behavioral Therapy, 12-step programs, and residential treatment. What is most important is that you use interventions that you are comfortable with and deem to be the best course of action BUT collaborate with the many resources available to provide support services and accountability.

Strong Medicine, Bitter Pills. Discover. Dec 2011 issue. Published online Feb 9, 2012.

2.

Bond GR, Woodward RW, Ho M. The Growing Impact of Pediatric Pharmaceutical Poisoning. The Journal of Pediatrics. Vol. 160(Issue 2);pages 265-270.e1, February 2012.

3.

Watkins PB, Kaplowitz N, Slattery JT, et al. Aminotransferase elevations in healthy adults receiving 4 grams of acetaminophen daily: a randomized controlled trial. JAMA. 2006;296(1):87-93.

4.

Inciardi JA, Surratt HL, Cicero TJ, et al. Prescription Opioid Abuse and Diversion in an Urban Community: The Results of an Ultrarapid Assessment. Pain Med. 2009 April;10(3):537-548.

5.

Retrieved August 14, 2012. www.csamasam.org/pdf/misc/dsm_criteria_ for_diagnosis.doc.

6.

The Merck Manual, 16th ed. 1992; p. 1560.

7.

Reeves RR, Pinkofsky HB, Struve FA, Bennett DM. Carisoprodol (soma): abuse potential and physician unawareness. J Addict Dis. 1999;18(2):51-6.

8.

Tartakovsky M. SSRI Discontinuation or Withdrawal Syndrome. Psych Central. Retrieved on August 10, 2012.

9.

Senay EC, et al. Physical Dependence on Ultram (tramadol hydrochloride): both opioid-like and atypical withdrawal symptoms occur. Drug and Alcohol Dependence. 2003;69;233-241.

Potential Financial Conflicts of Interest: By AJCM policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The author has stated that no such relationships exist. ®

References

10. Physicians’ Desk Reference, 66th ed. 2012; p. 2519. 11. Starrels JL, Becker WC, Weiner MG, et al. Low use of opioid risk reduction strategies in primary care even for high risk patients with chronic pain. J Gen Intern Med. 2011;Sep;26(9):958-64.

Physicians’ Responsibility with Prescription Drug Abuse


American Journal of Clinical Medicine® • Fall 2012 • Volume Nine Number Three

Call for Authors

Let your creative juices flow . . . Be a published author . . . Enhance your career and professional standing . . . Get personal satisfaction from seeing your work in print . . . Become known in your specialty . . . Take a step toward the Degree of Fellow

Have you considered writing an article for a medical journal? Or have you already begun an article and set it aside – now is the time to finish it. Stop thinking and start doing! “Take up your pen” – or computer, Notebook, or iPad, as the case may be – and submit your written items to the American Journal of Clinical Medicine®. WE WELCOME DIPLOMATES, MEMBERS, AND OTHER MEDICAL PROFESSIONALS TO SUBMIT ITEMS ON ANY MEDICAL OR HEALTH TOPIC. RESEARCH ARTICLES AND REVIEW ARTICLES Your original research or your review of others’ research. CASE REPORTS Have you had any interesting cases lately? Consider submitting your short, instructive case studies. They are easy to write and our readers love them. LETTERS TO THE EDITOR Have you read an article that triggers an immediate response? Send us your thoughts and comments. SOUNDING BOARD Do you have a specific opinion on a particular medical topic? Difficult patients? Not enough time? Insurance companies? Here’s your opportunity to express your opinions. RX CORNER You and a second author can debate the merits of a particular drug or treatment. MEDICAL ETHICS Respond to our regular feature, Medical Ethics Without the Rhetoric, or send us your medical ethics dilemma and get input from our readers. In addition to the printed version, your article will appear on the AAPS website and listed on BioMedLib and Google Scholar. Heed the call to submit your words of wisdom to the American Journal of Clinical Medicine®. Submit your items to editor@aapsus.org or contact Esther Berg at 813-433-2277 Ext. 18 for information. The American Journal of Clinical Medicine® is peer reviewed and listed in Google Scholar and BioMedLib.

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M E D I C A L E T H I C S WITHOUT THE RHETORIC Cases presented here involve real physicians and patients. Unlike the cases in medical ethics textbooks, these cases seldom involve human cloning, bizarre treatments, or stem cell research. We emphasize cases more common to the practice of medicine. Most cases are circumstantially unique and require the viewpoints of the practitioners and patients involved. For this reason, I solicit your input on the cases discussed here at councile@aol.com. Reader perspectives along with my own viewpoint are published in the issue following each case presentation. We are also interested in cases submitted by readers. The following case addresses the ethical conflicts that may arise when a physician is asked to provide care contrary to the wishes of a patient. Mark Pastin, PhD Mark Pastin, PhD, is president and CEO of the Council of Ethical Organizations, Alexandria, VA. The Council, a non-profit, non-partisan organization, is dedicated to promoting ethical and legal conduct in business, government, and the professions.

