"Playing God" as an act of hope.

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 three copies of the letter and 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 that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned. Diagnosing the Irritable Bowel Syndrome To the Editors: The two recent reviews of the irritable bowel syndrome (1, 2) are very helpful. However, both state that sigmoidoscopy is necessary in all patients to rule out organic disorders. As noted by Dr. Drossman, 15% to 20% of the population has the irritable bowel syndrome (2). Does sufficient evidence exist to warrant that many sigmoidoscopies? We could limit sigmoidoscopies to the one third of patients who seek medical care, but this limitation has no pathophysiologic basis. Kruis and colleagues (3) compared "gold standard" upper and lower endoscopies with a noninvasive diagnostic score derived from weighted clinical variables. Although no perfect cutoff score was given to diagnose the irritable bowel syndrome, more than half of patients with the irritable bowel syndrome scored greater than 50 points. The only other patient with an alternative diagnosis and a score above 50 points had a duodenal ulcer (unlikely to have been found by sigmoidoscopy). This finding suggests the existence of a subpopulation whose history and physical findings are so benign that sigmoidoscopy is unwarranted. Sigmoidoscopy could be reserved for patients who are unresponsive to empiric therapies. Perhaps further research will yield an easier decision rule (for example, patients meeting the Rome criteria without a selected list of warning markers do not need flexible sigmoidoscopy unless symptoms persist). It is difficult for me to refer patients with a benign history for sigmoidoscopy if they have normal complete blood counts, erythrocyte sedimentation rates, and chemistry results, as well as no fecal blood or prominent diarrhea, especially when they respond to empiric therapies. Bob Badgett, MD University of Texas Health Science Center San Antonio, TX 78284 References 1. Camilleri M, Prather CM. The irritable bowel syndrome: mechanisms and a practical approach to management. Ann Intern Med. 1992;116:1001-8. 2. Drossman DA, Thompson WG. The irritable bowel syndrome: review and a graduated multicomponent treatment approach. Ann Intern Med. 1992;116:1009-16. 3. Kruis W, Thieme CH, Weinzierl M, Schussler P, Holl J, Paulus W. A

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diagnostic score for the irritable bowel syndrome. Gastroenterology. 1984;87:1-7.

To the Editors: The recent article by Camilleri and Prather (1) was misleading in one respect. Although the authors stated that selective testing to exclude organic disease was required for "confirmation" of a diagnosis of the irritable bowel syndrome, they also indicated that a "positive symptomatic diagnosis" was possible, using the Manning criteria (2). Using four to six of the criteria, their sensitivity ranges from 91% to 94%, and their specificity ranges from 55% to 70% (2). Because specificity, not sensitivity, is the problem, they are not clinically acceptable to exclude organic disease. In addition, a recent study shows them to be completely unrelated to the irritable bowel syndrome in men, a smaller subset of patients with the disorder (3). The fact that patients with organic disease may have prominent psychological changes (4) suggests that neither physical nor psychological symptoms are of clinically relevant diagnostic value. Practitioners are best advised to obtain an objectively based, selective study to exclude organic disease before making a diagnosis of the irritable bowel syndrome and not to rely on the Manning criteria. Robert C. Smith, MD Michigan State University East Lansing, MI 48824 References 1. Camilleri M, Prather CM. The irritable bowel syndrome: mechanisms and a practical approach to management. Ann Intern Med. 1992;116:1001-8. 2. Manning AP, Thompson WG, Heaton KW, Morris AF. Towards positive diagnosis of the irritable bowel syndrome. Br Med J. 1978; 2:653-4. 3. Smith RC, Greenbaum DS, Vancouver JB, et al. Gender differences in Manning criteria in the irritable bowel syndrome. Gastroenterology. 1991;100:591-5. 4. Smith RC, Greenbaum DS, Vancouver JB, et al. Psychosocial factors are associated with health care seeking rather than diagnosis in irritable bowel syndrome. Gastroenterology. 1990;98:293-301.

In response: We thank Dr. Badgett for his comments. He makes a very good case for omitting flexible sigmoidoscopy in the initial evaluation and pursuing an empiric trial for patients with the Rome criteria and normal baseline laboratory evaluations including hematologic tests, chemistry tests, erythrocyte sedimentation rate, and the absence of fecal blood. We believe the difference in emphasis reflects our tertiary population and perception of the safety and cost-benefit ratio of flexible sigmoidoscopy. Our recommendations can be modified on an individual basis. The young adult with occasional symptoms and an otherwise negative evaluation may be observed for clinical improvement without a sigmoidoscopy. Factors such as older age, diarrhea, or the presence of fecal blood will, however, weigh more heavily. The potential gain from early identification of colorectal neoplasia cannot be overemphasized. The study by Kruis and colleagues, cited by Dr. Badgett, was not designed to test the value of sigmoidoscopy (1) and used regression analysis for the same patients in whom the criteria for the "diagnostic score" were developed. As expected, the score functioned well when tested in the cohort in which it was developed. A recent prospective evaluation of the Kruis diagnostic symptom score in a separate cohort showed a much worse diagnostic accuracy, with a predictive value of

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54% for men and 82% for women (sensitivity, 47% and 60%, respectively) (2). Two cases of neoplasia and nine cases of other organic digestive diseases were not identified by the symptom score. Until symptom criteria and other basic laboratory tests achieve a higher degree of accuracy, we believe that flexible sigmoidoscopy is warranted, once at the initial work-up of each patient with suspected irritable bowel syndrome and again if a significant alteration in symptoms (for example, weight loss, rectal bleeding) occurs. Finally, we agree with Dr. Badgett that we should not seek out the large number of patients in the community who have symptoms suggestive of the irritable bowel syndrome; this strategy would not be cost effective. We recognize, however, that flexible sigmoidoscopy in those who present for medical care is to some degree for the purpose of reassurance. Doctor Smith raises a minor inconsistency that may have confused readers. His own work indicates that the specificity of symptom-based diagnostic scores is inadequate and emphasizes the importance of a complement of tests that exclude organic disease. We routinely advocate such a work-up in our practice {see algorithm in Figure 2 of our paper). However, we wished to go further, that is, to emphasize the utility of the combined, stepwise approach with recognition of the symptoms of the irritable bowel syndrome, exclusion of organic disease, and performance of further evaluations of gastrointestinal function or therapeutic trials to confirm the diagnosis and to target treatment to the altered function. Michael Camilleri, MD Douglas A. Drossman, MD W. Grant Thompson, MD Mayo Clinic Rochester, MN 55905 References 1. Drossman DA. Diagnosis of the irritable bowel syndrome. A simple solution? Gastroenterology. 1984;87:224-5. 2. Frigerio G, Beretta A, Orsenigo G, Tadeo G, Imperiali G, Minoli G. Irritable bowel syndrome: still far from a positive diagnosis. Dig Dis Sci. 1992;37:164-7.

Acromegaly and Pituitary Carcinoma To the Editors: Growth hormone (GH)-secreting adenocarcinoma with clear evidence of distant metastasis has been unequivocally documented in only five patients (1, 2). We report the case of an acromegalic patient with pituitary adenocarcinoma and elevated levels of circulating GH (80 jLtg/L) and insulin-like growth factor (IGF)-I (10 U/mL) as well as spinal cord metastasis. A 35-year-old Japanese woman was referred for further management of a previously diagnosed pituitary adenoma. She had been treated surgically at 19 and 31 years of age and with radiation at 33 and 34 years of age. Previous computed tomography showed a pituitary tumor, histologically diagnosed as an acidophilic type of adenoma. The suprasellar pituitary tumor became large enough to compress the surrounding brain tissues, and the development of spinal cord metastasis predisposed the patient to sudden paraplegia (Figure \,A and B). In addition to replacement therapy with hydrocortisone, thyroxine, and desmopressin, somatostatin analog therapy was given for 2 weeks unsuccessfully. Bromocriptine, 5 mg/d, was started, and the patient's level of consciousness was completely restored. Magnetic resonance imaging showed a dramatic decrease in pituitary tumor size (Figure 1, B and C). Suppression of circulating GH (12 ± 6 /ig/L) and IGF-I (3.1 ± 1.6 U/mL) levels was also observed during the 5 months of treatment. Despite the continuation of bromocriptine therapy, 2 months later she died of respiratory failure as a result of her brain tumor. At autopsy, both the large invasive pituitary tumor and the spinal cord tumor were immunostained specifically with anti-GH antibody, but not with anti-prolactin/anti-thyroid-stimulating hormone (TSH) antibodies. Although the mechanism for the aggressive change occurring in this somatotroph adenoma remains unclear, the role of radiotherapy in the transformation

