Letters
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should: • Include no more than 400 words of text, three authors, and five references • Type with double-spacing • Send with the letter a transfer-of-copyright form (see Table of Contents for location) signed by all authors • Provide a self-addressed envelope if they want to be notified that the letter was received Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified only if their letter is accepted. Unpublished letters cannot be returned.
The State of Internal Medicine To the Editors: We strongly disagree with the proposal outlined by Dr. Stein (1) to increase internal medicine residency training to 4 years, for the purpose of increasing the attractiveness of general internal medicine. In his proposal, residents would spend 4 months of the fourth year in primary care settings and the other 8 months in subspecialty training. This proposal has several fallacies. First, there is no evidence that medical students choose not to go into internal medicine or that residents opt for subspecialities over general internal medicine because residency training is too short. A recent study of medical students notes "internal medicine [compared with other specialties] is perceived as being more stressful . . . with less leisure time and less income potential" (2). Adding another year of residency is likely to decrease, rather than increase, the proportion of students choosing internal medicine. Second, Dr. Stein argues that residents would have more time for training in primary care and subspecialities during residency. However, primary care internal medicine training programs have been able to provide more experience in primary care than traditional programs even within 3 years of training. Additionally, there is no evidence that 8 more months of largely inpatient subspecialty training will produce general internists better trained for the largely ambulatory and primary care practice of general internal medicne. Finally, Dr. Stein's assumption that lengthening residency will lead to a reduction of subspecialty fellowships is untested and may be inaccurate. Is there a need for longer training in general internal medicine? Dr. Stein offers no supporting evidence other than the assertion that the database of internal medicine has greatly increased over the last 50 years (1). Before we expand the length of residency, we should have greater documentation of deficiencies in training that are not correctable with experience and that result from a limited period of training rather than the content of training. Finally, fellowships in general medicine conceivably could offer a voluntary mechanism for interested residents to receive broader and lengthier training in general internal medicine, if these fellowships were reoriented toward this broader training in clinical practice rather than serving primarily as a preparation for academic medicine. 518
Residency training in internal medicine is rigorous and demanding enough for residents. There is insufficient evidence, educational or otherwise, to justify increasing its length. Gregg Coodley, MD Oregon Health Sciences University Portland, OR 97201-3098 Marcia Kerensky Coodley, MD Tualatin Professional Center 6464 S.W. Boreland Road Tualatin, OR 97062
References 1. Stein JH. Grand cru versus generic: different approaches to altering the ratio of general internists to subspecialties. Ann Intern Med. 1991;114:79-82. 2. Schwartz MD, Lizer M, Babbott D, et al. Medical student interest in internal medicine. Ann Intern Med. 1991;114:6-15.
To the Editors: I was very interested to read the article by Dr. Stein (1) concerning the undersupply of general internists. My experience as a general internist in a metropolitan area suggests that part of the problem stems from the attitude of physicians both in practice and in the training field. One of the major barriers to an increased interest in general internal medicine among trainees is a perception of this field as being somehow inferior to more specialized areas of internal medicine. On more than one occasion I have been called by the emergency department physician, offering me a patient with a straightforward problem such as congestive heart failure; the general internist was called because no specialist was available. There well may be pressures on the emergency department to call a subspecialist directly because of fears about liability: Education about the capabilities of general internists may help to alleviate this tendency and to improve the image of general internists (as well as the mix of patients referred to physicians in general medicine). Another issue relating to the image and desirability of general internal medicine is the low regard this field is sometimes given in the training setting. At the academic residency I attended, the chairman of the department met with the residents almost monthly to encourage us to pursue research fellowships (a stated goal was to have " m o s t " residents pursue subspecialty training, despite the directive by the state to the university to provide clinicians for the care of state residents). One colleague of mine who made no pretenses about his desire to practice primary care in his home town was told that if that was his goal, he might as well have attended an osteopathic college. There is no question that the ratio of specialists to generalists in internal medicine is very high; the number of cardiologists and gastroenterologists treating diabetic patients and uncomplicated hypertensive patients in Richmond attests to that. Although Dr. Stein's suggestions, such as increasing the length of training, have merit, general internal medicine will not flourish as long as the field is perceived to be inferior to the specialties. Arthur S. Harrow, MD 7660 Parham Road Richmond, VA 23294
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Reference 1. Stein JH. Grand cru versus generic: different approaches to altering the ratio of general internists to subspecialists. Ann Intern Med. 1991;114:79-82.
To the Editors: Most of the offerings in the 1 January 1991 issue are superb, but I was especially stimulated by those of Reitemeier (1) and McGuire (2). It would be interesting to know more about the premedical aspects of these writers' lives, for I suspect one has the sensitivity to those issues before embarking on a medical career. I wonder if the overemphasis on the biomedical aspects of medicine in recent decades distorted the picture so much that the best candidates to become excellent practitioners were not attracted or were even discriminated against in the selection process. Some medical schools have given up interviewing candidates, considering it to be wasteful of faculty and administrative time. I always felt it to be well worth the time, both because I often would learn something from the encounters and because I thought the identification of even a few who were unsuited to medicine was so important. (After a candidate is accepted, there is tremendous pressure to complete the job and to justify the admission, so it is much better to identify beforehand those who should be encouraged to pursue other careers.) The chairpersons of the academic departments are also in the best position to influence which students and residents are selected, of course, as well as to embark on the formidable tasks Reitemeier assigns. They will do well to listen to Leon Eisenberg's advice, as alluded to by Reitemeier. The heart of the solution lies in selecting and nurturing those who can see the beauty and utility of approaching medicine as McGuire (2) suggests: In all aspects of my work with patients I gave priority to comprehensiveness, integration, and education. I tried to pay attention to the whole life of the patient and to what having a given disease meant to the individual patients . . . Most patients recognized in my encounters with them . . . elements of support and hope. Further, it may be that showing the same consideration for students and residents that he advocated for patients would foster the improvements that several authors advocated elsewhere in the issue. As Reynolds (3) and others pointed out, physicians and teachers of physicians must be aware of being role models so that they will try to project the image they want to replicate—instead of an image that is counterproductive. There have always been some who have done this, of course, but now we must foster their work with all the support they deserve. The special issue should help enormously. John T. Garland, MD 1411 N. Flagler Drive West Palm Beach, FL 33401-3404 References 1. Reitemeier RJ. The leadership crisis in internal medicine: what can be done? Ann Intern Med. 1991;114:69-75. 2. McGuire LB. Just beyond the next bend in the river: reflections on a medical career. Ann Intern Med. 1991;114:83-7. 3. Reynolds PP. Professionalism in residency [Editorial]. Ann Intern Med. 1991;114:91-2.
To the Editors: The 1 January issue brightened the day for those of us who try to practice medicine in the way Dr. McGuire described so beautifully in his essay (1). His pleasure in his work shone in every sentence. I particularly appreciated the articles by Schwartz and colleagues (2) and Lewis and colleagues (3). I find that asking those questions about personal health practices and providing counseling about good health habits tend to promote the kind of physician-patient relationship we all treasure. When I teach Clinical Methods to sophomore medical students, the first thing I say is "I'm here to inoculate you against a loss of compassion." I will keep a copy of this issue to share
with students and residents as I try to describe and demonstrate for them the joys of internal medicine. Margaret N. Mermin, MD 484 Moreland Avenue, N.E. Atlanta, GA 30307 References 1. McGuire LB. Just beyond the next bend in the river: reflections on a medical career. Ann Intern Med. 1990;114:83-7. 2. Schwartz JS, Lewis CE, Clancy C, Kinosian MS, Radany MH, Koplan JP. Internists' practices in health promotion and disease prevention. A survey. Ann Intern Med. 1991;114:46-53. 3. Lewis CE, Clancy C, Leake B, Schwartz JS. The counseling practices of internists. Ann Intern Med. 1991;114:54-8.