CASE THIRTEEN JAIL TIME

Your medical group has a contract to provide medical services to prisoners in a state correctional facility. While you are usually called on to provide emergency services, the prison has a well equipped infirmary with facilities equivalent to a small hospital. You are confronted by a patient obviously engaged in a hunger strike, and the Warden has ordered a feeding tube for the patient. You do not consider the patient to be in immediate danger, although he could be if he continues the hunger strike much longer. The patient says that he does not want a feeding tube or any other medical care. You would not normally treat a patient against his or her will unless there was an imminent risk to the patient. Prisoners surrender a great deal of autonomy, but they still have some human rights. You wonder if the right to assent to or decline medical care is one of these rights. For example, you know that prisoners have the right to decline participation in medical experiments. But you also do not want to be party to the prisoner’s self-destructive actions. If you refuse to treat the patient at this time, you know that your group will be called on the carpet by the correctional facility. What should you do? This is an actual case. Of course, there are any number of complicating circumstances and additional details; but please address the case on the basis of the information provided. There will be an analysis of this case and a new case in the next issue.

Your input is requested. Email your responses to: councile@aol.com. © Copyright Council of Ethical Organizations 2012

Medical Ethics Without the Rhetoric


American Journal of Clinical Medicine® • Fall 2012 • Volume Nine Number Three

M E D I C A L E T H I C S WITHOUT THE RHETORIC CASE TWELVE ANALYSIS THE CUSTOMER IS ALWAYS RIGHT Our case from the last issue involves a physician caring for a patient recovering from colon cancer. The patient is appalled at the idea of wearing an external ostomy bag for the rest of her life and is considering surgery to allow creation of an internal ostomy bag (ilioanal pouch). The surgery to create the internal ostomy bag is controversial and carries risks. You candidly explain this to her but she seems so determined to avoid an external ostomy bag that she is not hearing what you are telling her. She is happy to sign a waiver indicating that you explained the risks, but you doubt that she even read it. The question is whether you should proceed with the surgery. The majority of our readers felt that you should not go ahead with the surgery until you are convinced that the patient has truly understood and evaluated the risks. I agree with this viewpoint. Because of her understandable response to the prospect of an external ostomy bag, the patient may not be thinking clearly. As practical it makes sense to delay the surgery until she has had more time to think things over. A significant minority of readers found this approach paternalistic and felt that as long as the patient signed the waiver, it was permissible to proceed with the surgery.

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American Journal of Clinical Medicine® • Fall 2012 • Volume Nine Number Three

Manuscript Criteria and Information The American Journal of Clinical Medicine® (AJCM®), the official journal of the American Association of Physician Specialists, Inc. (AAPS), is a peer-reviewed journal dedicated to improving the clinical practice of medicine by publishing educational and informational articles. AJCM® is the official journal of the American Association of Physician Specialists, Inc. Send all manuscripts via email to editor@aapsus.org in Microsoft Word format. No other file formats will be accepted. Manuscripts submitted by fax or mail to the Journal WILL NOT BE ACCEPTED AND WILL NOT BE RETURNED. Manuscripts received are not to be under simultaneous consideration by another publication. Accepted manuscripts become the permanent property of the American Journal of Clinical Medicine® and may not be published elsewhere without permission from the publisher. Authorship Responsibility, Financial Disclosure, Assignment of Copyright, and Acknowledgment Forms: Authorship responsibility forms must be completed and signed by each author and accompany submitted manuscripts. Each author must submit a statement that specifies whether he or she has financial or proprietary interest in the subject matter or materials discussed in the manuscript. These forms may be downloaded from the AAPS website www.aapsus.org or may be obtained by request to the AAPS office at 813-433-2277 ext 18 or 30. Authorship Responsibility: All accepted manuscripts are copyedited; an edited typescript is sent for the author’s approval. The author is responsible for all statements in the work, including the copy editor’s changes. Data Access and Responsibility: For reports containing original data, at least one author (e.g., the principal investigator) should indicate that he or she “had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis” (DeAngelis CD, Fontanarosa PB, Flanagin A. Reporting financial conflicts of interest and relationships between investigators and research sponsors. JAMA. 2001;286:89-91). Units of Measure: Conventional units of measure are preferred, with Système International (SI) units expressed secondarily (in parentheses). In tables and figures, a conversion factor to SI may be presented in the footnote or legend to economize space. Exceptions to this policy include calories, hematocrit, glycosylated hemoglobin, blood cell counts, and ejection fraction, for which conventional units alone should be expressed. The metric system is preferred for length, area, mass, and volume. Manuscript Preparation: Manuscript preparation should generally follow the guidelines outlined in The International Committee of Medical Journal Editors: “Uniform requirements

