Selasa, 24 Mei 2011
Senin, 16 Mei 2011
Mastectomy without Anesthesia: The Cases of Abigail Adams Smith and Fanny Burney
Elizabeth Edwards (1949-2010) survived breast cancer for 6 years. She had the benefits of modern medical science, including anesthesia and painkillers. Despite her disease, Edwards published 2 bestsellers and shared upbeat messages on Facebook about her fate. Two hundred years ago, before the discovery of anesthesia by ether and painkilling pharmaceuticals, the odds of dying from illness and infection were much worse; nevertheless, some breast cancer patients dared to submit to surgery. The stories of 2 such women—Abigail Adams Smith (1765-1813), first-born child of John and Abigail Adams, and British novelist Fanny (Frances) Burney (1752-1840)—have been well-documented, and offer inspiration to breast cancer victims as well as insight into the history of surgery.(1)
When Abigail Adams Smith, or “Nabby,” at age 46, noticed a lump in her breast, she decided to leave her family's farm in upstate New York and move back to her parents' home in Quincy, Massachusetts. She consulted with doctors Tufts and Rush, informing them her tumor was moving. Rush responded by mail to her father with this advice: “Her time of life calls for expedition in this business, for tumors such as hers tend much more rapidly to cancer after 45 than in more early life.” She must have a mastectomy.
Several Boston surgeons journeyed to Quincy, among them John Collins Warren, of Ether Dome fame. In November 1811, they performed a mastectomy on their patient in a bedroom of her parents' home.
To read this article in its entirety, please visit our website.
-- Helle Mathiasen, CandMag, PhD, AJM Specialty Editor
This article originally appeared in the May 2011 issue of The American Journal of Medicine.
When Abigail Adams Smith, or “Nabby,” at age 46, noticed a lump in her breast, she decided to leave her family's farm in upstate New York and move back to her parents' home in Quincy, Massachusetts. She consulted with doctors Tufts and Rush, informing them her tumor was moving. Rush responded by mail to her father with this advice: “Her time of life calls for expedition in this business, for tumors such as hers tend much more rapidly to cancer after 45 than in more early life.” She must have a mastectomy.
Several Boston surgeons journeyed to Quincy, among them John Collins Warren, of Ether Dome fame. In November 1811, they performed a mastectomy on their patient in a bedroom of her parents' home.
To read this article in its entirety, please visit our website.
-- Helle Mathiasen, CandMag, PhD, AJM Specialty Editor
This article originally appeared in the May 2011 issue of The American Journal of Medicine.
Senin, 09 Mei 2011
Long-Term Use of Aspirin and the Risk of Gastrointestinal Bleeding
Regular aspirin use has been associated with gastrointestinal bleeding, but many people take aspirin for heart disease prevention. How can they minimize their GI bleeding risk?
Abstract
Background
In short-term trials, aspirin is associated with gastrointestinal bleeding. However, the effect of dose and duration of aspirin use on risk remains unclear.
Methods
We conducted a prospective study of 87,680 women enrolled in the Nurses' Health Study in 1990 who provided biennial data on aspirin use. We examined the relative risk (RR) of major gastrointestinal bleeding requiring hospitalization or blood transfusion.
Results
During a 24-year follow-up, 1537 women reported a major gastrointestinal bleeding. Among women who used aspirin regularly (≥2 standard [325 mg] tablets/week), the multivariate RR of gastrointestinal bleeding was 1.43 (95% confidence interval [CI], 1.29-1.59) when compared with nonregular users. Compared with women who denied any aspirin use, the multivariate RRs of gastrointestinal bleeding were 1.03 (95% CI, 0.85-1.24) for women who used 0.5 to 1.5 standard aspirin tablets/week, 1.30 (95% CI, 1.07-1.58) for women who used 2 to 5 tablets/week, 1.77 (95% CI, 1.44-2.18) for women who used 6 to 14 tablets/week, and 2.24 (95% CI, 1.66-3.03) for women who used more than 14 tablets/week (Ptrend<.001). Similar dose-response relationships were observed among short-term users (≤5 years; Ptrend<.001) and long-term users (>5 years; Ptrend<.001). In contrast, after adjustments were made for dose, increasing duration of use did not confer a greater risk of bleeding (Ptrend = .28).