To the Editors: Is it not logical for medical students and residents to shun the exciting challenges of the practice of general internal medicine when the leaders of internal medicine have permitted subspecialists to dominate while paying lip service to most of us surviving and enjoying our lives on the front lines? The article by Braunwald (1) is especially troublesome. In my opinion, based on serving under four Department of Medicine chairpersons in two major medical schools, there is little difference in whether the department is organized * 'horizontally" or "vertically." The fundamental question is whether or not the departmental chairperson has the wisdom, courage, knowledge, vision, political suavity, persistence, and leadership ability to be the team leader who can control the troops and make the decisions that will be beneficial for the department and its obligations to society. The tail must never wag the dog. Dr. Thier (2) suggests that perhaps "solutions to the problems confronting internal medicine are different when framed from the perspective of patients . . . rather than why internists are unhappy." It is interesting that the opinion of the patient is seldom mentioned in articles published on medical advances or techniques. It seems that a good method of evaluating quality of care would be at least to ask patients whether their encounters with the health care system made the quality of their lives better, unchanged, or worse. The editorials by Federman (3) and Reynolds (4) eloquently expressed the need to teach medical students and internal medicine residents and fellows "the art of balancing science, technology, and research with compassion, service, and clinical wisdom." In addition, I would add personal morality, dedication, and the ability and desire to teach. John W. Frost, MD 1066 Browns Mill Road Freeport, IL 61032 References 1. Braunwald E. Subspecialists and internal medicine: a perspective. Ann Intern Med. 1991;114:76-8. 2. Thier SO. The future of internal medicine: framing the questions [Editorial]. Ann Intern Med. 1991;114:88-9. 3. Federman DD. A perspective on medical student education for internal medicine [Editorial]. Ann Intern Med. 1991; 114:90. 4. Reynolds PP. Professionalism in residency [Editorial]. Ann Intern Med. 1991;114:91-2.
l,25(OH) 2 Vitamin D for Osteoporosis To the Editors: I am intrigued by the findings recently reported by Gallagher and Goldgar (1). They describe a significant increase in vertebral bone mineral density in patients with postmenopausal osteoporosis treated with l,25(OH)2 vitamin D. However, although their data suggest the possible utility of l,25(OH)2 vitamin D in the treatment of postmenopausal osteoporosis, most of their patients were substantially hypercalcuric by the end of the study. According to the authors' Table 2, the average urinary calcium in the treated patients was 6.4 mmol/d (256 mg/d). This means that more than 50% of their
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patients met conventional criteria for hypercalcuria (2). I wonder then whether patients treated with such high doses of activated vitamin D are at increased long-term risk for nephrolithiasis. Harold Rosen, MD Harvard Medical School Boston, MA 02215 References 1. Gallagher JC, Goldgar D. Treatment of postmenopausal osteoporosis with high doses of synthetic calcitriol. A randomized controlled study. Ann Intern Med. 1990;113:649-55. 2. Insogna KL, Broadus AE. Nephrolithiasis. In: Felig P, Baxter JD, Broadus AE, Frohman LA, eds. Endocrinology and Metabolism. New York: McGraw-Hill Book Co.; 1987:1500-77.
In response: Dr. Rosen has raised an interesting question about the potential risk for developing renal stones among patients treated with vitamin D metabolites. In our study (1), such patients had an average 24-hour urine calcium of 6.4 mmol (256 mg), which suggests to Dr. Rosen that therapy with high-dose vitamin D metabolites could increase the risk for stones because more than 50% of the patients had hypercalcuria. He has used the definition of hypercalcuria that was originally proposed by Hodgkinson and Pyrah (2) in 1956, namely, that hypercalcuria is present if the 24-hour urine calcium exceeds an arbitrary value of 6.25 mmol (250 mg), a definition based on the fact that 90% of normal women had values less than 6.25 mmol (250 mg). However, more recent epidemiologic studies have shown that for women, the normal 90% limits are now around 7.5 mmol/d (300 mg/d) and, for men, 10 mmol/d (400 mg/d) (3, 4). Our own recent measurements of the 24-hour urine calcium in 60 normal elderly women (average daily calcium intake, 19 mmol [760 mg]) support this figure. We found that 20% of women had urine calcium values that exceeded 6.25 mmol/d (250 mg/d) and 6% had values that exceeded 7.5 mmol/d (300 mg/d). Thus, based on these new criteria, the calcitriol-treated osteoporotic group did not have hypercalcuria. Another issue concerns the relative importance of hypercalcuria in kidney stone formation. Risk-factor analysis has ranked the following factors in order of importance for stone formation: urine volume, urine oxalate, uric acid, pH, inhibitors, and urine calcium (5). Given these more recent findings, one should not be alarmed at an average urine calcium of 6.4 mmol/d (256 mg/d). More importantly, the 24-hour urine calcium should be kept at less than 7.5 mmol (300 mg) and an increase in water intake would add a measure of safety. J. C. Gallagher, MD Creighton University Omaha, Nebraska 68131-2197 References 1. Gallagher JC, Goldgar D. Treatment of postmenopausal osteoporosis with high doses of synthetic calcitriol. A randomized controlled study. Ann Intern Med. 1990;113:649-55. 2. Hodgkinson A, Pyrah LN. The urinary excretion of calcium and inorganic phosphate in 344 patients with calcium stone of renal origin. Br J Surg. 1958;46:10-8. 3. Bulusu L, Hodgkinson A, Nordin BE, Peacock M. Urinary excretion of calcium and creatinine in relation to age and body weight in normal subjects and patients with renal calculus. Clin Sci. 1970;38: 601-12. 4. Davis RH, Morgan DB, Rivlin RS. The excretion of calcium in the urine and its relation to calcium intake, sex and age. Clin Sci. 1970;39:1-12. 5. Robertson WG, Peacock M, Heyburn PJ, Marshall DH, Clark PB. Risk factors in calcium stone disease of the urinary tract. Br J Urol. 1978;50:449-54.
