The

n e w e ng l a n d j o u r na l

resection of cavity shave margins, are nil. Furthermore, the use of oncoplastic principles to improve cosmesis and the resection of cavity shave margins are not mutually exclusive. We look forward to further investigation into surgical techniques to improve care of patients with breast cancer; perhaps in so doing, there will be movement toward more personalized surgery as well. Anees B. Chagpar, M.D., M.P.H. Yale University School of Medicine New Haven, CT [email protected]

of

m e dic i n e

Since publication of her article, the author reports no further potential conflict of interest. 1. Moran MS, Schnitt SJ, Giuliano AE, et al. Society of Surgical

Oncology-American Society for Radiation Oncology consensus guideline on margins for breast-conserving surgery with wholebreast irradiation in stages I and II invasive breast cancer. Ann Surg Oncol 2014;21:704-16. 2. Houssami N, Macaskill P, Marinovich ML, Morrow M. The association of surgical margins and local recurrence in women with early-stage invasive breast cancer treated with breastconserving therapy: a meta-analysis. Ann Surg Oncol 2014;21: 717-30. DOI: 10.1056/NEJMc1511344

For the trial investigators

Palliative Care To the Editor: Kelley and Morrison (Aug. 20 issue)1 describe the changes in palliative care over the past decade and its distinct meaning vis-à-vis hospice care in the United States and, increasingly, most other countries. Unfortunately, the category of “most countries” does not include many countries in Asia, where attitudes and practices vary widely according to regional, economic, cultural, and religious differences and differences in legal systems.2 Neither does this category include Iran, a nation of more than 75 million people in which medical science is advanced; sophisticated therapies such as kidney, heart, and lung transplantation are available; and investigational procedures such as stem-cell transplantation are performed. Nevertheless, end-of-life care remains largely unaddressed.3 Iran has yet to establish a single hospice. As physicians practicing in Iran, we are mindful of the critical need for palliative and hospice care in our country. We look forward to learning from the international community. S. Mohammadreza Hashemian, M.D. Shahid Beheshti University of Medical Sciences Tehran, Iran [email protected]

James Miller, F.C.C.M. Iranian-American Partnership for Medical Science   and Public Health Association Oxford, MS No potential conflict of interest relevant to this letter was reported. 1. Kelley AS, Morrison RS. Palliative care for the seriously ill.

N Engl J Med 2015;373:747-55. 2. Phua J, Joynt GM, Nishimura M, et al. Withholding and withdrawal of life-sustaining treatments in intensive care units in Asia. JAMA Intern Med 2015;175:363-71.

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3. Iranmanesh S, Dargahi H, Abbaszadeh A. Attitudes of Ira-

nian nurses toward caring for dying patients. Palliat Support Care 2008;6:363-9. DOI: 10.1056/NEJMc1511946

To the Editor: We would like to add to the discussion by Kelley and Morrison a comment on the emerging role of the emergency department in palliative care. The emergency department provides an excellent opportunity to implement palliative care early in a patient’s hospital course. Discussions regarding illness, prognostication, goals of care, and patient fears and the mobilization of an interdisciplinary team that will follow a patient throughout hospitalization can begin in the emergency department. Many emergency physicians are uncomfortable with these discussions, but we are actively trying to improve.1,2 In its Choosing Wisely campaign, the American College of Emergency Physicians recently advocated for early palliative and hospice intervention when appropriate.3 The shortage of physicians practicing hospice and palliative care medicine — as many as 18,000 additional physicians are needed — is daunting, but we need to move forward and work together to provide the proper palliative and hospice resources for our patients.4 Terrance McGovern, D.O., M.P.H. Anthony Catapano, D.O. Ninad Shroff, M.D. St. Joseph’s Regional Medical Center Paterson, NJ [email protected] No potential conflict of interest relevant to this letter was reported.

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correspondence 1. Lamba S, Nagurka R, Zielinski A, Scott SR. Palliative care

provision in the emergency department: barriers reported by emergency physicians. J Palliat Med 2013;16:143-7. 2. Barbera L, Taylor C, Dudgeon D. Why do patients with cancer visit the emergency department near the end of life? CMAJ 2010;182:563-8. 3. American College of Emergency Physicians. Choosing wisely. October 14, 2013, and October 27, 2014 (http://www

.choosingwisely.org/societies/american-college-of-emergency -physicians). 4. Lupu D, American Academy of Hospice and Palliative Medicine Workforce Task Force. Estimate of current hospice and palliative medicine physician workforce shortage. J Pain Symptom Manage 2010;40:899-911. DOI: 10.1056/NEJMc1511946

Hypoplastic Metatarsals — Beyond Cosmesis To the Editor: Hypoplastic metatarsals, or idiopathic brachymetatarsia, is a relatively frequent diagnosis in podiatric practice. Patients with this abnormality typically seek surgery because of cosmetic concerns, difficulty wearing shoes, or foot discomfort. Hypoplastic metatarsals may be accompanied by other physical features, most often related to Albright’s hereditary osteodystrophy. When findings indicative of Albright’s hereditary osteodystrophy are present in conjunction with laboratory abnormalities, pseudohypoparathyroidism type 1a is the likely diagnosis. However, the case we describe here shows that isolated hypoplastic metatarsals can be the initial presentation of pseudohypoparathyroidism type 1b. Pseudohypoparathyroidism type 1b has been considered distinct from type 1a. Patients with either form of pseudohypoparathyroidism present A

C

with parathyroid hormone (PTH)–resistant hypocalcemia and hyperphosphatemia and may have resistance to other hormones. Both disorders are caused by genetic or epigenetic defects that involve the GNAS complex, which encodes the alpha subunit of the stimulatory G protein and splice variants thereof.1-3 Pseudohypoparathyroidism type 1a is caused by maternal inactivating mutations affecting GNAS exons 1 through 13, and type 1b is caused by maternal GNAS or STX16 deletions, paternal uniparental disomy involving chromosome 20q, or as-yet-undefined genetic mutations that alter GNAS methylation imprints. Despite the fact that the two types of pseudohypoparathyroidism are caused by distinct genetic defects, growing evidence indicates that there is considerable overlap between the two disorders, as shown by the case we describe here. D

E

F

B

Figure 1. Images of the Toes before and after Surgery. The patient’s shortened fourth toes before distraction osteogenesis are shown in Panel A. Panel B shows the toes after the procedure; the right toe appears normal, whereas the left toe is not completely corrected, because of an infection that required removal of the external fixators. Radiographs of the shortened left fourth metatarsal before surgical intervention are shown in Panel C. Panel D shows the left foot after osteotomy, with external fixation in place and overcorrection of the metatarsal. Panel E shows the foot after removal of the external fixation device and shortening osteotomy to relocate the joint, leaving only two screws in place. Panel F shows a normal-appearing right fourth metatarsal 9 years after distraction osteogenesis.

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