for manuscripts submitted to biomedical journals,” The Journal of the American Medical Association, March 19, 1997;277:927934. An abstract of 100-150 words is required. The main text should be narrative in form and should be broken up into appropriate headings and/or subheadings. Any abbreviations used should be completely defined upon the first usage. The style of writing should conform to acceptable English usage and syntax. Please avoid slang, medical jargon, obscure abbreviations, and abbreviated phrasing. Manuscripts should be submitted electronically online to the email address above as a Microsoft Word document. Authors’ names should be on the title page ONLY. Revisions, editorials, and editorial correspondence follow the same procedures outlined, including a word count. Title Page: All submissions must include a title page. Titles should be concise, specific, informative, and should contain the key points of the work. Authors’ names should be on the title page only. Include the full names, degrees, and academic affiliations of all authors, indication of the corresponding author, his/her address, phone, fax, e-mail, address for reprint requests, and, if the abstract or any portion of the manuscript was presented at a meeting, the name of the organization, place, and date on which it was read. Include a word count for text only, exclusive of title, abstract, references, figure legends, and tables. Include brief biographical information including current position. Financial disclosure information should be included as a footnote. Acknowledgment Section: List all persons who have made substantial contributions to the work reported in the manuscript (including writing and editing assistance), but who are not authors; any financial interest in the subject matter or materials discussed in the manuscript; any research or project support/funding; any grant support. Manuscripts with statistical evaluations should include the name and affiliation of statistical reviewer(s). Original Research: For authors who wish to submit original research, including reports of randomized controlled trials, please contact the editor-in-chief for instructions and criteria for publication. Format: Articles should be submitted in Times New Roman 12 point font, single spaced with no additional or unnecessary styles applied to text. References: List references numerically (not alphabetically). All subsequent reference citations should be to the original number. Cite all references in the text or tables. Unpublished data and personal communications should not be listed as references. References to journal articles should include (1) author(s) (list all authors and/or editors up to three; if more than


American Journal of Clinical Medicine® • Fall 2012 • Volume Nine Number Three

three, list first three and “et al.”), (2) title, (3) journal name (as abbreviated in PubMed), (4) year, (5) volume number, and (6) inclusive page numbers. References to books should include (1) author(s) (list all authors and/or editors up to six; if more than six, list first three and “et al.”), (2) chapter title (if any), (3) editor (if any), (4) title of book, (5) city of publication, (6) publisher, and (7) year. Volume and edition numbers, specific pages, and name of translator should be included when appropriate. The reference numbers in the reference list (if any) should be keystroked. Do not let the word processing program generate the reference numbers, using such features as automatic footnotes or endnotes. The author is responsible for the accuracy and completeness of the references and for their correct text citation. Please note how reference is set in text in example below. Set yours to match. References in Text: The following is an example of how to list references within the text: “The Hawaii outbreak included at least one autochthonous case.”7 Do not include “personal communications” in the list of references. Authors who name an individual as a source for information in a personal communication, be it through conversation, a letter, e-mail message, or telephone call, should obtain written permission from the named individual. Tables, Illustrations, Legends: Number all tables and illustrations in the order of their citation in the text. Include a title for each table and figure – a brief, succinct phrase, preferably no longer than 10 to 15 words. Keep in mind all tables, illustrations and legends will be printed in grayscale and color-coded images may be difficult to interpret. Tables: Title all tables and number them in order of their citation in the text. Double-space each table on separate sheets of standard size white paper. If a table must be continued, repeat the title on a second sheet, followed by “cont.” Illustrations: Illustrations should be submitted online as a separate document. Most standard programs will be accepted. Please refer to the next section for details. Digital Art Submissions: Digital images must be submitted electronically online as a separate file from the manuscript. The canvas size of continuous-tone images should be at least five inches wide (depth not important) with an image resolution of at least 300 dpi. Line art images should have a minimum resolution of 1270 ppi. Formats accepted are EPS, TIFF, and JPG. Keep in mind all tables, illustrations, and legends will be printed in grayscale and color-coded images may be difficult to interpret. Legends: Include double-spaced legends (maximum length 40 words) on separate pages. Indicate magnification and stain used for photomicrographs and method of enhancement for digitally enhanced images.

Photographic Consent: A letter of consent must accompany all photographs of patients in which a possibility of identification exists. Remove identifying information from photos, x-rays, scans, etc. It is not sufficient to cover the eyes to mask identity. Acknowledgments: Acknowledge illustrations from other publications and, when applicable, include author(s), title of article, title of journal or book, volume number, page(s), month, and year. The publisher’s permission to reproduce in print and online and in AJCM® licensed versions should be submitted to the AJCM® when the manuscript is submitted. Disclaimer: Publication of any article or statement in the AJCM® does not constitute an endorsement by the AJCM® or its editors. Publication of any advertisement in the AJCM® does not constitute an endorsement by the AJCM® or its editors.