Castleman Disease-POEMS Syndrome Overlap To the Editors: Feigert and colleagues (1) have described an unusual association between multicentric angiofollicular lymph 520
node hyperplasia (AFLNH) (multicentric Castleman disease) and a unique clinical syndrome of peripheral neuropathy, pseudotumor cerebri, IgA dysproteinemia, and thrombocytosis in four women. The authors assume that this symptom complex represents a distinct clinicopathologic entity taking a place among the various conditions in which AFLNH may be observed. They admit that there may be some relation between the complex and the POEMS (or Crow-Fukase) syndrome (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes) (2), but none of their patients showed the complete form of this disease. We present the case of a woman with all the symptoms described by Feigert and colleagues (1) who developed a typical POEMS syndrome. A 46-year-old woman was hospitalized for evaluation of abdominal pain and diarrhea. She had hepatosplenomegaly, diffuse lymphadenopathy, and Raynaud phenomenon. Serum Immunoelectrophoresis showed a small IgAA monoclonal spike. A bone marrow biopsy specimen showed no abnormality. An exploratory laparotomy showed a spleen infarction, and splenectomy was done. The spleen (1 kg) and enlarged lymph nodes contained typical AFLNH. After surgery, the patient developed thrombocytosis (platelet count, 2000 x 109/L) which necessitated the administration of hydroxycarbamide. One year later she was re-evaluated for increasing walking difficulties. She had papilledema and a chronic sensorimotor polyneuropathy in her lower limbs. Protein level in cerebrospinal fluid was 1.13 g/L. Motor nerve conduction velocities were low (peroneal nerve: 22 m/s; normal > 40 m/s). The oral glucose tolerance test was abnormal. Subsequently, skin changes, including acrocyanosis, dermal thickening, hyperpigmentation, hypertrichosis, and telangiectasias, were noted and the diagnosis of the POEMS syndrome was made. Other systemic abnormalities included diffuse arteriopathy and organic renal failure. Bone roentgenograms showed a slight osteosclerosis in the left humerus. Despite cyclophosphamide therapy, her clinical status progressively deteriorated and she died from anasarca 8 years after the onset of the first symptoms. The autopsy findings have been previously reported (3). In this case, the presenting manifestations of the POEMS syndrome were those described by Feigert and colleagues (1). As studies have shown, these symptoms are commonly seen in patients with the POEMS syndrome: polyneuropathy (166 of 167; >99%), papilledema (88 of 144; 61%), AFLNH (19 of 30; 63%), polycythemia or thrombocytosis, or both (45 of 158; 28%) (4); monoclonal IgA gammopathy (32 of 96; 33%); or polyclonal gammopathy (11 of 94; 11%) (2). Moreover, incomplete forms of the POEMS syndrome are common outside Japan (2). Finally, it would be better to consider the reported symptom complex as a particular form of the POEMS syndrome as a broad entity, that is, as including the overlapping systemic manifestations of AFLNH (2, 4). Romain K. Gherardi, MD Denis Malapert, MD Jean-Denis Degos, MD Centre Hospitalier Universitaire Henri Mondor Creteil, France 94010
References 1. Feigert JM, Sweet DL, Coleman M, et al. Multicentric angiofollicular lymph node hyperplasia with peripheral neuropathy, pseudotumor cerebri, IgA dysproteinemia, and thrombocytosis in women. A distinct syndrome. Ann Intern Med. 1990;113:362-7. 2. Nakanishi T, Sobue I, Toyokura Y, et al. The Crow-Fukase syndrome: a study of 102 cases in Japan. Neurology. 1984;34:712-20. 3. Gherardi R, Baudrimont M, Kujas M, et al. Pathological findings in three non-Japanese patients with the POEMS syndrome. Virchows Arch (A). 1988;413:357-65. 4. Gherardi R, Zuber M, Viard JP. Les neuropathies dysglobulin6miques. Rev Neurol (Paris). 1988;144:391-408.
In response: Dr. Gherardi and colleagues describe a patient with classic POEMS syndrome who also had thrombocytosis and pseudotumor cerebri. The clinical similarities between this patient and those patients in our study (1) are obvious. Dr. Gherardi and colleagues suggest that all of these clinical find-
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ings are found to varying degrees in patients with the POEMS syndrome and therefore should be considered as constituting a variant of the POEMS syndrome as a broad entity rather than as a variant of AFLNH. We prefer to view these broad clinical manifestations in terms of multiple, partially overlapping circles that create unique syndromes that share features with each other. Because of our lack of understanding of the basic operative mechanism, we are much like blind men assessing an elephant, each describing a particular property such as the trunk or the tail. The common thread is not POEMS or AFLNH but this unknown mechanism (the "elephant"), perhaps hyperimmune stimulation or some acquired linked genetic defect (or both) that creates unique clinical and pathologic syndromes. We are pleased that recognition of these unusual clinical and pathologic findings is increasing and hope that further investigation may shed some light on the pathogenesis of these disorders. John M. Feigert, MD New Hampshire Oncology-Hematology, PA Hooksett, NH 03106 Morton Coleman, MD New York Hospital-Cornell Medical Center New York, NY 10021 Reference 1. Feigert JM, Sweet DL, Coleman M, et al. Multicentric angiofollicular lymph node hyperplasia with peripheral neuropathy, pseudotumor cerebri, IgA dysproteinemia, and thrombocytosis in women. A distinct syndrome. Ann Intern Med. 1990;113:362-7.
benefit from thrombolytic therapy with minimal risk. For patients with an uninterpretable ECG for ischemia, more information is required to substantiate the diagnosis of acute myocardial infarction. This group should receive emergent catheterization and appropriate treatment with intracoronary thrombolytic therapy or direct coronary angioplasty. This strategy will identify most patients presenting with an acute myocardial infarction and will allocate appropriate and timely therapy in an attempt to limit infarct size and improve mortality rates.
Matthew J. Sorrentino, MD The University of Chicago Medical Center Chicago, IL 60637
References 1. Muller DW, Topol EJ. Selection of patients with acute myocardial infarction for thrombolytic therapy. Ann Intern Med. 1990;113:94960. 2. Sorrentino MJ, Feldman T. Clinical and electrocardiographic limitations on the diagnosis of acute myocardial infarction: implications for thrombolytic therapy. Journal of Invasive Cardiology. 1990;2:187-92. 3. Simon AB, Feinleib M, Thompson HK. Components of delay in the pre-hospital phase of acute myocardial infarction. Am J Cardiol. 1972;30:476-82. 4. Rouan GW, Lee TH, Cook EF, Brand DA, Weisberg MC, Goldman L. Clinical characteristics and outcome of acute myocardial infarction in patients with initially normal or nonspecific electrocardiograms. Am J Cardiol. 1989;64:1087-92. 5. Andre-Fouet X, Pillot M, Leizorovicz A, Finet G, Gayet C, Milon H. "Non-Q-wave" alias "nontransmural," myocardial infarction: a specific entity. Am Heart J. 1989;117:892-902.
