I
CORRESPONDENCE
AMBIGUITIES OF CURRENT ISSUESIN HYPERCHOLESTEROLEMIA To the Edltor: The perceptive analysis by Brett [l] regarding the psychologic effects of the diagnosis and treatment of hypercholesterolemia could be beneficially extended to the physician’s caring for these patients. A basic problem is that physicians, like their patients, are uncomfortable with the ambiguities of the current issues regarding hypercholesterolemia. Most, unless immersed in the field, are unable to sort out the conflicting information regarding normal variations in cholesterol measurements in the same patient, the same laboratory, or a different laboratory from time to time; the clinical implications of changing an asymptomatic elevated cholesterol level and how to translate this into a concrete example for a patient; the issues regarding dietary alterations of polyunsaturated versus monounsaturated fatty acids; the different effectiveness, safety, side effects, and targets of the various hypocholesterolemic medications; issues such as hypertriglyceridemia and LDL:HDL ratios and the absolute levels of LDL and HDL and their implications; the reasons why diets may not be very effective; the reasons for a prolonged dietary trial and how to separate noncompliance from lack of effect; the issues of medications used to treat other significant conditions that may result in unfavorable lipid profiles; and so forth. The sense of confusion within the medical community supplements the ready access of the lay community to news summaries of the latest research pronouncement before the practitioner can evaluate the original paper or read a critical scientific appraisal.
When physicians are less confused and less psychologically “mixed up” concerning these issues, their message to patients will result in a reduction of “angst.” As long as the profession is unsure and uncomfortable, so too will the patients be. ROBERTMATZ,M.D. Mount Sinai Medical Center New York, New York 1. Brett AS. Psychologic effects of the diagnosis and treatment of hypercholesterolemia: lessons from case studies. Am J Med 1991; 91: 642-7. Submitted
January
28, 1992, and accepted
March 18. 1892
NANCYFUTRELL,M.D. CLARKMILLIKAN,M.D. Henry Ford Health Sciences Center Detroit, Michigan 1. American Geriatrics Society. Curriculum guidelines on the care of the elderly for internal medicine residency training programs. Am J Med 1991; 91: 449-52. 2. Barry PP. Geriatrics in internal medicine: the time has come [editorial]. Am J Med 1991; 91: 447-8. 3. Wiebers DO, Adams HP, Whist-rant JP. Animal models of stroke: are they relevant to human disease? Stroke 1990; 21: l-3. 4. Zivin JA. Grotta JC. Animal stroke models: they are relevant to human disease. Stroke 1990; 21: 981-3. 5. Futrell N, Garcia JH, Peterson E, Millikan C. Embolic stroke in aged rats. Stroke. In press. Submitted
EXPERIMENTALMODELSOF STROKE To the Editor: We agree enthusiastically with the need for specialized medical training with emphasis on the particular requirements of our aging population, as recently published in The American Journal of Medicine [1,2]. This applies to clinical medicine and also to the experimental study of diseases associated with aging. It is startling that experimental models of stroke, the number 3 killer in the United States and a clinical disorder associated with aging, are studied in the animal laboratory using young adult (2to 3-month-old rats, for example) animals [3,4]. We have recently produced stroke in geriatric (24month-old Fisher) rats, and have found marked alterations in the response of the aged brain to infarction, particularly a decrease in macrophage infiltration into the infarcted tissue as compared with that in the young rat [5]. It is important to consider all of the ramifications of the aging process when designing clinical approaches to individual patients [l] and when designing animal models of diseases associated with aging [5]. August
1992
The American
December
30, 1991,
and accepted March 19, 1992
MALABSORPTIONDUE TO GASTROINTESTINAL HISTOPLASMOSIS To the Editor: I would like to point out another aspect of gastrointestinal histoplasmosis in addition to that reviewed in the excellent discussion by Dr. Lawrence Gelb in the Clinicopathologic Conference in the January issue of the Journd [l]. Although the most common clinical manifestation of gastrointestinal histoplasmosis is mucosal ulceration, this disease can less commonly cause functional impairment of gastrointestinal function in the absence of structural damage of the gut. In this journal, we reported a case of disseminated histoplasmosis that presented with the malabsorption syndrome [2]. This patient had no gastrointestinal ulceration but had well-documented features of fat malabsorption as well as protein-losing enteropathy. Organisms consistent with Histoplasma capsulatum were observed in small bowel biopsy specimens, and the malabsorption resolved after treatment with amphotericin. Bank et al [3] also reported a case of gastrointestinal histoplasJournal
of Medicine
Volume
93
237