Figure 1. Sagittal magnetic resonance images (spin-echo 750/20) of a 35-year-old Japanese woman with pituitary acromegaly. At the time of sudden-onset paraplegia, no evidence of spinal cord tumor was noted in Tl-weighted images (A, left). However, irregular densities (high and low mixture) in the spinal cord lesions were detected in T 2 -weighted images (A, right). The low densities of brain stem region detected in T r weighted image before bromocriptine therapy (B) were somewhat improved after 2 months of treatment (C).

of a benign pituitary adenoma to adenocarcinoma has been reported (3). Clinical trials of somatostatin analog or bromocriptine (4, 5) in the treatment of inoperable cases of GHsecreting pituitary tumors have been reported. This is the first documented case of decreased tumor size in a pituitary adenocarcinoma. Our experience suggests that bromocriptine could be effective as palliative treatment of patients with poor prognoses. Shunichi Yamashita, MD Motomori Izumi, MD Shigenobu Nagataki, MD Nagasaki University School of Medicine Nagasaki 852, Japan References 1. Mountcastle RB, Roof BS, Mayfield RK, et al. Case report: pituitary adenocarcinoma in an acromegalic patient: response to bromocriptine and pituitary testing: a review of the literature on 36 cases of pituitary carcinoma. Am J Med Sci. 1989;298:109-18. 2. Melmed S. Acromegaly. N Engl J Med. 1990;322:966-77. 3. Waltz TA, Brownell B. Sarcoma: possible late result of effective radiation therapy for pituitary adenoma: report of two cases. J Neurosurg. 1966;24:901-7. 4. Lamberts SW, Zweens M, Verschoor L, Del Pozo E. A comparison among the growth hormone-lowering effects in acromegaly of the somatostatin analogue SMS 201-995, bromocriptine, and the combination of both drugs. J Clin Endocrinol Metab. 1986;63:16-9. 5. Chiodini PG, Cozzi R, Dallabonzana D, et al. Medical treatment of




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acromegaly with SMS 201-995, a somatostatin analog: a comparison with bromocriptine. J Clin Endocrinol Med. 1987;64:447-54. Diclofenac-induced Isolated Myonecrosis and the Nicolau Syndrome To the Editors: The Nicolau syndrome is a rare adverse reaction at the site of intramuscular drug injection resulting from acute ischemia. Within hours, patients develop severe pain and a localized erythematous rash followed by a pale marble-like discoloration and necrosis of the skin (1), sometimes accompanied by gangrene (2) and muscle necrosis. A 35-year-old male sports teacher complaining of acute neck pain was treated with 75 mg of diclofenac intramuscularly in the proximal anterolateral part of the left upper leg. After 2 days, severe pain developed at the site of injection; it gradually decreased over the following 4 months. No skin reaction or swelling was present. Three months after injection, the patient noted a decreased circumference of the distal anterolateral part of the left upper leg. On physical examination, the shape of the left Musculus vastus lateralis suggested muscular atrophy. The femoral artery pulses of both legs could be clearly palpated, and no bruits were heard over the arteries. Muscle reflexes were normal. The strength of the left Musculus quadriceps femoris was slightly diminished. Neurologic and routine laboratory examination, including levels of creatine kinase in blood and urine, were unremarkable. Magnetic resonance imaging (MRI) showed atrophy of the distal part of the Musculus vastus lateralis of the left leg with decreased muscle volume and increased fatty tissue (Figure 1). The Nicolau syndrome results from intra-arterial injection with subsequent obliteration of the artery and ischemic necrosis of the area that depends on blood supplied by that artery (3). A skin reaction is pathognomonic, as exemplified by its synonym "embolia cutis medicamentosa." To our knowledge, isolated muscle necrosis has not been described. We believe that the site of arterial damage in our patient was probably distal from the part of the Ramus descendens of the Arteria circumflexae femoris lateralis from which the blood supply to the skin originates. The figure shows muscle damage in the distal part of the Musculus vastus lateralis at the site where the Arteria circumflexae femoris lateralis goes to the Rete articulare genu between the Musculus vastus lateralis and the Musculus vastus intermedius. We suspect that diclofenac, which was injected in the proximal part of the Musculus vastus lateralis, probably injured the artery and later caused embolism in the lower part of the Arteria circumflexae femoris lateralis. This hypothesis is consistent with the development of severe pain 2 days after (rather than immediately after) injection and with the fact that no damage was noted on MRI at the site of injection in the proximal part of the left upper leg. Similar cases have been reported after intramuscular diclofenac administration (3-5) and have also been associated with other nonsteroidal anti-inflammatory drugs such as phen-

Figure 1. Magnetic resonance imaging of both legs. Atrophy of the distal part of the left Musculus vastus lateralis (-»). 1058


ylbutazone (3). It is not certain whether the reaction results from diclofenac or from an additive (for example, sodium pyrosulphite). Use of parenteral diclofenac should be discouraged. B. H. Ch. Strieker, MB, PhD Netherlands Center for Monitoring of Adverse Reactions to Drugs Rijswijk, 2280 HK, The Netherlands B. J. van Kasteren, MD, PhD St. Joseph Hospital Veldhoven, The Netherlands References 1. Nicolau SG. Dermatite livedoide et gangreneuse de la fesse consecutive aux injections intramusculaires dans la syphilis. A propos d'un cas embolie arterielle bismuthique. Ann Mai Ven. 1925;20:321-39. 2. Talbert JL, Haslam RH, Haller JA. Gangrene of the foot following intramuscular injection in the lateral thigh: a case report with recommendations for prevention. J Pediatr. 1967;70:110-21. 3. Muller-Vahl H. Aseptische Gewebsnekrose: eine schwerwiegende Komplikation nach intramuskularer Injektion. Dtsch Med Wochenschr. 1984;109:786-92. 4. Tweedie DG. Unusual reaction to diclofenac. Anaesthesia. 1989;44: 932. 5. Ali MT, Mathias IM. Continued problems with diclofenac injections. Anaesthesia. 1991 ;46:1089.

Paresthesias and Mefloquine Prophylaxis To the Editors: Central neurologic side effects of mefloquine have been described previously (1-5), but 'to our knowledge peripheral nervous system toxicity has not. We report a case of paresthesias and painful dysesthesias associated with mefloquine chemoprophylaxis. A previously healthy, 45-year-old, white, male oral surgeon presented in preparation for a 2-week trip to rural Kenya. Mefloquine (Lariam, Roche Laboratories, Nutley, New Jersey), 250 mg weekly, was prescribed. Treatment was to begin the week before departure and to continue through 4 weeks after return. On returning from Africa (week 3 of treatment), the patient noted a transient (30- to 45-minute) episode of paresthesias involving the volar surface of the right fourth finger. Over the next 2 weeks, he noted episodic daytime positional paresthesias in the left hand. The week following his fifth mefloquine dose, he was awakened at night with profound anesthesia and paresthesia of the left hand (anesthesia in the lateral palm and paresthesia in the digits). The following night, symptoms were noted in both hands. Bilateral symptoms recurred nightly, greater in the left hand, with all digits and the palms affected. During the daytime he experienced a burning sensation on the plantar surfaces of both feet ("like standing on hot asphalt with shoes on") as well as paresthesias of the left hand. The patient had no associated history of repetitive trauma or overuse injury. He had no previous history of autoimmune disorders or the carpal tunnel syndrome and was not using other medications. Because symptoms were suspected to be caused by mefloquine, the patient withheld the sixth and final dose. Results of general physical and neurologic examinations were within normal limits. Laboratory evaluation showed a normal erythrocyte sedimentation rate, and results of tests for rheumatoid factor and antinuclear antibody were negative. Serum electrolytes were within normal limits, as were serum B12 and folate levels. Nerve conduction studies were unremarkable. The patient's symptoms gradually improved after discontinuation of mefloquine, with total resolution occurring 3 weeks after the fifth dose. Although case reports cannot prove causality, our patient's symptoms developed with mefloquine administration and resolved after its discontinuation. One other patient has reported nocturnal extremity paresthesias associated with the drug (Mayer H, Roche Laboratories. Personal communication). Clinicians should be aware of this potential side effect because