Thrombolytic Therapy To the Editors: In their review of the selection of patients with acute myocardial infarction for thrombolytic therapy, Muller and Topol (1) pointed out the current limitations in applying this therapy to a larger number of patients. The decision to withhold thrombolytic therapy, however, is based not only on the recognition of risk factors but also on our inability to make an accurate and timely diagnosis of an acute myocardial infarction (2). Eligibility criteria for thrombolytic trials have usually relied on a typical history of chest pain and specific electrocardiographic (ECG) findings of acute ischemia. Up to 50% of patients with an acute myocardial infarction, however, present with symptoms other than chest pain (3). Likewise, only 14% to 30% of patients presenting with typical chest pain ultimately are found to have an acute myocardial infarction (2). The ECG findings are even more problematic. Over 20% of patients with an acute myocardial infarction present with a normal or nonspecific ECG (4). Even patients presenting with ST-segment elevation may be misdiagnosed. About 40% of patients who later develop a non-Q-wave myocardial infarction present with ST-segment elevation on the ECG (5). False-positive diagnoses of acute myocardial infarction may be made in patients with early repolarization, left ventricular aneurysm, pericarditis, or coronary spasm. In addition, many patients present with ECGs that are uninterpretable for ischemia due to conduction abnormalities or left ventricular hypertrophy. Patients who are misdiagnosed are at risk of receiving therapy that may cause harm or will not be considered for therapy that may impart substantial benefit. Despite the difficulties in accurately diagnosing an acute myocardial infarction, a strategy for prompt therapy with the goal of limiting infarct size must be developed. The ECG can be used to stratify patients presenting with a presumed acute myocardial infarction according to risk and to help direct appropriate therapy (2). Patients presenting with a normal or nonspecific ECG have an excellent prognosis and a very low complication rate. Thrombolytic therapy is not likely to offer any significant benefit in this group of patients, and conservative therapy is warranted. Patients presenting with classic ECG changes are readily identified and can potentially gain maximal
"Seronegative" Syphilis in AIDS To the Editors: Several articles have recently been published reporting what has been called "seronegative" secondary syphilis in HIV-infected persons. We question the terminology used. On close inspection of these reports, what is being labeled "seronegative" secondary syphilis might more accudvrately be termed delayed conversion to seropositivity. In the case report by Hicks and colleagues (1) and in a letter by Strobel and coworkers (2), HIV-infected patients with histologically diagnosed secondary syphilis failed to show reactive serologic results with initial VDRL testing. In each case, however, with repeated VDRL studies, seropositivity later developed. Although Hicks describes this as "seronegative" secondary lues, we prefer the designation of delayed seroconversion used by Larsen (4) and also by Strobel and colleagues (2). We have been unable to find any report of an HIV-positive patient diagnosed with "seronegative" secondary syphilis who did not ultimately develop a positive VDRL result on followup. In the case reported by Gregory and colleagues (3), a patient was diagnosed with secondary syphilis when a skin biopsy confirmed the presence of treponemes. Although the patient tested positive for antibodies to human immunodeficiency virus (HIV), he was nonreactive to RPR and MHA-TP tests and was considered as having "seronegative" secondary syphilis. He was treated but then was lost to follow-up. Thus, his subsequent VDRL status was left undetermined. In light of the unusual immunologic responses in HIV-positive persons that may alter serologic diagnosis, we suggest a more painstaking diagnostic pursuit. One should not, for example, quickly abandon a diagnosis of secondary syphilis in HIV-infected persons on the basis of negative serologic tests alone. If clinical suspicion suggests syphilis in the absence of reactive serologic tests, other tests such as dark field microscopy and skin biopsy should be used. The laboratory should be advised to dilute the specimen for testing and eliminate the possibility of the prozone phenomenon. In addition, we suggest that serologic tests be repeated in such patients in order to
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identify the subsequent development of serologic reactivity or lack thereof. Alicia Zalka, BA Mount Sinai School of Medicine New York, NY 10029 Marc E. Grossman, MD David N. Silvers, MD College of Physicians and Surgeons Columbia University New York, NY 10032 References 1. Hicks CB, Benson PM, Lupton GP, Tramont E. Seronegative secondary syphilis in a patient infected with the human immunodeficiency virus (HIV) with Kaposi's sarcoma. Ann Intern Med. 1987;107:492-5. 2. Strobel M, Beauclair P, LaCave J. Seronegative syphilis during the course of AIDS [Letter]. La Presse Med. 1989;18:1440. 3. Gregory N, Sanchez M, Buchness MR. The spectrum of syphilis in patients with human immunodeficiency virus infection. J Am Acad Dermatol. 1990;22:1061-7. 4. Larsen SA. Serologic reactions when syphilis and HIV occur as coinfections. CAP Today. 1989;October:36-9.
and patient discomfort that might have interfered with the effective performance of the examination in a clinical situation. Despite their limitations, however, use of synthetic models has proved useful in physical examination studies because they allow the investigator to evaluate clinical skills in a controlled environment and without undue discomfort to patients (4). Ann K. Ferris, MD Stanford University Medical Center Stanford, CA 94305 Marilyn M. Schapira, MD, MPH Mark J. Young, MD Medical College of Wisconsin Milwaukee, WI 53295 References 1. Wigton RS, Blank LL, Nicolas JA, Tape TG. Procedural skills training in internal medicine residencies. Ann Intern Med. 1989;111:932-8. 2. Ranney B, Ahmad MI. Early identification, differentiation, and treatment of ovarian neoplasia. Int J Gynaecol Obstet. 1979;17:209-17. 3. Hanley J A, Lippman-Hand A. If nothing goes wrong, is everything all right? Interpreting zero numerators. JAMA. 1983;249:1743-5. 4. Fletcher SW, O'Malley MS, Bruce LA. Physicians' abilities to detect lumps in silicone breast models. JAMA. 1985;253:2224-8.
Accuracy of Pelvic Examination To the Editors: There is renewed interest in critically evaluating the physical examination skills that are taught to medical students and residents (1). The bimanual pelvic examination is a method of detecting ovarian cancer (2) and other diseases. However, the sensitivity and specificity of the bimanual pelvic examination in the detection of an adnexal mass have not been well established. We report on a study that used synthetic models of the female pelvis to evaluate the ability of internal medicine residents to detect an adnexal mass by bimanual pelvic examination. The participants were 30 internal medicine residents at a university medical center who were asked to report the presence or absence of a mass on pelvic examination. A total of 60 pelvic examinations were done on a synthetic model of the female pelvis. The model was either not fitted with an adnexal mass or fitted with a small, medium, or large unilateral adnexal mass of dimensions 3 x 1 cm, 4 x 2.5 cm, or 6 x 4 cm, respectively. The presence and size of the mass were randomly assigned. Results of the pelvic examinations were stratified for the size of the adnexal mass, year of residency training, and reported medical school experience with doing pelvic examinations. Results of the study showed that medical residents were able to detect an adnexal mass with a sensitivity and specificity of 67% (95% CI, 55% to 79%) and 100% (CI, 95% to 100%), respectively (3). The sensitivity of the pelvic examination increased with the size of the mass and with the degree of medical school experience the resident had with doing pelvic examinations. A limitation of the study was the use of a synthetic pelvic model. The model, which simulated a thin woman, was not representative of the general patient population. In addition, the use of a model removed an element of physician anxiety
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Correction: Spelling of Author's Name The correct spelling of the author's name in a recent letter (1) is Thomas D. Wendel. Reference 1. Mendez TD. Clinical prediction rules [Letter]. Ann Intern Med. 1991; 114:172.
Correction: Streptokinase Meta-Analysis There were three errors in the article by Midgette and colleagues (1). In the abstract the sentence in the Results section should have read: "A total of 9650 patients with suspected inferior infarction had a mortality rate in the control group of 7.6%." The fourth paragraph on page 964 should have read: "Among the 9650 patients with suspected acute inferior myocardial infarction, the overall mortality in the control group was 7.6%, whereas that for treated patients was 6.6%." In table 3, the mean risk difference for patients with anterior myocardial infarction should have been minus 4.8 ( - 4.8). Andre S. Midgette, MD, MPH Veterans Affairs Hospital White River Junction, VT 05001 Reference 1. Midgette AS, O'Connor GT, Baron JA, Bell J. Effect of intravenous streptokinase on early mortality in patients with suspected acute myocardial infarction. A meta-analysis by anatomic location of infarction. Ann Intern Med. 1990;113:961-8.