Conclusion
Regular aspirin use is associated with gastrointestinal bleeding. Risk seems more strongly related to dose than duration of aspirin use. Efforts to minimize adverse effects of aspirin therapy should emphasize using the lowest effective dose among both short- and long-term users.
To read this article in its entirety, please visit our website.
-- Edward S. Huang, MD, MPH, Lisa L. Strate, MD, MPH, Wendy W. Ho, MD, MPH, Salina S. Lee, MD, Andrew T. Chan, MD, MPH
This article originally appeared in the May 2011 issue of The American Journal of Medicine.
Abstract
Background
In short-term trials, aspirin is associated with gastrointestinal bleeding. However, the effect of dose and duration of aspirin use on risk remains unclear.
Methods
We conducted a prospective study of 87,680 women enrolled in the Nurses' Health Study in 1990 who provided biennial data on aspirin use. We examined the relative risk (RR) of major gastrointestinal bleeding requiring hospitalization or blood transfusion.
Results
During a 24-year follow-up, 1537 women reported a major gastrointestinal bleeding. Among women who used aspirin regularly (≥2 standard [325 mg] tablets/week), the multivariate RR of gastrointestinal bleeding was 1.43 (95% confidence interval [CI], 1.29-1.59) when compared with nonregular users. Compared with women who denied any aspirin use, the multivariate RRs of gastrointestinal bleeding were 1.03 (95% CI, 0.85-1.24) for women who used 0.5 to 1.5 standard aspirin tablets/week, 1.30 (95% CI, 1.07-1.58) for women who used 2 to 5 tablets/week, 1.77 (95% CI, 1.44-2.18) for women who used 6 to 14 tablets/week, and 2.24 (95% CI, 1.66-3.03) for women who used more than 14 tablets/week (Ptrend<.001). Similar dose-response relationships were observed among short-term users (≤5 years; Ptrend<.001) and long-term users (>5 years; Ptrend<.001). In contrast, after adjustments were made for dose, increasing duration of use did not confer a greater risk of bleeding (Ptrend = .28).
Conclusion
Regular aspirin use is associated with gastrointestinal bleeding. Risk seems more strongly related to dose than duration of aspirin use. Efforts to minimize adverse effects of aspirin therapy should emphasize using the lowest effective dose among both short- and long-term users.
To read this article in its entirety, please visit our website.
-- Edward S. Huang, MD, MPH, Lisa L. Strate, MD, MPH, Wendy W. Ho, MD, MPH, Salina S. Lee, MD, Andrew T. Chan, MD, MPH
This article originally appeared in the May 2011 issue of The American Journal of Medicine.
Jumat, 06 Mei 2011
May 2011: New articles in press posted on AJM's website
Here are links to some of the new case studies now online...
Elephantiasic Thyroid Dermopathy
Bath Salts as a “Legal High”
Hydroxycitric Acid Dietary Supplement-Related Herbal Nephropathy
Kamis, 05 Mei 2011
Some Simple Rules for Effective Communication in Clinical Teaching and Practice Environments
“It is still not enough for language to have clarity and content … it must also have a goal and an imperative. Otherwise from language we descend to chatter, from chatter to babble, and from babble to confusion.”
René Daumal, French writer and poet, 1908-1944
Effective communication in clinical practice and teaching is, in my opinion, one of the most important skills that physicians in academic and community practice should strive to acquire. During my many years in medicine, I have often witnessed serious failures in effective communication between physicians and patients and among physicians speaking to each other. The commonest failure in communicating information is the result of inattentive or inaccurate listening. When an individual fails to comprehend what is being said either explicitly or implicitly, misunderstandings may result that require prolonged discussion and negotiation before resolution is achieved. We can all agree that confusion often results when careful listening is not exercised. So, how does one learn to listen effectively? This essay lists examples of a few communication failures with guidelines that I try to follow to improve my own communication skills in what I say or write.