mefloquine is increasingly being used for prophylaxis and treatment of chloroquine-resistant malaria. Patrick E. Olson, MD Charles A. Kennedy, MD Paul D. Morte, MD Naval Hospital San Diego, CA 92134 References 1. Singh K, Shanks GD, Wilde H. Seizures after mefloquine. Ann Intern Med. 1991;114:994. 2. Bjorkmann A. Acute psychosis following mefloquine prophylaxis. Lancet. 1989;2:865. 3. Arthur JD, Shanks GD, Echeverria P. Mefloquine prophylaxis. Lancet. 1990;1:972. 4. Changes of dosing regimen for malaria prophylaxis with mefloquine. MMWR. 1991;40:72-3. 5. Rouveix B, Bricaire F, Michon C, et al. Mefloquine and an acute brain syndrome. Ann Intern Med. 1989;110:577-8.

Consistency in Prescription Writing To the Editors: Despite repeated admonitions, patients continue to misread and misinterpret prescription label directions (1). Inability to read or to comprehend does not explain it (2). The simplest way to promote effective communication is to be consistent. Research indicates that a consistent ordering of the elements of prescription label directions would be optimal for comprehension (2). Patients may already have a mental schema for taking medications, and thus "instructions should be better understood when organized to match this knowledge" (3). A recent analysis of over 10 000 computerized signatures of three national chain pharmacies suggests that a simple schema or orderly system for communicating prescription label directions might take the following form: 1. The command verb (take, give, apply). " Y o u " is the understood subject. 2. Amount and dosage form (one tablet, one teaspoon). 3. Method or route of administration (by mouth, under the tongue). 4. Frequency, duration, and time of administration (twice a day at 10 a.m. and 10 p.m. for 10 days). 5. Indications for use (for cough, for pain). 6. Addendum: usually a prepositional phrase expanding on one or more of the previous components (if pain persists; after 10 doses, stop). An appropriate example of label directions is: "Take one tablet by mouth twice a day at 8 a.m. and 8 p.m. for 10 days for ear infection, then call doctor." All components should be included in the same order for any label or direction. The specific wording would be determined by the physician. Harvey M. Rappaport, PhD College of Pharmacy and Health Sciences Northeast Louisiana University Monroe, LA 71209-0470 References 1. Kessler DA. Communicating with patients about their medications. N Engl J Med. 1992;325:1650-2. 2. Morrell RW, Park DC, Poon LW. Quality of instructions on prescription drug labels: effects on memory and comprehension in young and old adults. Gerontology. 1989;29:345-54. 3. Morrow D, Leirer V, Altieri P, Tanke E. Elders' schema for taking medication: implications for instruction design. J Gerontol. 1991 ;46: 378-85.

Physicians and Cost Control To the Editors: Dr. Sulmasy's article "Physicians, Cost Control, and Ethics" (1) is an interesting analysis of the complicated situation of today's physicians. He contends that it is immoral for physicians to assist in the allocation of resources in the care of patients. I think physicians have two professional imperatives, first to eliminate disease and suffering and second to work for the overall good of society. The divergence of these moral imperatives may result in what the author calls a "moral stress test," but this burden of stress must be borne as a professional responsibility. The author would also have society write the rules, physicians deliver care by those rules, and society provide the funding for what society wishes to have. In an ideal world, physicians' moral responsibility then would be delineated, and they could function free of "moral stress." We do not live in an ideal world. Although society can do much more in promoting rules such as practice guidelines, technology assessment, and cost caps, it would be morally irresponsible for the physician community not to participate in the writing and application of those rules. Is doing so not de facto "bedside rationing"? The argument that incentives for cost-effective practice are immoral makes the assumption that our current reimbursement system is moral. Our current system encourages more health care. But more health care, although more expensive, is not necessarily better. If health care becomes so expensive that it can only be delivered to a smaller segment of the population, or at the expense of other important societal concerns (such as decent housing and adequate education), then the health care system is richer, but society is not better off. Where is the morality in that? Our society has discovered that its resources really are limited, and so physicians must struggle to serve two masters, knowing that they will not completely meet the needs of either. Physicians will suffer moral stress in this endeavor, but by their suffering gain a claim to nobility. Robert C. Osburne, MD Health Partners of Alabama, Suite 500 600 Beacon Parkway West Birmingham, AL 35209 Reference 1. Sulmasy DT. Physicians, cost control, and ethics. Ann Intern Med. 1992;116:920-6.

In response: Dr. Osburne incorrectly asserts that I believe it is immoral for physicians to assist in the allocation of health care resources. In fact, I argued that medical doctors ought to assist in the macroallocation of health care resources but only through their roles as citizens. I argued that doctors ought to bring their expert knowledge to the public debate on health care financing, but not act out this debate at the bedside. Physician participation in public debate on'health care financing is not "bedside rationing" but proper to their role as citizens. If the roles of physician and citizen are kept separate, then there may be moral stresses, but no excessive moral burdens should occur when a physician, qua physician, treats a patient. The "moral stress test" to which I referred arises only when health care policy is guided by the belief that the role of the physician as citizen is inseparable from the role as physician and uses a system of cost-control in which the physician must explicitly violate his or her own financial interests to help the patient. I do not, as Dr. Osburne asserts, assume that the current system of reimbursement in health care is morally ideal. In my paper, I explicitly excoriate the practice of "factitious gatekeeping" in which physicians provide unnecessary services solely for profit. What I reject is the assertion that a policy of "restrictive gatekeeping" is morally equivalent to the present system. As I argue in my paper, alternatives such as salary reimbursement, although not ideal, may be morally preferable. When a physician begins an interview by asking a patient,




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"How can I help y o u ? " the physician makes an implicit pledge to act as that patient's agent. The noble physician, in caring for that patient, must adhere to the scriptural admonition, " N o one can serve two masters" (Mt. 6:24). Daniel P. Sulmasy, OFM, MD Georgetown University Medical Center Washington, DC 20007

To the Editors: Most of the letters written in response to Dr. LaCombe's "Playing God" (1) were analytical, as if reviewing a scientific manuscript. Few accepted this story for what it was, a piece of literature. Its purpose, through poetic license, was to evoke a response, piercing the armor of indifference to reveal the intense interior life of a physician. As I read the story of Kitty and Earl for the first time I was overcome by raw emotion. My response was similar to my children's when they eat a special treat, taking a few bites, then tucking it away so they can repeat their experience later. I too savored "Playing God," reading a paragraph or two, stopping, digesting them and starting again. By the time I finished the last sentence, I felt drained. It was as if I had been in the kitchen with Kitty after Earl's death. After tearing the veneer from the physician's persona and exposing the pillars of his life's work, does the title really matter? Need we argue the semantics of "Playing God"? Doesn't debating the plausibility of Kitty's doctor's actions miss the focus of the essay? I believe so. Let the writing stand for itself—an eloquent expose on the physician's world—a mixed metaphor of suffering, tragedy, terror, compassion, and redemption, but most importantly, a triumph of hope. Vaclav Havel, Czechoslovakian poet and former president, writes that "hope is an orientation of the spirit, an orientation of the heart; it is not the conviction that something will turn out well, but the certainty that something makes sense, regardless of


Michael T. Kovalchik, MD Charlotte Hungerford Hospital 540 Litchfield Street Torrington, CT 06790 Reference 1. LaCombe MA. Playing God. Ann Intern Med. 1992;116:161-2.