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The Editors welcome submissions for possible publication in the Letters section. Authors of letters should: • Include no more than 400 words of text, three authors, and five references • Type with double-spacing • Send with the letter a transfer-of-copyright form (see Table of Contents for location) signed by all authors • Provide a self-addressed envelope if they want to be notified that the letter was received Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified only if their letter is accepted. Unpublished letters cannot be returned.
The State of Internal Medicine To the Editors: We strongly disagree with the proposal outlined by Dr. Stein (1) to increase internal medicine residency training to 4 years, for the purpose of increasing the attractiveness of general internal medicine. In his proposal, residents would spend 4 months of the fourth year in primary care settings and the other 8 months in subspecialty training. This proposal has several fallacies. First, there is no evidence that medical students choose not to go into internal medicine or that residents opt for subspecialities over general internal medicine because residency training is too short. A recent study of medical students notes "internal medicine [compared with other specialties] is perceived as being more stressful . . . with less leisure time and less income potential" (2). Adding another year of residency is likely to decrease, rather than increase, the proportion of students choosing internal medicine. Second, Dr. Stein argues that residents would have more time for training in primary care and subspecialities during residency. However, primary care internal medicine training programs have been able to provide more experience in primary care than traditional programs even within 3 years of training. Additionally, there is no evidence that 8 more months of largely inpatient subspecialty training will produce general internists better trained for the largely ambulatory and primary care practice of general internal medicne. Finally, Dr. Stein's assumption that lengthening residency will lead to a reduction of subspecialty fellowships is untested and may be inaccurate. Is there a need for longer training in general internal medicine? Dr. Stein offers no supporting evidence other than the assertion that the database of internal medicine has greatly increased over the last 50 years (1). Before we expand the length of residency, we should have greater documentation of deficiencies in training that are not correctable with experience and that result from a limited period of training rather than the content of training. Finally, fellowships in general medicine conceivably could offer a voluntary mechanism for interested residents to receive broader and lengthier training in general internal medicine, if these fellowships were reoriented toward this broader training in clinical practice rather than serving primarily as a preparation for academic medicine. 518
Residency training in internal medicine is rigorous and demanding enough for residents. There is insufficient evidence, educational or otherwise, to justify increasing its length. Gregg Coodley, MD Oregon Health Sciences University Portland, OR 97201-3098 Marcia Kerensky Coodley, MD Tualatin Professional Center 6464 S.W. Boreland Road Tualatin, OR 97062
References 1. Stein JH. Grand cru versus generic: different approaches to altering the ratio of general internists to subspecialties. Ann Intern Med. 1991;114:79-82. 2. Schwartz MD, Lizer M, Babbott D, et al. Medical student interest in internal medicine. Ann Intern Med. 1991;114:6-15.
To the Editors: I was very interested to read the article by Dr. Stein (1) concerning the undersupply of general internists. My experience as a general internist in a metropolitan area suggests that part of the problem stems from the attitude of physicians both in practice and in the training field. One of the major barriers to an increased interest in general internal medicine among trainees is a perception of this field as being somehow inferior to more specialized areas of internal medicine. On more than one occasion I have been called by the emergency department physician, offering me a patient with a straightforward problem such as congestive heart failure; the general internist was called because no specialist was available. There well may be pressures on the emergency department to call a subspecialist directly because of fears about liability: Education about the capabilities of general internists may help to alleviate this tendency and to improve the image of general internists (as well as the mix of patients referred to physicians in general medicine). Another issue relating to the image and desirability of general internal medicine is the low regard this field is sometimes given in the training setting. At the academic residency I attended, the chairman of the department met with the residents almost monthly to encourage us to pursue research fellowships (a stated goal was to have " m o s t " residents pursue subspecialty training, despite the directive by the state to the university to provide clinicians for the care of state residents). One colleague of mine who made no pretenses about his desire to practice primary care in his home town was told that if that was his goal, he might as well have attended an osteopathic college. There is no question that the ratio of specialists to generalists in internal medicine is very high; the number of cardiologists and gastroenterologists treating diabetic patients and uncomplicated hypertensive patients in Richmond attests to that. Although Dr. Stein's suggestions, such as increasing the length of training, have merit, general internal medicine will not flourish as long as the field is perceived to be inferior to the specialties. Arthur S. Harrow, MD 7660 Parham Road Richmond, VA 23294
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Reference 1. Stein JH. Grand cru versus generic: different approaches to altering the ratio of general internists to subspecialists. Ann Intern Med. 1991;114:79-82.
To the Editors: Most of the offerings in the 1 January 1991 issue are superb, but I was especially stimulated by those of Reitemeier (1) and McGuire (2). It would be interesting to know more about the premedical aspects of these writers' lives, for I suspect one has the sensitivity to those issues before embarking on a medical career. I wonder if the overemphasis on the biomedical aspects of medicine in recent decades distorted the picture so much that the best candidates to become excellent practitioners were not attracted or were even discriminated against in the selection process. Some medical schools have given up interviewing candidates, considering it to be wasteful of faculty and administrative time. I always felt it to be well worth the time, both because I often would learn something from the encounters and because I thought the identification of even a few who were unsuited to medicine was so important. (After a candidate is accepted, there is tremendous pressure to complete the job and to justify the admission, so it is much better to identify beforehand those who should be encouraged to pursue other careers.) The chairpersons of the academic departments are also in the best position to influence which students and residents are selected, of course, as well as to embark on the formidable tasks Reitemeier assigns. They will do well to listen to Leon Eisenberg's advice, as alluded to by Reitemeier. The heart of the solution lies in selecting and nurturing those who can see the beauty and utility of approaching medicine as McGuire (2) suggests: In all aspects of my work with patients I gave priority to comprehensiveness, integration, and education. I tried to pay attention to the whole life of the patient and to what having a given disease meant to the individual patients . . . Most patients recognized in my encounters with them . . . elements of support and hope. Further, it may be that showing the same consideration for students and residents that he advocated for patients would foster the improvements that several authors advocated elsewhere in the issue. As Reynolds (3) and others pointed out, physicians and teachers of physicians must be aware of being role models so that they will try to project the image they want to replicate—instead of an image that is counterproductive. There have always been some who have done this, of course, but now we must foster their work with all the support they deserve. The special issue should help enormously. John T. Garland, MD 1411 N. Flagler Drive West Palm Beach, FL 33401-3404 References 1. Reitemeier RJ. The leadership crisis in internal medicine: what can be done? Ann Intern Med. 1991;114:69-75. 2. McGuire LB. Just beyond the next bend in the river: reflections on a medical career. Ann Intern Med. 1991;114:83-7. 3. Reynolds PP. Professionalism in residency [Editorial]. Ann Intern Med. 1991;114:91-2.
To the Editors: The 1 January issue brightened the day for those of us who try to practice medicine in the way Dr. McGuire described so beautifully in his essay (1). His pleasure in his work shone in every sentence. I particularly appreciated the articles by Schwartz and colleagues (2) and Lewis and colleagues (3). I find that asking those questions about personal health practices and providing counseling about good health habits tend to promote the kind of physician-patient relationship we all treasure. When I teach Clinical Methods to sophomore medical students, the first thing I say is "I'm here to inoculate you against a loss of compassion." I will keep a copy of this issue to share
with students and residents as I try to describe and demonstrate for them the joys of internal medicine. Margaret N. Mermin, MD 484 Moreland Avenue, N.E. Atlanta, GA 30307 References 1. McGuire LB. Just beyond the next bend in the river: reflections on a medical career. Ann Intern Med. 1990;114:83-7. 2. Schwartz JS, Lewis CE, Clancy C, Kinosian MS, Radany MH, Koplan JP. Internists' practices in health promotion and disease prevention. A survey. Ann Intern Med. 1991;114:46-53. 3. Lewis CE, Clancy C, Leake B, Schwartz JS. The counseling practices of internists. Ann Intern Med. 1991;114:54-8.