Effective listening requires a conscious effort by the listener in order to understand what the speaker is trying to communicate. This kind of listening requires complete and focused attention on the part of the listener. It requires an expenditure of energy; it will not occur if the listener is distracted by other thoughts or by a handheld device such as a smart phone. When I am trying to communicate with someone, and they are scanning through messages on the screen of their handheld device, it irritates me because I feel that they are not focusing their attention on what is being said. In addition to being downright discourteous, listening is not occurring. The simple guideline to follow here is to focus one's attention actively and consciously on what is being said. This is the first of 5 communication failures with corrective guidelines that will be discussed in this editorial. Each failure interferes with effective communication and understanding.
To read this article in its entirety, please visit our website.
-- Joseph S. Alpert, MD, editor-in-chief, The American Journal of Medicine
This article originally appeared in the May 2011 issue of The American Journal of Medicine.
René Daumal, French writer and poet, 1908-1944
Effective communication in clinical practice and teaching is, in my opinion, one of the most important skills that physicians in academic and community practice should strive to acquire. During my many years in medicine, I have often witnessed serious failures in effective communication between physicians and patients and among physicians speaking to each other. The commonest failure in communicating information is the result of inattentive or inaccurate listening. When an individual fails to comprehend what is being said either explicitly or implicitly, misunderstandings may result that require prolonged discussion and negotiation before resolution is achieved. We can all agree that confusion often results when careful listening is not exercised. So, how does one learn to listen effectively? This essay lists examples of a few communication failures with guidelines that I try to follow to improve my own communication skills in what I say or write.
Effective listening requires a conscious effort by the listener in order to understand what the speaker is trying to communicate. This kind of listening requires complete and focused attention on the part of the listener. It requires an expenditure of energy; it will not occur if the listener is distracted by other thoughts or by a handheld device such as a smart phone. When I am trying to communicate with someone, and they are scanning through messages on the screen of their handheld device, it irritates me because I feel that they are not focusing their attention on what is being said. In addition to being downright discourteous, listening is not occurring. The simple guideline to follow here is to focus one's attention actively and consciously on what is being said. This is the first of 5 communication failures with corrective guidelines that will be discussed in this editorial. Each failure interferes with effective communication and understanding.
To read this article in its entirety, please visit our website.
-- Joseph S. Alpert, MD, editor-in-chief, The American Journal of Medicine
This article originally appeared in the May 2011 issue of The American Journal of Medicine.
Rabu, 04 Mei 2011
The Green Cerebrospinal Fluid
Presentation
A sample of cerebrospinal fluid from a 52-year-old-woman told an interesting tale. The patient reported a 1-week history of worsening headache, shortness of breath, and fatigue but denied any fever, chest pain, orthopnea, paroxysmal nocturnal dyspnea, nausea, vomiting, abdominal pain, or diarrhea. She had experienced a subarachnoid hemorrhage 7 months earlier, and at that time, she had required several ventricular shunts for persistent hydrocephalus. When she was admitted to the Rush University Medical Center, she had a functioning ventriculopleural shunt. The original device was inserted 4 months before her current illness but replaced 2 months later at the same site after it malfunctioned.
Assessment
On admission, the patient was afebrile and had normal vital signs. Her conjunctivae were not pale, and her cardiac examination results were unremarkable. Breath sounds were decreased in the left lung field, but the patient's extremities were free of edema. A neurologic examination indicated she was alert and oriented without any signs of meningitis.
A chest radiograph showed a left-sided pleural effusion; this was the same side where the current shunt had been placed. Because of concern for a malfunctioning shunt and possible central nervous system infection, the patient underwent shunt externalization with external ventricular drain attachment. Cerebrospinal fluid collected directly from the shunt catheter was sent for examination on a daily basis throughout her hospital course. Of note, the sample color was consistently green (Figure). Initially, the cerebrospinal fluid showed 10,000 red blood cells/μL and 40 white blood cells/μL (corrected, 38 white blood cells/μL) with 58% monocytes and 14% neutrophils. Cerebrospinal fluid glucose and total protein were normal at 87 mg/dL (simultaneous peripheral blood glucose, 117 mg/dL) and 10.1 mg/dL, respectively. Gram stain showed gram-negative rods.
To read this article in its entirety, please visit our website.
-- Gerome Escota, MD, James Como, MD, Harold Kessler, MD
This article originally appeared in the May 2011 issue of The American Journal of Medicine.
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