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how it turns out." I think he would have enjoyed Dr. LaCombe's story.

In response: I thank Dr. Kovalchik for his fine letter. Let me respond with some questions about why physicians are so analytical when reading narrative, whether it be truth or fiction. I believe it has to do with what our training has done to us. We are taught to " c l o s e " very quickly, pressured as we are by the ceaseless demands of our professional life. We take the history—the patient's narrative—as efficiently as possible, (if we take it at all), missing its color, discarding its emotion, insisting on "just the facts, ma'am, please." We need a diagnosis. We haven't the time for stories. Our mental processes become algorithmic analysis. We have forgotten how to think. We engage in what Mencken called "grooved thought." Wait! Before you utter, "Yes, but . . . " and assume what de Bono has termed the cheapest form of thinking (the adversarial approach, another product of our training), consider a few more questions. How many of us read novels these days, and how many just glance at the book reviews? When last did you sit down for an hour or more with a poem, just one poem, and read it, read it again, and then a third time, aloud to yourself, and wonder over its emotion, its metaphors, its images, swallow it, digest it, and recite it to yourself on the drive to work? When did you last listen to a patient, really listen? Michael A. LaCombe, MD Oxford Hills Internal Medicine Group Norway, ME 04268



THANKS TO REVIEWERS—1992 T h e strength of Annals depends in large measure on the ability and efforts of m a n y hundreds of reviewers. Below, w e have listed the consultants w h o reviewed between 1 N o v e m b e r 1991 and 31 October 1992. T h e y have provided a great service—for editors, to be sure—but also for authors, readers, and the medical community as a w h o l e . T h a n k you! Richard Aach Joseph A Abbott Francois M Abboud Nabih I Abdou Darrell R Abernethy Donald I Abrams Fredrick R Abrams Jonathan Abrams Edgar Achkar James L Achord John S Adams Patricia Adams Daniel C Adelman Philip A Ades Yosef Aelony Arthur S Agatston Vincent Agnello Frederick R Ahmann Yeon S Ahn Robert K Ahrens Jaffer A Ajani Stephen Akers Graciela S Alarcon Abass Alavi Gregory W Albers Michael H Alderman Louis M Aledort Cathy A Alessi E Russell Alexander Elaine Alexander Allen C Alfrey Giuseppe Aliperti Carmen Allegra Michael Allon Joseph S Alpert Martin A Alpert Miriam J Alter Lawrence K Altman Leonard C Altman John Ambrose Arthur J Ammann Claudio Anasetti James W Anderson Odin W Anderson William H Anderson Warren A Andiman Dennis Andrulis Aubie Angel Jack E Ansell Peter C Appelbaum William B Applegate Robert Arbeit Ronald A Arky James O Armitage Donald Armstrong Paul Armstrong Frank C Arnett Robert Arnold William J Arnold Wilbert S Aronow Mark Aronson Richard Asinger Arne Astrup Richard L Atkinson William Atkinson

Robert C Austrian Steven D Averbuch Jerry Avorn Carlos R Ayers J Carlos Ayus Daniel L Azarnoff Larry M Baddour John Baillie C Noel Bairey Alfred L Baker James P Baker Louis Balart Henry H Balfour Jr John A Balint David Ballard Rachel Ballard-Barbash Stanley P Ballou Mark Ballow James E Balow John S Banas Jr Simmy Bank Arthur Bankhurst Richard A Bankowitz John Banwell Daniel Baran Alan Barbour Lewellys F Barker Jamie S Barkin H Verdain Barnes G Octo Barnett John A Baron Elizabeth Barrett-Connor A Sidney Barritt III Michele Barry Arthur J Barsky William Barson John G Bartlett Doris G Bartuska Nathan Bass Joseph H Bates Susan Bates Murray D Batt Stephen Baum Kay Bauman William G Baxt Thomas R Beam Miles Beaman Scott Bearman Mark A Bechtel Laurence H Beck Charles E Becker Colin B Begg Claudia Beghe Raymond Begin Malcolm Bell Norman H Bell William R Bell Jorge L Benach Mahmoud Benbarka Bradley Bender Stanley B Benjamin Nancy E Bennet John M Bennett Neal L Benowitz

Gordon D Benson David W Bentley Gerald S Berenson Frederick Berg Ruth Ann Berkelman Samuel A Berkman Jesse A Berlin James L Bernat Daniel S Bernstein David Berry Jack Berryman Sandra Bertman Anatole Besarab Richard W Besdine Alice N Bessman Joel Betesh Robert F Betts Jesus Bianco Philip Bierman Judyann Bigby Edward G Biglieri Roger A Billhardt Philip Binkley Alan L Bisno Jon D Blachley Donald W Black Martin Black George L Blackburn Neil R Blacklow Michael Blackstone Donald C Blair Martin J Blaser Thomas P Bleck Andres T Blei Sheldon J Bleicher Laurence M Blendis Peter C Block E Richard Blonsky Bernard S Bloom Charles D Bluestone Joanne L Blum Manfreed Blum Ronald H Blum Michael Blumenkrantz David Blumenthal Guenther Boden Morton D Bogdonoff Kline W Bolton Brian Bolwell Roger C Bone Robert Bonow David Borenstein Louis Borgenicht Kenneth M Borow Daniel Bosch Sylvia S Bottomley Harisios Boudoulas Randall Bovbjerg Edwin G Bovill Raleigh Bowden David L Bowton John M Boyce James M Boyle Eugene M Bozymski Samuel Bozzette




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Newton C Brackett Jr Suzanne F Bradley Edward L Bradley HI Roscoe O Brady Michael N Braffman Robert L Braham Hayden G Braine Sidney Braman Lenore J Brancato William T Branch Jason Brandt Glenn D Braunstein Emmanuel L Bravo Dale G Breaden John Breitner Troyen Brennan Donald J Brenner Lawrence H Brent Donald Breslin Daniel W Brock Samuel Broder David L Bronson Robert H Brook Scott W Brooks Michael Brotsky Phillip Brown Kelly D Brownell Sheldon Brownstein Daniel B Brubaker Philip A Brunell Louis L Brunetti John C Brust Aby Buchbinder Thomas Buckingham Helen R Buckley Stephen Bulova Howard Burchell Kathryn L Burgio John P Burke John F Burnum James F Burris Benjamin Burrows John R Burton Charles A Bush Peter Bushunow Elsworth Buskirk James B Bussel Ronald Busuttil Donald E Butkus Vincent P Butler Nelson Butters Timothy Byers Joseph Cady James H Caldwell Frank M Calia Robert Califf Evan Calkins Christopher Callahan C Wayne Callaway Jeffrey P Callen Michael Camilleri Jaime Campos John J Canary Lauralyn Cannistra Louis R Caplan Blase A Carabello George J Caranasos Paul P Carbone Timothy Carey William D Carey Victoria Cargill Robert L Carithers Jr

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Richard Carlson Jose Caro Dina F Caroline David T Carr J Gregory Carroll Paul Casale Robert Case Richard Cash Edwin H Cassem Donald O Castell William P Castelli Lon Castle Samuel Cataland James F Cawley C Gene Cayten Randall D Cebul David D Celentano David F Cella Robert M Centor James M Cerletty Bruce Chabner Robert A Chahine Richard E Chaisson Michael J Chamberlain Henry Chambers Prem K G Chandran Eugene Chang Te-Wen Chang Mary Charlson Rita Charon Arthur B Chausmer Joseph A Chazan Melvin D Cheitlin James D Cherry Charles E Cherubin Elliot Chesler Charles Chesnut III Bruce D Cheson William Y Chey Homer Chin Keith Chirgwin Rowan T Chlebowski Joan S Chmiel Sunwen Chou James Christensen Charles L Christian A Richard Christlieb Steven G Chrysant Jacob Churg Douglas B Cines Marc L Citron Roberto Civitelli Carolyn M Clancy Bayard Clarkson Harris R Clearfield Lynn M Cleary Mary Lou Clements Clifton R Cleaveland G Dennis Clifton Leonard A Cobb C Glenn Cobbs Frank Cockerill Jay D Coffman Cecil H Coggins Eric Cohen Harvey J Cohen Jules Cohen Mary A Cohen Myron S Cohen Stuart J Cohen Jay N Cohn Martin Cohn Graham A Colditz