To the Editors: Is it not logical for medical students and residents to shun the exciting challenges of the practice of general internal medicine when the leaders of internal medicine have permitted subspecialists to dominate while paying lip service to most of us surviving and enjoying our lives on the front lines? The article by Braunwald (1) is especially troublesome. In my opinion, based on serving under four Department of Medicine chairpersons in two major medical schools, there is little difference in whether the department is organized * 'horizontally" or "vertically." The fundamental question is whether or not the departmental chairperson has the wisdom, courage, knowledge, vision, political suavity, persistence, and leadership ability to be the team leader who can control the troops and make the decisions that will be beneficial for the department and its obligations to society. The tail must never wag the dog. Dr. Thier (2) suggests that perhaps "solutions to the problems confronting internal medicine are different when framed from the perspective of patients . . . rather than why internists are unhappy." It is interesting that the opinion of the patient is seldom mentioned in articles published on medical advances or techniques. It seems that a good method of evaluating quality of care would be at least to ask patients whether their encounters with the health care system made the quality of their lives better, unchanged, or worse. The editorials by Federman (3) and Reynolds (4) eloquently expressed the need to teach medical students and internal medicine residents and fellows "the art of balancing science, technology, and research with compassion, service, and clinical wisdom." In addition, I would add personal morality, dedication, and the ability and desire to teach. John W. Frost, MD 1066 Browns Mill Road Freeport, IL 61032 References 1. Braunwald E. Subspecialists and internal medicine: a perspective. Ann Intern Med. 1991;114:76-8. 2. Thier SO. The future of internal medicine: framing the questions [Editorial]. Ann Intern Med. 1991;114:88-9. 3. Federman DD. A perspective on medical student education for internal medicine [Editorial]. Ann Intern Med. 1991; 114:90. 4. Reynolds PP. Professionalism in residency [Editorial]. Ann Intern Med. 1991;114:91-2.
l,25(OH) 2 Vitamin D for Osteoporosis To the Editors: I am intrigued by the findings recently reported by Gallagher and Goldgar (1). They describe a significant increase in vertebral bone mineral density in patients with postmenopausal osteoporosis treated with l,25(OH)2 vitamin D. However, although their data suggest the possible utility of l,25(OH)2 vitamin D in the treatment of postmenopausal osteoporosis, most of their patients were substantially hypercalcuric by the end of the study. According to the authors' Table 2, the average urinary calcium in the treated patients was 6.4 mmol/d (256 mg/d). This means that more than 50% of their
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patients met conventional criteria for hypercalcuria (2). I wonder then whether patients treated with such high doses of activated vitamin D are at increased long-term risk for nephrolithiasis. Harold Rosen, MD Harvard Medical School Boston, MA 02215 References 1. Gallagher JC, Goldgar D. Treatment of postmenopausal osteoporosis with high doses of synthetic calcitriol. A randomized controlled study. Ann Intern Med. 1990;113:649-55. 2. Insogna KL, Broadus AE. Nephrolithiasis. In: Felig P, Baxter JD, Broadus AE, Frohman LA, eds. Endocrinology and Metabolism. New York: McGraw-Hill Book Co.; 1987:1500-77.
In response: Dr. Rosen has raised an interesting question about the potential risk for developing renal stones among patients treated with vitamin D metabolites. In our study (1), such patients had an average 24-hour urine calcium of 6.4 mmol (256 mg), which suggests to Dr. Rosen that therapy with high-dose vitamin D metabolites could increase the risk for stones because more than 50% of the patients had hypercalcuria. He has used the definition of hypercalcuria that was originally proposed by Hodgkinson and Pyrah (2) in 1956, namely, that hypercalcuria is present if the 24-hour urine calcium exceeds an arbitrary value of 6.25 mmol (250 mg), a definition based on the fact that 90% of normal women had values less than 6.25 mmol (250 mg). However, more recent epidemiologic studies have shown that for women, the normal 90% limits are now around 7.5 mmol/d (300 mg/d) and, for men, 10 mmol/d (400 mg/d) (3, 4). Our own recent measurements of the 24-hour urine calcium in 60 normal elderly women (average daily calcium intake, 19 mmol [760 mg]) support this figure. We found that 20% of women had urine calcium values that exceeded 6.25 mmol/d (250 mg/d) and 6% had values that exceeded 7.5 mmol/d (300 mg/d). Thus, based on these new criteria, the calcitriol-treated osteoporotic group did not have hypercalcuria. Another issue concerns the relative importance of hypercalcuria in kidney stone formation. Risk-factor analysis has ranked the following factors in order of importance for stone formation: urine volume, urine oxalate, uric acid, pH, inhibitors, and urine calcium (5). Given these more recent findings, one should not be alarmed at an average urine calcium of 6.4 mmol/d (256 mg/d). More importantly, the 24-hour urine calcium should be kept at less than 7.5 mmol (300 mg) and an increase in water intake would add a measure of safety. J. C. Gallagher, MD Creighton University Omaha, Nebraska 68131-2197 References 1. Gallagher JC, Goldgar D. Treatment of postmenopausal osteoporosis with high doses of synthetic calcitriol. A randomized controlled study. Ann Intern Med. 1990;113:649-55. 2. Hodgkinson A, Pyrah LN. The urinary excretion of calcium and inorganic phosphate in 344 patients with calcium stone of renal origin. Br J Surg. 1958;46:10-8. 3. Bulusu L, Hodgkinson A, Nordin BE, Peacock M. Urinary excretion of calcium and creatinine in relation to age and body weight in normal subjects and patients with renal calculus. Clin Sci. 1970;38: 601-12. 4. Davis RH, Morgan DB, Rivlin RS. The excretion of calcium in the urine and its relation to calcium intake, sex and age. Clin Sci. 1970;39:1-12. 5. Robertson WG, Peacock M, Heyburn PJ, Marshall DH, Clark PB. Risk factors in calcium stone disease of the urinary tract. Br J Urol. 1978;50:449-54.