Manuscript Submission Checklist  Submit manuscript electronically online as a Microsoft Word document to editor@aapsus.org. Use Times New Roman 12 point font. Leave right margins unjustified (ragged).  On the title page, designate corresponding author with complete address, telephone, fax numbers, and e-mail address. Authors’ names should be on the title page ONLY. This allows reviews to be anonymous. Each author must also include current employment/position information and any other biographical information that author wishes to be included at the end of the article.  On the title page, include word count for text only, exclusive of title, abstract, references, tables, and figure legends.  Complete Authorship Responsibility Form, which includes Financial Disclosure, Assignment of Copyright and Acknowledgement. Include signed form with your submission.  Include statement signed by corresponding author that written permission has been obtained from all persons named in the acknowledgment (if applicable).  Include research or project support/funding in an acknowledgment (if applicable).  Check all references for accuracy and completeness. Put references in proper format in numerical order, making sure each is cited in sequence in the text. Please see In-Text Example above and make sure your references are set the same way.  Include a title for each table and figure – a brief, succinct phrase, preferably no longer than 10 to 15 words.  Submit illustrations electronically online in a file separate from the manuscript.  For digitally enhanced images, indicate method of enhancement in legend and submit electronically online.  Include informed consent forms for identifiable patient descriptions, photographs, and pedigrees (if applicable).  Include written permission from publishers (or other copyright owner) to reproduce or adapt previously published illustrations and tables (if applicable). Rev. 2/12

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American Journal of Clinical Medicine® • Fall 2012 • Volume Nine Number Three


The American Association of Physician Specialists, Inc., and the American Board of Physician Specialties are proud to introduce our staff and headquarters. EXECUTIVE DEPARTMENT

CERTIFICATION DEPARTMENT

Responsible for management and operations of Executive Committee, Board of Directors, Academies of Medicine, House of Delegates, Past Presidents, Awards, and Degree of Fellow

Responsible for all matters pertaining to Certification

William J. Carbone, CEO

including Initial Inquiries, Requirements, Recertification, Boards of Certification, Examination Information

Nadine B. Simone, Executive Assistant

Andrea N. Balboa, Assistant Director of Certification

CME, MEETINGS AND MEMBERSHIP

Christina Stebbins, Manager of Test Development

Responsible for Continuing Medical Education, Meeting Planning and Management, Membership, Publications

Susan C. LoBianco, Certification Coordinator

Esther L. Berg, Director of CME, Meetings, & Membership Keely M. Clarke, CME, Meetings, & Membership Coordinator

Marilyn D. Whitfield, Certification Coordinator

FINANCE & OPERATIONS

GOVERNMENTAL AFFAIRS

Responsible for Dues, Billing and Payments, Facilities, and Personnel

Responsible for State and Federal Legislation, Legislative and Recognition Issues, Medical Mission Outlook

Anthony J. Durante, Director of Finance and Operations

Lauren E. Withrow, Governmental Affairs Coordinator

Debi S. Colmorgen, Communications Coordinator

COMMUNICATIONS & EXTERNAL AFFAIRS Responsible for directing and implementing program activities and services related to AAPS/ABPS Government Affairs, PR/Marketing Communications and Outreach Programs.

Jeffery L. Morris, Jr., Director of Communications & External Affairs

PUBLIC RELATIONS AND MARKETING Responsible for Public Relations, Media Relations, Image Advertising, Products and Services Marketing

James G. Marzano, Director of Public Relations & Marketing

We welcome your ideas and suggestions. Donâ&#x20AC;&#x2122;t hesitate to call on your AAPS Team.


5550 West Executive Drive • Suite 400 Tampa, Florida 33609-1035

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Refer

a Colleague

DO YOU KNOW QUALIFIED PHYSICIANS WHO ARE INTERESTED IN ADDING A BOARD CERTIFICATION TO THEIR CV? Tell them that the American Board of Physician Specialties® (ABPS) provides medical specialty certification and recertification in the following specialties: • Anesthesiology • Dermatology • Diagnostic Radiology • Disaster Medicine • Emergency Medicine • Family Medicine Obstetrics • Family Practice • Geriatric Medicine • Hospital Medicine

• Internal Medicine • Obstetrics and Gynecology • Ophthalmology • Orthopedic Surgery • Psychiatry • Radiation Oncology • Surgery • Urgent Care

ABPS ALSO PROVIDES RECERTIFICATION FOR ELIGIBLE DIPLOMATES FROM MEMBER BOARDS OF ABMS AND AOABOS

Requirements are available at www.abpsus.org. For additional information, contact the ABPS Certification Department at 813.433.2277

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