15 December 1992 • Annals of Internal Medicine • Volume 117 • Number 12


Monroe Cole Martin J Collen Ann C Collier Virginia U Collier David S Colville Philip C Comp George W Comstock John J Condemi Hadley L Conn Jr Julia E Connelly Edward M Connor John P Conomy Robert Coombs David S Cooper Richard Cooper John B Copley Laurence Corash Eugene C Corbett Lawrence Corey Fernando G Cosio F Susan Cowchock Ronald Cranford Lawrence M Crapo Philip C Craven Jeffrey Crawford John C Crawhall Ralph Crawshaw William H Crosby Jr Kent B Crossley John Robin Crouse William F Crowley Jr Clyde S Crumpacker Mark R Cullen J Randall Curtis Janet Cuttner Ivan D'Cruz John A D'Elia David C Dale Thomas M Daniel Norman Daniels Marion Danis Gabriel M Danovitch David R Dantzker Daniel Danzel Kiron Das Raymond J Dattwyler William H Daughaday Richard J Davey John K Davidson Paul T Davidson Richard Davidson Gary L Davis Janet L Davis John S Davis Lisa E Davis Paul J Davis Paula Davis James W Davis Jr Susan Day Raphael J De Horatius J Raymond De Paulo Robert F Debusk G William Dec G Michael Deeb Elaine Defreitas Greg Dehmer Herman C Denber Margo Denke Floyd W Denny Vincent L Dequattro Richard A Deremee Roger M Des Prez

Marc Desmet Roger Detels Robert Detrano Richard B Devereux Richard A Deyo George A Diamond Herbert S Diamond Louis Diamond Philip T Diaz Anthony G DiBartolomeo Robert DiBianco Gordon Dickinsin Andrew K Diehl Anna M Diehl James C Dillon Vasken Dilsizian John DiMarco Charles Dinarello Vincente P Dinoso Vincent A Discala William O Dobbins III Malin Dollinger Jeremiah Donovan Sam T Donta John L Doppman John Douglas Pamela S Douglas Adam Drewnowski Douglas A Drossman Daniel Drucker Lewis M Drusin Gary Dubin Robert W Dubois Kurt M Dubowski David B Duggan Richard J Duma George Dunea Lee Dunn Marvin Dunn Herbert L Dupont Asim K Dutt Johanna Dwyer Kim A Eagle R Philip Eaton John Edwards William D Edwards Richard A Eiferman Howard Eisen John M Eisenberg Mickey Eisenberg Robert A Eisenberg Jack A Elias Michael Eliastam Uri Elkayam Kenneth Ellenbogen David H Ellison Jerrold J Elmer Arthur S Elstein Guy Emery Linda L Emmanuel Jack Ende Paul F Engstrom Arnold M Epstein Leonard Epstein William L Epstein Allan J Erslev Gerald Escovitz Max Essex J Worth Estes N A Mark Estes III David S Ettinger Neil Ettinger

Arthur Evans Dolores Evans Robert Evans Ronald G Evens James E Everhart Gordon A Ewy Michael Ezekowitz John L Fahey Virgil F Fairbanks Harrison W Farber Henry M Feder Jr John Feightner Lawrence E Feinberg Susan Feinglos Saya V Feinman Donald Feinstein Stephen M Feinstone Thomas Fekete Ronald Feld Arthur Feldman Harvey A Feldman Mark Feldman Ross D Feldman Vincent J Felitti David T Felson Carol H Fenichel Gladys Fenichel Robert P Ferguson Jack Ferlinz Victor J Ferrans John R Feussner Marshal P Fichman Robert B Fick Stanley B Fiel Robert Figlin Stephan Fihn S Edwin Fineberg Jordan N Fink Wayne H Finley Thomas E Finucane James E Fish Lawrence M Fishman Janice Fisler Annette Fitz Faith T Fitzgerald Kenneth Flegel Eugene C Fletcher John S Floras Nancy Flowers John C Floyd Jr Michael R Fogel Richard N Fogoros Kathleen M Foley Aaron R Folsom Marshal F Folstein Mary Ann Forciea Christopher C Fordham III Marvin Forland Paul Fortin Willis Foster Fetnat M Fouad Michelle Fox James N Frame Charles Francis Gary S Francis Barbara Frank David W Fraser Joseph F Fraumeni Jr Susan Frayne Linda M Frazier Donald S Fredrickson David L Freeman

Howard E Freeman Richard B Freeman Jacob K Frenkel Bruce Freundlich Eli A Friedman Lawrence S Friedman Richard B Friedman Sandor A Friedman James F Fries Victor F Froelicher Harold Frucht Howard Frumkin June Fry Dennis G Fryback Gahnem Fuad Mark G Fuller W Bruce Fye William Gaasch Thomas G Gabuzda Thomas R Gadacz Georgio Galetto Robert S Galvin Eugene J Gangarosa Nelson M Gantz Hasan Garan Judy Garber Timothy J Gardner Marc B Garnick Robert Garrison Nancy E Gary Robert Gaston Stephen Gebarski J Bernard L Gee Michael A Geheb H Jack Geiger David W Gelfand Edward Genton Saul Genuth James N George Paul D Gerber Walter L Gerber Julie L Gerberding Philip P Gerbino Dale N Gerding Robert J Gerety Pearl S German Bernard J Gersh M Eric Gershwin Stanton L Gerson Neil Gesundheit Joanne Getsy Thomas E Getzen Michael Gheorghiade Ralph E Gianelly Alexandra Gibas Raymond Gibbons James J Gibson Thomas D Giles Joan Gill Thomas M Gill Sander L Gilman Allen L Ginsberg Henry Ginsberg Robert Ginsburg Harold M Ginzburg Janis Giorgi Donald E Girard Norman Gitlin John A Glaspy Richard J Glassock Jeffrey Glassroth Frederick L Glauser



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Richard Gleckman Norbert Gleicher Alan Glombicki Michael Glovsky James J Goedert Mark S Gold Paul Gold Mark A Goldberg Richard Golden Stephen Goldfinger John A Goldman Scott M Goldman Nora Goldschlager Ralph S Goldsmith Elliot Goldstein Robert A Goldstein Joseph W Goldzieher Joseph S Gonnella Ernesto Gonzalez Scott Goodnight Laurence T Goodnough Sherwood L Gorbach Fred Gordin David J Gordon Gary V Gordon Joel M Gore Paul Gorman Charles Gornick Charles Gottlieb Michael S Gottlieb Antonio M Gotto Jr Alan L Graber Thomas B Graboys Norman D Grace Edward J Gracely Deborah G Grady David Y Graham Neil M Graham J Thomas Grayston Arthur Grayzel Anthony Greco David Green George R Green Michael S Greenberg Norton J Greenberger Philip Greenland William B Greenough III Jeffrey I Greenstein M Andrew Greganti Jean Grem Michael R Grey Diane E Griffin Clarence E Grim Jerome E Groopman Charles Grose Peter Gross William Grossman Scott M Grundy Richard L Guerrant Mary Guinan Subhash C Gulati Ashok K Gumbhir Helen Guthrie David Gutknecht Leonard Gutnik Nortin M Hadler Richard Hafner Wayne A Hale Russell P Hall Phillip Halloran Allan C Halpern Scott Halstead