CORRESPONDENCE
AMBIGUITIES OF CURRENT ISSUESIN HYPERCHOLESTEROLEMIA To the Edltor: The perceptive analysis by Brett [l] regarding the psychologic effects of the diagnosis and treatment of hypercholesterolemia could be beneficially extended to the physician’s caring for these patients. A basic problem is that physicians, like their patients, are uncomfortable with the ambiguities of the current issues regarding hypercholesterolemia. Most, unless immersed in the field, are unable to sort out the conflicting information regarding normal variations in cholesterol measurements in the same patient, the same laboratory, or a different laboratory from time to time; the clinical implications of changing an asymptomatic elevated cholesterol level and how to translate this into a concrete example for a patient; the issues regarding dietary alterations of polyunsaturated versus monounsaturated fatty acids; the different effectiveness, safety, side effects, and targets of the various hypocholesterolemic medications; issues such as hypertriglyceridemia and LDL:HDL ratios and the absolute levels of LDL and HDL and their implications; the reasons why diets may not be very effective; the reasons for a prolonged dietary trial and how to separate noncompliance from lack of effect; the issues of medications used to treat other significant conditions that may result in unfavorable lipid profiles; and so forth. The sense of confusion within the medical community supplements the ready access of the lay community to news summaries of the latest research pronouncement before the practitioner can evaluate the original paper or read a critical scientific appraisal.
When physicians are less confused and less psychologically “mixed up” concerning these issues, their message to patients will result in a reduction of “angst.” As long as the profession is unsure and uncomfortable, so too will the patients be. ROBERTMATZ,M.D. Mount Sinai Medical Center New York, New York 1. Brett AS. Psychologic effects of the diagnosis and treatment of hypercholesterolemia: lessons from case studies. Am J Med 1991; 91: 642-7. Submitted
January
28, 1992, and accepted
March 18. 1892
NANCYFUTRELL,M.D. CLARKMILLIKAN,M.D. Henry Ford Health Sciences Center Detroit, Michigan 1. American Geriatrics Society. Curriculum guidelines on the care of the elderly for internal medicine residency training programs. Am J Med 1991; 91: 449-52. 2. Barry PP. Geriatrics in internal medicine: the time has come [editorial]. Am J Med 1991; 91: 447-8. 3. Wiebers DO, Adams HP, Whist-rant JP. Animal models of stroke: are they relevant to human disease? Stroke 1990; 21: l-3. 4. Zivin JA. Grotta JC. Animal stroke models: they are relevant to human disease. Stroke 1990; 21: 981-3. 5. Futrell N, Garcia JH, Peterson E, Millikan C. Embolic stroke in aged rats. Stroke. In press. Submitted
EXPERIMENTALMODELSOF STROKE To the Editor: We agree enthusiastically with the need for specialized medical training with emphasis on the particular requirements of our aging population, as recently published in The American Journal of Medicine [1,2]. This applies to clinical medicine and also to the experimental study of diseases associated with aging. It is startling that experimental models of stroke, the number 3 killer in the United States and a clinical disorder associated with aging, are studied in the animal laboratory using young adult (2to 3-month-old rats, for example) animals [3,4]. We have recently produced stroke in geriatric (24month-old Fisher) rats, and have found marked alterations in the response of the aged brain to infarction, particularly a decrease in macrophage infiltration into the infarcted tissue as compared with that in the young rat [5]. It is important to consider all of the ramifications of the aging process when designing clinical approaches to individual patients [l] and when designing animal models of diseases associated with aging [5]. August
1992
The American
December
30, 1991,
and accepted March 19, 1992
MALABSORPTIONDUE TO GASTROINTESTINAL HISTOPLASMOSIS To the Editor: I would like to point out another aspect of gastrointestinal histoplasmosis in addition to that reviewed in the excellent discussion by Dr. Lawrence Gelb in the Clinicopathologic Conference in the January issue of the Journd [l]. Although the most common clinical manifestation of gastrointestinal histoplasmosis is mucosal ulceration, this disease can less commonly cause functional impairment of gastrointestinal function in the absence of structural damage of the gut. In this journal, we reported a case of disseminated histoplasmosis that presented with the malabsorption syndrome [2]. This patient had no gastrointestinal ulceration but had well-documented features of fat malabsorption as well as protein-losing enteropathy. Organisms consistent with Histoplasma capsulatum were observed in small bowel biopsy specimens, and the malabsorption resolved after treatment with amphotericin. Bank et al [3] also reported a case of gastrointestinal histoplasJournal
of Medicine
Volume
93
237