Castleman Disease-POEMS Syndrome Overlap To the Editors: Feigert and colleagues (1) have described an unusual association between multicentric angiofollicular lymph 520
node hyperplasia (AFLNH) (multicentric Castleman disease) and a unique clinical syndrome of peripheral neuropathy, pseudotumor cerebri, IgA dysproteinemia, and thrombocytosis in four women. The authors assume that this symptom complex represents a distinct clinicopathologic entity taking a place among the various conditions in which AFLNH may be observed. They admit that there may be some relation between the complex and the POEMS (or Crow-Fukase) syndrome (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes) (2), but none of their patients showed the complete form of this disease. We present the case of a woman with all the symptoms described by Feigert and colleagues (1) who developed a typical POEMS syndrome. A 46-year-old woman was hospitalized for evaluation of abdominal pain and diarrhea. She had hepatosplenomegaly, diffuse lymphadenopathy, and Raynaud phenomenon. Serum Immunoelectrophoresis showed a small IgAA monoclonal spike. A bone marrow biopsy specimen showed no abnormality. An exploratory laparotomy showed a spleen infarction, and splenectomy was done. The spleen (1 kg) and enlarged lymph nodes contained typical AFLNH. After surgery, the patient developed thrombocytosis (platelet count, 2000 x 109/L) which necessitated the administration of hydroxycarbamide. One year later she was re-evaluated for increasing walking difficulties. She had papilledema and a chronic sensorimotor polyneuropathy in her lower limbs. Protein level in cerebrospinal fluid was 1.13 g/L. Motor nerve conduction velocities were low (peroneal nerve: 22 m/s; normal > 40 m/s). The oral glucose tolerance test was abnormal. Subsequently, skin changes, including acrocyanosis, dermal thickening, hyperpigmentation, hypertrichosis, and telangiectasias, were noted and the diagnosis of the POEMS syndrome was made. Other systemic abnormalities included diffuse arteriopathy and organic renal failure. Bone roentgenograms showed a slight osteosclerosis in the left humerus. Despite cyclophosphamide therapy, her clinical status progressively deteriorated and she died from anasarca 8 years after the onset of the first symptoms. The autopsy findings have been previously reported (3). In this case, the presenting manifestations of the POEMS syndrome were those described by Feigert and colleagues (1). As studies have shown, these symptoms are commonly seen in patients with the POEMS syndrome: polyneuropathy (166 of 167; >99%), papilledema (88 of 144; 61%), AFLNH (19 of 30; 63%), polycythemia or thrombocytosis, or both (45 of 158; 28%) (4); monoclonal IgA gammopathy (32 of 96; 33%); or polyclonal gammopathy (11 of 94; 11%) (2). Moreover, incomplete forms of the POEMS syndrome are common outside Japan (2). Finally, it would be better to consider the reported symptom complex as a particular form of the POEMS syndrome as a broad entity, that is, as including the overlapping systemic manifestations of AFLNH (2, 4). Romain K. Gherardi, MD Denis Malapert, MD Jean-Denis Degos, MD Centre Hospitalier Universitaire Henri Mondor Creteil, France 94010
References 1. Feigert JM, Sweet DL, Coleman M, et al. Multicentric angiofollicular lymph node hyperplasia with peripheral neuropathy, pseudotumor cerebri, IgA dysproteinemia, and thrombocytosis in women. A distinct syndrome. Ann Intern Med. 1990;113:362-7. 2. Nakanishi T, Sobue I, Toyokura Y, et al. The Crow-Fukase syndrome: a study of 102 cases in Japan. Neurology. 1984;34:712-20. 3. Gherardi R, Baudrimont M, Kujas M, et al. Pathological findings in three non-Japanese patients with the POEMS syndrome. Virchows Arch (A). 1988;413:357-65. 4. Gherardi R, Zuber M, Viard JP. Les neuropathies dysglobulin6miques. Rev Neurol (Paris). 1988;144:391-408.
In response: Dr. Gherardi and colleagues describe a patient with classic POEMS syndrome who also had thrombocytosis and pseudotumor cerebri. The clinical similarities between this patient and those patients in our study (1) are obvious. Dr. Gherardi and colleagues suggest that all of these clinical find-
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ings are found to varying degrees in patients with the POEMS syndrome and therefore should be considered as constituting a variant of the POEMS syndrome as a broad entity rather than as a variant of AFLNH. We prefer to view these broad clinical manifestations in terms of multiple, partially overlapping circles that create unique syndromes that share features with each other. Because of our lack of understanding of the basic operative mechanism, we are much like blind men assessing an elephant, each describing a particular property such as the trunk or the tail. The common thread is not POEMS or AFLNH but this unknown mechanism (the "elephant"), perhaps hyperimmune stimulation or some acquired linked genetic defect (or both) that creates unique clinical and pathologic syndromes. We are pleased that recognition of these unusual clinical and pathologic findings is increasing and hope that further investigation may shed some light on the pathogenesis of these disorders. John M. Feigert, MD New Hampshire Oncology-Hematology, PA Hooksett, NH 03106 Morton Coleman, MD New York Hospital-Cornell Medical Center New York, NY 10021 Reference 1. Feigert JM, Sweet DL, Coleman M, et al. Multicentric angiofollicular lymph node hyperplasia with peripheral neuropathy, pseudotumor cerebri, IgA dysproteinemia, and thrombocytosis in women. A distinct syndrome. Ann Intern Med. 1990;113:362-7.
benefit from thrombolytic therapy with minimal risk. For patients with an uninterpretable ECG for ischemia, more information is required to substantiate the diagnosis of acute myocardial infarction. This group should receive emergent catheterization and appropriate treatment with intracoronary thrombolytic therapy or direct coronary angioplasty. This strategy will identify most patients presenting with an acute myocardial infarction and will allocate appropriate and timely therapy in an attempt to limit infarct size and improve mortality rates.
Matthew J. Sorrentino, MD The University of Chicago Medical Center Chicago, IL 60637
References 1. Muller DW, Topol EJ. Selection of patients with acute myocardial infarction for thrombolytic therapy. Ann Intern Med. 1990;113:94960. 2. Sorrentino MJ, Feldman T. Clinical and electrocardiographic limitations on the diagnosis of acute myocardial infarction: implications for thrombolytic therapy. Journal of Invasive Cardiology. 1990;2:187-92. 3. Simon AB, Feinleib M, Thompson HK. Components of delay in the pre-hospital phase of acute myocardial infarction. Am J Cardiol. 1972;30:476-82. 4. Rouan GW, Lee TH, Cook EF, Brand DA, Weisberg MC, Goldman L. Clinical characteristics and outcome of acute myocardial infarction in patients with initially normal or nonspecific electrocardiograms. Am J Cardiol. 1989;64:1087-92. 5. Andre-Fouet X, Pillot M, Leizorovicz A, Finet G, Gayet C, Milon H. "Non-Q-wave" alias "nontransmural," myocardial infarction: a specific entity. Am Heart J. 1989;117:892-902.