1064

Charles H Halsted John Hamilton Karl Hammermeister Bruce H Hamory Stephen B Hanauer Barry Handwerger Ruth S Hanft William Hansen John Hansen-Flaschen James B Hanshaw Douglas W Hanto Victoria A Harden William G Hardison Robert T Harris Russell Harris Sandra L Harris Linda L Hart L Howard Hartley Roger J Hartman Peter Hasselbacher Marilyn T Haupt R Brian Haynes Marguerite T Hays Ron D Hays William R Hazzard Louis A Healey Jr Joseph Healy Robert P Heaney David Heber Paul S Heckerling Terry D Heiman-Patterson John Heit Ted Hendershot Edward S Henderson Thomas R Hendrix Curtis J Henke Robert I Henkin Keith S Henley David H Henry David P Henry II Ronald B Herberman Victor D Herbert Irving Herling William H Herman Roberto Heros Howard Herrmann William Hersh Linda A Hershey Ahvie Herskowitz Evelyn V Hess Frederick A Heupler Steven B Heymsfield Jeane Hicks H Patrick Higgins Frank J Hildner David Hillis Alan L Hillman Bruce E Hillner Alan R Hinman Jules Hirsch Martin S Hirsch Shalom Z Hirschman Basil I Hirschowitz Jack Hirsh Mark A Hlatky David D Ho Marc C Hochberg Robert H Hodge Robert Hoeldtke Ronald Hoffman Phillip E Hoffsten John H Holbrook Charles Hollander



Harry Hollander Peter Holt Donald A Holub Timothy J Holzer Howard D Homesley Edward W Hook III Thomas M Hooton Ronald R Hope Leo Horan Richard B Hornick Mary M Horowitz David Horwitz David L Horwitz Ralph I Horwitz Daniel F Hoth Joel Howell Reed W Hoyt Anastacio Hoyumpa Jr Donald E Hricik James M Hughes Siu L Hui Russell D Hull Herbert N Hultgren Donald B Hunninghake Vernon B Hunt Kathryn M Hunter Tim B Hunter Eric R Hurd Grover M Hutchins Edward J Huth Mary Devereaux Hutton Richard W Hyde Thomas M Hyers Jonathan S Ilowite Mark Ingermann Tsuyoski Inoshita Herling Irving Henry D Isenberg Abdulmassih S Iskandrian Jeffrey M Isner Douglas Jabs Marc Jacobson Sheldon Jacobson Allan S Jaffe Harold W Jaffe Israeli A Jaffe Kenneth Jamerson Stephen James Thomas N James Michael Jamieson Joseph S Janicki William R Jarvis David J A Jenkins Anthony S Jennings Gordon Jensen Michael D Jensen Norman M Jensen Robert T Jensen Sergio A Jimenez Jared B Jobe Joseph F John Caroline Johnson David H Johnson Lawrence F Johnson Russell Johnson Timothy Johnson Warren D Johnson Jr David E Johnston Anne Hudson Jones E Anthony Jones Judith K Jones

Peter Jones Thomas V Jones M Colin Jordan Joseph Jorizzo Diane K Jorkasky Robert J Joy Claude R Joyner Alan Kadish Stephanie D Kafonek Lawrence J Kagen Henry S Kahn Robert Kaiser Robin Kanarek Phyllis Kanki Richard E Kanner Harvey S Kantor Rajendia Kapilla Andre A Kaplan Marshall M Kaplan Norman M Kaplan Robert Kaplan Sherrie H Kaplan Wishwa Kapoor Joan Kapusnik-Unner Monroe Karetzky Judith E Karp Michael Karpf Richard A Kaslow David Kass Jeffrey Katt Norman Kattwinkel Mitchell Katz Paul Katz Steven Katz Sanjiv Kaul Hymie Kavin Emmet Keeffe Mark A Kelley John G Kelton Harvey Kemp Harold L Kennedy Daniel L Kent James P Keogh Gerald T Keusch Thomas C Keyserling Muhammad A Khan David T Kiang Thomas S Kickler Pamela Kidd Douglas P Kiel Joseph M Kiely Michael G Kienzle James W Kikendall Kaye H Kilburn John Killen Thomas Killip III Soo Kim Robert P Kimberly Abby King Spencer B King III Bruce Kinosian Charles H Kirkpatrick John Kirkwood Jay W Kislak Abbas Kitabchi Carl M Kjellstrand Charles R Kleeman Michael Kleerekoper George J Klein Irwin Klein Lloyd W Klein Ron Klein

David L Kleinberg Anne Klibanski Paul Kligfield John H Klippel Frederick A Klipstein Albert B Knapp James P Knochel Alfred Knudson Scott Koenig Raymond S Koff Marin H Kollef Walter Koltun Anthony L Komaroff Marvin A Konstam Hermes A Kontos Stanley G Korenman Paul Kornblith William J Kostuk Karen Kotlof Robert M Kotloff Thomas Kottke Joseph A Kovacs Sandor Kovacs Peter R Kowey Richard A Kozarek Sumner C Kraft Mark S Kramer Norman Krasnow Eric H Kraut Robert A Kreisberg Joel Kremer Robert L Krigel Kurt Kroenke Charles L Krone Ronald Krone Richard Kronick Thomas H Kruelen James A Kruse Friedrich Kueppers Thomson Kuhn Donald H Kuiper Lewis Kuller Peter B Kurnik Rebecca Kurth Razelle Kurzrock Robert Kushner Steven Kutalek Kristan L'Abbe John La Puma Arthur J Labovitz Douglas Labrecque Michael A Lacombe F Marc Laforce Stephen Lagakos Robert Lahita Kwan K Lai Loren Laine Carol L Lake Charles Lambert J Thomas Lamont C Seth Landefeld Lewis Landsberg H Clifford Lane Timothy W Lane David Langleben Paul N Lanken John H Laragh Robert A Larsen Sandy A Larsen Eric B Larson Bret A Lashner Norman Lasker

Robert J Laskowski Andreas Laupacis Jeffrey Laurence Jeffrey Lautit William J Lawton A Joseph Layon Michael M Lederman Belle L Lee Kerry Lee Robert E Lee Sum P Lee Thomas H Lee William M Lee Jay H Lefkowitch Michael Lehmann Carl V Leier Sanford Leiken Louis Lemberger Neil Lempert Jeffrey A Leppo Caryn Lerman A Martin Lerner Barron H Lerner Phillip I Lerner E Carwile Leroy Jon Levenson Gerald S Levey Richard Levin Benjamin D Levine Gary M Levine Joel Levine Peter H Levine Shirley Levine Wendy Levinson David Levitsky Michael D Levitt Michael H Levy Paul S Levy Sharon Levy Charles E Lewis James H Lewis Jon Lewis Robert B Lewis Matthew H Liang Peter R Lichstein Charles W Lidz Jack Lieberman Philip R Liebson Richard W Light Joao A Lima Stuart L Linas Marie Lindner Calvin C Linnemann Jr Mark Linzer Zbigniew J Lipowski James J Lipsky Martin J Lipsky Robert Lisak Sheldon A Lisker Donald Liss Benjamin Littenberg William Little Hans Liu Kiang Liu Robert B Livingston Geronimo Lluberas-Acosta Bernard Lo Richard Lofgen Kathleen Lohr Jacob J Lokich W Thomas London William B Long Dan L Longo



1065

Floyd Loop Charles Loprinzi Joseph Loscalzo Thomas Louis Frank Lowy James P Luby Jerry C Luck Jurgen Ludwig Russell Luepker Sheila A Lukehart Barbara P Lukert Nicole Lurie Harvinder S Luthra Joanne Lynn Lorna Lynn Richard P MacDermott John MacDonald Scott L Mader Eufronio G Maderazo Adel A F Mahmoud Timothy Mahoney Daniel Malamud Harry Malech Hartmut H Malluche Donna Mancini Martin M Mandel Jeanne Mandelblatt Brian F Mandell Kenneth F Mangan David Mann Stavros C Manolagas Joann E Manson Paul R Marantz Sally L Marchesi Victor J Marder James R Margolis Karen Margolis Robert Marion Daniel Mark Joseph A Markenson Daniel B Marks Jay W Marks Melvin I Marks William H Marsh John B Marshall David Martin Paul Martin Steven Martin Fernando Martinez Diana Marver Edward Mascioli Robert U Massey Barry Massie Henry Masur Daniel R Masys William Matthai Robert Matz Peter Mauch Chester J Maxson Douglas R Maxwell Lawrence Mayer Robert J Mayer John W McBride Richard W McCallum Daniel J McCarty William M McConahey William M McCormack Keith McCrae Jack D McCue Paul R McCurdy Jane McCusker Clement J McDonald