Thrombolytic Therapy To the Editors: In their review of the selection of patients with acute myocardial infarction for thrombolytic therapy, Muller and Topol (1) pointed out the current limitations in applying this therapy to a larger number of patients. The decision to withhold thrombolytic therapy, however, is based not only on the recognition of risk factors but also on our inability to make an accurate and timely diagnosis of an acute myocardial infarction (2). Eligibility criteria for thrombolytic trials have usually relied on a typical history of chest pain and specific electrocardiographic (ECG) findings of acute ischemia. Up to 50% of patients with an acute myocardial infarction, however, present with symptoms other than chest pain (3). Likewise, only 14% to 30% of patients presenting with typical chest pain ultimately are found to have an acute myocardial infarction (2). The ECG findings are even more problematic. Over 20% of patients with an acute myocardial infarction present with a normal or nonspecific ECG (4). Even patients presenting with ST-segment elevation may be misdiagnosed. About 40% of patients who later develop a non-Q-wave myocardial infarction present with ST-segment elevation on the ECG (5). False-positive diagnoses of acute myocardial infarction may be made in patients with early repolarization, left ventricular aneurysm, pericarditis, or coronary spasm. In addition, many patients present with ECGs that are uninterpretable for ischemia due to conduction abnormalities or left ventricular hypertrophy. Patients who are misdiagnosed are at risk of receiving therapy that may cause harm or will not be considered for therapy that may impart substantial benefit. Despite the difficulties in accurately diagnosing an acute myocardial infarction, a strategy for prompt therapy with the goal of limiting infarct size must be developed. The ECG can be used to stratify patients presenting with a presumed acute myocardial infarction according to risk and to help direct appropriate therapy (2). Patients presenting with a normal or nonspecific ECG have an excellent prognosis and a very low complication rate. Thrombolytic therapy is not likely to offer any significant benefit in this group of patients, and conservative therapy is warranted. Patients presenting with classic ECG changes are readily identified and can potentially gain maximal
"Seronegative" Syphilis in AIDS To the Editors: Several articles have recently been published reporting what has been called "seronegative" secondary syphilis in HIV-infected persons. We question the terminology used. On close inspection of these reports, what is being labeled "seronegative" secondary syphilis might more accudvrately be termed delayed conversion to seropositivity. In the case report by Hicks and colleagues (1) and in a letter by Strobel and coworkers (2), HIV-infected patients with histologically diagnosed secondary syphilis failed to show reactive serologic results with initial VDRL testing. In each case, however, with repeated VDRL studies, seropositivity later developed. Although Hicks describes this as "seronegative" secondary lues, we prefer the designation of delayed seroconversion used by Larsen (4) and also by Strobel and colleagues (2). We have been unable to find any report of an HIV-positive patient diagnosed with "seronegative" secondary syphilis who did not ultimately develop a positive VDRL result on followup. In the case reported by Gregory and colleagues (3), a patient was diagnosed with secondary syphilis when a skin biopsy confirmed the presence of treponemes. Although the patient tested positive for antibodies to human immunodeficiency virus (HIV), he was nonreactive to RPR and MHA-TP tests and was considered as having "seronegative" secondary syphilis. He was treated but then was lost to follow-up. Thus, his subsequent VDRL status was left undetermined. In light of the unusual immunologic responses in HIV-positive persons that may alter serologic diagnosis, we suggest a more painstaking diagnostic pursuit. One should not, for example, quickly abandon a diagnosis of secondary syphilis in HIV-infected persons on the basis of negative serologic tests alone. If clinical suspicion suggests syphilis in the absence of reactive serologic tests, other tests such as dark field microscopy and skin biopsy should be used. The laboratory should be advised to dilute the specimen for testing and eliminate the possibility of the prozone phenomenon. In addition, we suggest that serologic tests be repeated in such patients in order to
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identify the subsequent development of serologic reactivity or lack thereof. Alicia Zalka, BA Mount Sinai School of Medicine New York, NY 10029 Marc E. Grossman, MD David N. Silvers, MD College of Physicians and Surgeons Columbia University New York, NY 10032 References 1. Hicks CB, Benson PM, Lupton GP, Tramont E. Seronegative secondary syphilis in a patient infected with the human immunodeficiency virus (HIV) with Kaposi's sarcoma. Ann Intern Med. 1987;107:492-5. 2. Strobel M, Beauclair P, LaCave J. Seronegative syphilis during the course of AIDS [Letter]. La Presse Med. 1989;18:1440. 3. Gregory N, Sanchez M, Buchness MR. The spectrum of syphilis in patients with human immunodeficiency virus infection. J Am Acad Dermatol. 1990;22:1061-7. 4. Larsen SA. Serologic reactions when syphilis and HIV occur as coinfections. CAP Today. 1989;October:36-9.
and patient discomfort that might have interfered with the effective performance of the examination in a clinical situation. Despite their limitations, however, use of synthetic models has proved useful in physical examination studies because they allow the investigator to evaluate clinical skills in a controlled environment and without undue discomfort to patients (4). Ann K. Ferris, MD Stanford University Medical Center Stanford, CA 94305 Marilyn M. Schapira, MD, MPH Mark J. Young, MD Medical College of Wisconsin Milwaukee, WI 53295 References 1. Wigton RS, Blank LL, Nicolas JA, Tape TG. Procedural skills training in internal medicine residencies. Ann Intern Med. 1989;111:932-8. 2. Ranney B, Ahmad MI. Early identification, differentiation, and treatment of ovarian neoplasia. Int J Gynaecol Obstet. 1979;17:209-17. 3. Hanley J A, Lippman-Hand A. If nothing goes wrong, is everything all right? Interpreting zero numerators. JAMA. 1983;249:1743-5. 4. Fletcher SW, O'Malley MS, Bruce LA. Physicians' abilities to detect lumps in silicone breast models. JAMA. 1985;253:2224-8.
Accuracy of Pelvic Examination To the Editors: There is renewed interest in critically evaluating the physical examination skills that are taught to medical students and residents (1). The bimanual pelvic examination is a method of detecting ovarian cancer (2) and other diseases. However, the sensitivity and specificity of the bimanual pelvic examination in the detection of an adnexal mass have not been well established. We report on a study that used synthetic models of the female pelvis to evaluate the ability of internal medicine residents to detect an adnexal mass by bimanual pelvic examination. The participants were 30 internal medicine residents at a university medical center who were asked to report the presence or absence of a mass on pelvic examination. A total of 60 pelvic examinations were done on a synthetic model of the female pelvis. The model was either not fitted with an adnexal mass or fitted with a small, medium, or large unilateral adnexal mass of dimensions 3 x 1 cm, 4 x 2.5 cm, or 6 x 4 cm, respectively. The presence and size of the mass were randomly assigned. Results of the pelvic examinations were stratified for the size of the adnexal mass, year of residency training, and reported medical school experience with doing pelvic examinations. Results of the study showed that medical residents were able to detect an adnexal mass with a sensitivity and specificity of 67% (95% CI, 55% to 79%) and 100% (CI, 95% to 100%), respectively (3). The sensitivity of the pelvic examination increased with the size of the mass and with the degree of medical school experience the resident had with doing pelvic examinations. A limitation of the study was the use of a synthetic pelvic model. The model, which simulated a thin woman, was not representative of the general patient population. In addition, the use of a model removed an element of physician anxiety
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Correction: Spelling of Author's Name The correct spelling of the author's name in a recent letter (1) is Thomas D. Wendel. Reference 1. Mendez TD. Clinical prediction rules [Letter]. Ann Intern Med. 1991; 114:172.
Correction: Streptokinase Meta-Analysis There were three errors in the article by Midgette and colleagues (1). In the abstract the sentence in the Results section should have read: "A total of 9650 patients with suspected inferior infarction had a mortality rate in the control group of 7.6%." The fourth paragraph on page 964 should have read: "Among the 9650 patients with suspected acute inferior myocardial infarction, the overall mortality in the control group was 7.6%, whereas that for treated patients was 6.6%." In table 3, the mean risk difference for patients with anterior myocardial infarction should have been minus 4.8 ( - 4.8). Andre S. Midgette, MD, MPH Veterans Affairs Hospital White River Junction, VT 05001 Reference 1. Midgette AS, O'Connor GT, Baron JA, Bell J. Effect of intravenous streptokinase on early mortality in patients with suspected acute myocardial infarction. A meta-analysis by anatomic location of infarction. Ann Intern Med. 1990;113:961-8.
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