1066

E R McFadden Jr William C McGaghie William G McGehee Douglas B McGgill Henry D Mcintosh Guy McKhann David S McKinsey Victor McKusick Brian McMahon Laurence F McMahon Jr Bruce M McManus James P McManus Thomas F Meaney Antone A Medeiros Thomas A Medsger H Erik Meema Jawahar L Mehta Diane E Meier Gordon Meiklejohn Curtis L Meinert Steven G Meister James C Melby Peter Melby L Joseph Melton Wallace B Mendelson Jay E Menitove Matthew Menken Thomas Merigan Geno J Merli Richard H Merrill Gregory J Mertz Franz H Messerli Stephen Mette Richard D Meyer Holly R Middlekauff Steven H Miles Anthony Miller I George Miller John Miller Myron Miller Wallace Miller Clark H Millikan Richard P Millman Si Chun Ming Gary S Mintz Richard A Mintzer Gerry Y Minuk Robert I Misbin Mack C Mitchell Robert C Moellering Jr Peter Mogielnicki Pramod K Mohanty John Molavi D Gay Moldow Mark E Molitch David Moller Julio S Montaner John G Moore Richard D Moore Aroor V Moorthy Fred Morady John Morley Laura Morlock C Douglas Morris J Glenn Morris Jon B Morris Anthony D Morrison Gail Morrison K John Morrow Jr Steven Morse George Morstyn Richard H Moseley Kenneth M Moser



Marvin Moser Robert H Moser Arnold M Moses Alan J Moskowitz William J Mroczek Robert R Muder Maurice A Mufson Charles Mullany Michael F Mullarkey Thomas F Mulrooney Cynthia D Mulrow Patrick Mulrow Robert Munford Santiago J Munoz Sheila A Murphey George F Murphy Michael Murphy Robert L Murphy Thomas H Murray Alvin I Mushlin David Mutch Joseph M Mylotte Gerald Naccarelli Irving Nachamkin Navin C Nanda Rudolph J Napodano Robert G Narins Thomas J Nasca David B Nash David T Nash Charles Natanson Ann B Nattinger Martin S Neff David Neiblum James Neidhart David E Ness Paul Ness Victor R Neufeld Duncan Neuhauser Daniel R Neuspiel Maria I New Georgia L Newman Craig R Nichols Jan Nicholson Giorgio L Nicolis Lindsay E Nicolle Lynette K Nieman Steven Nissen Allen R Nissenson Gary R Noble John Noble John J Norcini Robert G Norfleet Joe R Norman Robert Norris Timothy Nostrant Robert H Noth Richard M Nowak Moreye Nusbaum Martin L Nusynowitz Donald O Nutter William L Nyhan John O'Connell Gerald T O'Connor Matthew Ochs Frederick P Ognibene Carrie P Ogorek Martin M Oken Jeffrey W Olin Robert Olson Walter L Olson Jr

William C Orr Eric S Orwoll Kwame Osei Gerry Oster Susan M Ott Catherine Otto Jouni Ouitto Robert F Ozols Milton Packer Seymour Packman Alan G Palestine Harold Palevsky Thomas Palker Mark Pallansch Darwin L Palmer Wilfred H Palmer Genaro M A Palmieri Janardan P Pandey George A Pankey Fitzhugh C Pannill Richard S Panush Peter G Pappas Irvin Paradis Lawrence C Parish Ruth M Parker Robertson Parkman Gavril W Pasternak Reuven Pasternak Patrick S Pasulka Randolph Patterson Thomas Patterson Stephen G Pauker Bernadine Z Paulshock Harold E Paulus Richard Payne Harold L Paz George J Pazin James E Peacock Gary S Pearl Richard D Pearson Thomas A Pearson Mark S Pecker Steven J Peitzman John L Penner Mark A Peppercorn John R Perfect Gerald T Perkoff Carl Perlino Paul E Perlman Solbert Permutt Michael C Perry Mitch Perry Edward L Pesanti James B Peter Marion Peters Robert G Petersdorf Lynn M Peterson Phillip K Peterson Carol K Petito Carla Pettinelli Thomas L Petty John Philbrick John T Philbrick Terence M Phillips Stephan Phinney Thomas G Pickering Claus A Pierach Gordon Pierpot Ileana L Pina Theodore Pincus Alvaro A Pineda Ronald J Pion

Anthony W Pisciotta Henry A Pitt Mark R Pittelkow Chris C Plato Frederic Piatt Richard Piatt Gary Plotnick Vance Plumb Philip J Podrid James E Pointer Ronald Polk Richard B Pollard Bruce Polsky Roger J Pomerantz William Pomidor Peter Pompei Mortimer Poncz Charles E Pope Donald M Poretz Robert Lyman Potter Gail J Povar William Powderly Neil Powe Ananda S Prasad Melvin R Pratter Marion M Preston Thomas J Preziosi Kathleen I Pritchard Thaddeus E Prout Eric N Prystowsky Carmello A Puccio David P Purtilo Reed E Pyeritz Peter Rabins Sol Rafer Thomas A Raffin Derek Raghavan James J Rahal Jr Peter S Rahko Kanti R Rai Joel Raichlen Lawrence G Raisz Albert E Raizner Joe W Ramsdell Cynthia Rand Kenneth H Rand David F Ransohoff John Ranson R Harsha Rao Lee Ratner Robert Ratner Oscar D Ratnoff Kenneth R Ratzan Elliot J Rayfield Robert Recker K Rajender Reddy Margaret M Redfield Charles E Reed Guy S Reeder William C Reeves Lee B Reichman Richard C Reichman Marcus M Reidenberg Louis Reik Peggy Reiley Brendan M Reilly Richard A Reinhart Lawrence Repsher Robert H Resnick Herbert Y Reynolds Telfer B Reynolds Frank S Rhame

James B Rhodes Mitchell L Rhodes Andrew Rice Michael Rich Charles T Richardson Joel E Richter Robert Riddell Paul M Ridker Caroline Riely Basil M Rifkind Nancy Rigotti David J Riley Louis J Riley Jr Michael G Rinaldi Wallace P Ritchie Cheryl Ritenbaugh Louis F Rittelmeyer Jr David C Robbins John Robbins Marjorie Robert-Guroff John Roberts Richard B Roberts R Paul Robertson Albert P Rocchini N Wilson Rodger Arvey I Rogers C Stewart Rogers Martha Rogers Robert T Rolfs Barbara Romanowski John L Rombeau Allan Ronald Richard K Root Edward C Rosenow III Mark Rosenthal David Y Rosenzweig Fred Rosner Douglas S Ross Philip D Ross Luciano Rossetti Thomas H Rossing Milton D Rossman Leslie S Rothenberg Bruce Rothschild Harold H Rotman Ronenn Roubenoff David Rovner Janet D Rowley David J Roy Frederick L Ruben Arthur H Rubenstein Laurence Rubenstein Harvey Rubin Haya R Rubin Laurence A Rubin Lewis J Rubin Robert H Rubin Mark A Rudberg Michael M Rudnick Basil Rudusky Nicholas Ruocco John Russell R Patterson Russell Richard O Russell Jr Paul J Rutala Richard A Ryder Michael S Saag Alfred J Saah Zarif Saahenk Leon D Sabath Henry S Sacks Rulando E Saenz



1067

Wael Salameh Deeb N Salem David Salerno Stephen Sallen Paul Saltman Gerald Sandler David C Sane Jay P Sanford Robert A Sanowski William Santamore Victor Santana Teodoro V Santiago Francisco L Sapico Joseph D Sapira Louis D Saravolatz George A Sarosi Fred R Sattler Edward A Sausville Paul D Saville Virginia Savin Robert M Saywell Jr John A Sbarbaro Angelo M Scano David S Schade Robert Schade Donald W Schafer William A Schaffer Fenton Schaffner Morris Schambelan Peter M Schantz David V Schapira Gisela Schechter Gordon Schectman Melvin M Scheinman Howard I Scher Lawrence Scherr Eugene R Schiff Charles A Schiffer Joan H Schiller Lawrence R Schiller Richard L Schilsky Robert C Schlant Charles J Schleupner Patrick M Schliever David Schlossberg Arthur B Schneider Henry Schneiderman Steven M Schnittman Robert T Schooley Anna Schorer Alan D Schreiber Robert W Schrier Edward T Schroeder Kenneth W Schroeder Steven A Schroeder David E Schteingart Lynn M Schuchter H Ralph Schumacher Jr Stanley H Schuman Barbara Schuster Allan Schutt William Schwab Brian Schwartz Roger H Seeker-Walker Leonard B Seeff Sandy Sehgal James R Seibold Herbert A Selenkow Harry P Selker Kenneth W Sell Edward M Sellers Andrew P Selwyn Peter A Selwyn

1068

Pravin M Shah Charles Shapiro Martin Shapiro Gerard J Sheehan Thomas W Sheehy Albert L Sheffer John D Shepherd David H Shepp David S Sheps Renslow Sherer Kimberly Sherrill David S Shimm I David Shocket Jeanette Shorey Edward H Shortliffe Joseph Shrager Victor W Sidel Frederick P Siegal David Siegel Elliot R Siegel Roger M Siervogel Leonard H Sigal Rebecca A Silliman Richard M Silver Stephen Silvis Michael S Simberkoff David L Simel Michael Simenhoff Gregory E Simon Thomas W Simpson Ross J Simpson Jr Ethan A Sims Frederick R Singer Joel Singer David Siscovick Albert L Siu Emil Skamene Roland Skeel Kelley Skeff Neil S Skolnik Paul Skolnik David Skorton Charles Slemenda Peter Small Jerry D Smilack James W Smith Jill P Smith Robert C Smith Dixie E Snider Jr David R Snydman Ruy Soeiro J Stuart Soeldner Konrad H Soergel Allen Soffer Kim Solez Rachel E Solomon Keyoumars Soltani John H Sorenson Michael F Sorrell Harold C Sox Jr Philip J Spagnuolo Robert Spanheimer Robert Spanier Stuart J Spechler J David Spence Michael R Spence Carol Spencer Stuart F Spicker Harry Spiera Gary Spitzer Roger E Spitzer Thomas Spitzer Norton Spritz



Spotswood L Spruance Alagarsamy Srinivasan Edward Stadtmauer Stephan Stapczynski John A Starkweather Mark Starling William B Stason William W Stead Roy Steigbigel Myron Stein Sherman C Stein Gary Steinberg Laurel Steinherz Donald M Steinwachs Larry Stephenson Judy Stern Cladd E Stevens Mary B Stevens William Stevenson Paula L Stillman James L Stinnett John D Stoeckle Paul D Stolley Alan Stoudemire Diane Stover David J Straus Stephen E Straus Larry J Strausbaugh David H P Streeten Leopold Streletz Brian Strom Jeoffrey K Stross William C Sturtridge Ramiah Subramian Alan M Sugar Daniel Sulmasy Warren Summer Karl E Sussman David S Svahn William R Swaim Morris Swartz Robert M Swenson Ronald Swerdloff James A Talcott Nicholas J Talley Carlo H Tamburro Thomas Tape Angelo Taranta Alvin R Tarlov Carl Taylor Henry Tazelar Grethe Tell James Tenney Fred C Tenover Peter B Terry Steve Thacker David C Thomasma Gerald E Thomson Ken Thorpe Swan N Thung William M Tierney William A Tisdale Susan W Tolle Keith G Tolman John Tomaszewski Eric J Topol Phillip Toskes Charles D Tourtellotte Joseph Treat Gordon M Trenholme Jerry S Trier Bruce Trock

Richard Trohmann Joel Tsevat Carmalita U Tuazon Joseph R Tucci Henry M Tufo Paul A Tunick Alan Tunkel Elaine Tuomanen Zoltan Turi Alexander G Turpie Jessica Tuttle Frank H Tyler Herman Tyroler Manuel Tzagournis Richard Uhlmann Alvin L Ureles Barry Uretsky Saroj Vadhan-Raj Paul Vaitkus William M Valenti Martin D Valentine Jorge E Valenzuela Richard G Van Dellen Andre J Van Herle Jerome V Van Ruiswyk Mary Lee Vance Byron Vandenberg Jerry B Vannatta Neal A Vanselow Rajiv R Varma Gloria Vega Ramon Velez Abraham Verghese Sten Vermund Robert E Vestal John W Vester Victor Villagra David Vlahov Georgia B Vogelsang Paul Volberding Robert Volpe Daniel D Von Hoff Michael Von Korf Julie M Vose Tom J Wachtel Frans J Wackers James C Wade Edward H Wagner Galen S Wagner Heinz Wahner Albert L Waldo James E C Walker Eleanor Z Wallace Stanley Wallach Lisa Wallenstein Steven Wallner A Terry Walman Mackenzie Walser

Peter D Walzer Jack R Wands L Samuel Wann John W Ward Susan Ward Raymond P Warrell Jr John W Warren Kenneth S Warren Alan Wasserstein John Wasson Chatrchai Watanakunakorn David Waters Menashe Waxman Jerome D Waye Michael A Weber John G Weg Richard Weinberg Myron H Weinberger Amy Weiner Roland L Weinsier Arthur Weinstein Melvin P Weinstein Michael Weintraub William Weintraub Robert Weir Richard L Weiss David E Weissman Michael R Weitekamp Jeffrey I Weitz Marc E Weksler Charles R Welford Bennett E Werner Victoria Werth John Werthermer Stanford Wessler Maxwell P Westerman Laura Wexler John White Neil H White Fred W Whitehouse Frederick C Whittier Larry Wickerham Lawrence E Widman Stanley L Wiener Peter H Wiernik Russell N Wiesner C Mel Wilcox Michael Wilkes Walter Willett Alan E Williams Darryl M Williams H James Williams Mark Williams Redford Williams Sankey Williams John W Williamson Janice Willms Richard A Willson Andrew N Wilner Marjorie Wilson Walter R Wilson James F Winchester

John B Winfield Edward J Wing Rena R Wing John R Wingard Michael Winniford Drew J Winston Thomas Wise Jay B Wish Kenneth A Woeber Constance B Wofsy John Wolfe Sheldon M Wolff Nathan D Wong Roy K Wong Peter Wood David Woodley Theodore E Woodward Charles F Wooley James O Woolliscroft Gary P Wormser Nelda P Wray Taylor M Wray Keith D Wrenn Peter Wright Teresa L Wright Albert W Wu Ernst Wynder Joshua Wynne Tadataka Yamada Robert Yarchoan Henry Yeager Iven S Young James B Young Mary Young David S Younger M Donna Younger Stuart J Youngner William Yount Victor L Yu Adel A Yunis Gary P Zaloga Michael H Zaroukian Mohammed H Zarrabi Michael Zasloff Leonard Zegans Jerome B Zeldis Steven M Zeldis Lesley Zieve Irwin Ziment Carol Ziminski Hyman J Zimmerman Robert D Zipser Gregory Zuccaro Jr Thomas F Zuck Gary R Zuckerman Abigail Zuger Robert B Zurier



1069

Playing God: the rock opera that endeavors to become a bioethics education tool.

An anatomy of hope.

Heparin: does it act as an antioxidant in vivo?

God as a father-projection: the theory and the evidence.

An Act of Unpredictability.

Terrible God.

Does verapamil act as an immunomodulatory drug in vivo?

The names of God.

My brother God.

In the name of God: How children and adults judge agents who act for religious versus secular reasons.

The God of death and the God of life: A study of Nietzsche.

God made Capsulorrhexis.

God was born prematurely.

God Psychiatry Versus Good Psychiatry.

"I was mad at God".

Suicide as a political act.

Piano playing festination as initial symptom of Parkinson's disease.

SMOC can act as both an antagonist and an expander of BMP signaling.

An enabling act.

Hospice and hope: an incompatible duo.

Role-playing as a method in nursing research.

'There, but for the grace of God'.

God put a thought into my mind: the charismatic Christian experience of receiving communications from God.

Hope.