Letters
Annals of Internal Medicine COMMENTS
AND
RESPONSES
Acute Gastrointestinal Bleeding TO THE EDITOR: We compliment Kerlin and Tokar (1) for a good,
thorough review of acute gastrointestinal bleeding. However, we would like to point out a few areas of discrepancy in the literature. We disagree with their recommendation that colonoscopy be done within 12 to 24 hours of presentation for lower gastrointestinal bleeding. The only study indicating that colonoscopy altered outcomes in diverticular bleeding episodes was by Jensen and colleagues (2). Follow-up studies by Green and associates (3) and Laine and coworkers (4) did not show any reduction in need for colectomy, change in clinical outcome, or reduction in cost. As a result, early endoscopy within 24 hours has not been shown to be superior to elective colonoscopy within 72 hours (3, 4). Furthermore, the authors do not indicate that the currently more used test of choice for diverticular hemorrhage is emergent computed tomography angiography. With the improvement in computed tomography angiography, localization of the lesion is feasible, with subsequent interventional angiography successfully treating any bleeding vessel (5, 6). In addition, the authors comment that to prevent gastrointestinal bleeding in patients with chronic liver disease, nonselective -blockers can reduce portal pressure, thereby reducing variceal bleeding. However, the current American Association for the Study of Liver Diseases guideline does not recommend -blockers for all patients with chronic liver disease (7). Primary prophylaxis is indicated in patients with underlying cirrhosis who have medium or large varices or small varices with high-risk stigmata on endoscopy (for example, red wale marks). Alternatively, -blockers can be used in patients with cirrhosis without high-risk features, but as the American Association for the Study of Liver Diseases (AASLD) guidelines note, long-term benefit has not been established. Secondary prophylaxis is indicated after any variceal bleeding (7). In addition, the authors advise that if balloon tamponade is used to treat variceal hemorrhage, the balloon should be inflated for no more than 12 hours. Published trials of the Sengstaken–Blakemore or Minnesota tube effectively use the gastric balloons inflated for up to 24 hours (8, 9). In the rare situation that an esophageal balloon is used, then deflating it every 6 to 12 hours is indicated to avoid pressure necrosis of the esophagus (9). We do commend Kerlin and Tokar for writing a good summary of this broad topic of gastrointestinal bleeding. Joseph D. Feuerstein, MD Daniel A. Leffler, MD, MS Beth Israel Deaconess Medical Center Boston, Massachusetts Potential Conflicts of Interest: Dr. Leffler: Consultancy and grants/ grants pending: Prometheus Diagnostics, Alba Pharmaceuticals, Alvine Therapeutics, Shire Therapeutics. References 1. Prasad Kerlin M, Tokar JL. Acute gastrointestinal bleeding. Ann Intern Med. 2013; 159:ITC2-15. [PMID: 23922080]
2. Jensen DM, Machicado GA, Jutabha R, Kovacs TO. Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage. N Engl J Med. 2000;342: 78-82. [PMID: 10631275] 3. Green BT, Rockey DC, Portwood G, Tarnasky PR, Guarisco S, Branch MS, et al. Urgent colonoscopy for evaluation and management of acute lower gastrointestinal hemorrhage: a randomized controlled trial. Am J Gastroenterol. 2005;100:2395-402. [PMID: 16279891] 4. Laine L, Shah A. Randomized trial of urgent vs. elective colonoscopy in patients hospitalized with lower GI bleeding. Am J Gastroenterol. 2010;105:2636-41. [PMID: 20648004] 5. Martı´ M, Artigas JM, Garzo´n G, Alvarez-Sala R, Soto JA. Acute lower intestinal bleeding: feasibility and diagnostic performance of CT angiography. Radiology. 2012; 262:109-16. [PMID: 22084211] 6. Loffroy R. Multidetector CT angiography for the detection of colonic diverticular bleeding: when, how, and why? [Editorial]. Dig Dis Sci. 2013;58:1822-4. [PMID: 23695874] 7. Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W; Practice Guidelines Committee of the American Association for the Study of Liver Diseases. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007;46: 922-38. [PMID: 17879356] 8. Feneyrou B, Hanana J, Daures JP, Prioton JB. Initial control of bleeding from esophageal varices with the Sengstaken-Blakemore tube. Experience in 82 patients. Am J Surg. 1988;155:509-11. [PMID: 3257849] 9. Vlavianos P, Gimson AE, Westaby D, Williams R. Balloon tamponade in variceal bleeding: use and misuse. BMJ. 1989;298:1158. [PMID: 2500170]
IN RESPONSE: Regarding management of patients with varices, Drs.
Feuerstein and Leffler accurately point out that the AASLD does not advocate nonselective -blockers for primary prophylaxis of variceal bleeding for all patients with chronic liver disease, only those with higher-risk varices. We agree that, in our practices, many patients with small, low-risk varices typically do not routinely receive these agents for primary prophylaxis. That said, the AASLD guidelines (1) do not recommend that patients with small varices should never receive -blockers but state that “prophylaxis with beta-blockers should be used in patients with small varices who are at high risk for bleeding; that is, those with advanced liver disease and the presence of red wale marks on varices” and that “other patients with small varices can receive beta-blockers to prevent variceal growth, although their long-term benefit has not been well established.” A subsequent expert review recommends that “these agents are considered optional” in patients with low-risk varices (2). Our article also states that the balloon for tamponade in acute management of variceal hemorrhage should not be inflated for more than 12 hours. We were referring to the esophageal balloon, which can induce pressure necrosis of the esophagus. Indeed, the gastric balloon can safely be inflated for up to 24 hours. Our intent was to reduce the risk for misinterpretation and inadvertent inflation of the esophageal balloon continuously for 24 hours. The comments about management of patients with acute lower gastrointestinal bleeding are also valuable. Drs. Feuerstein and Leffler accurately point out that performing colonoscopy within 12 to 24 hours remains controversial. We stated this viewpoint in our article and that the opportunity for intervention may be limited, hoping to highlight these limitations of colonoscopy. Although colonoscopy is still performed within 24 hours at many institutions, we agree that existing data are inadequate to make absolute recommendations. We also appreciate the reminder that computed tomography angiography is a useful diagnostic test for lower gastrointestinal bleeding, although we are unaware of data supporting their assertion © 2013 American College of Physicians 793
Downloaded From: https://annals.org/ by a Kaohsiung Medica University User on 11/23/2018
Letters that it is “the currently more used test of choice.” The article that they reference, albeit encouraging, had a relatively small sample size and was recognized by its authors as a feasibility study (3). Furthermore, we believe that urgent computed tomography angiography is not always available, there remains a paucity of comparative data, and professional guidelines advocating its use as the initial test are lacking. Meeta Prasad Kerlin, MD, MSCE The Perelman School of Medicine at the University of Pennsylvania Philadelphia, Pennsylvania Jeffrey L. Tokar, MD Fox Chase Cancer Center Philadelphia, Pennsylvania Potential Conflicts of Interest: Dr. Kerlin: Consulting fee or honorarium: American College of Physicians; Grants/grants pending: National Heart, Lung, and Blood Institute, Centers for Disease Control and Prevention. References 1. Garcia-Tsao G, Sanyal AJ, Grace ND, Carey WD; Practice Guidelines Committee of American Association for Study of Liver Diseases. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Am J Gastroenterol. 2007;102:2086-102. [PMID: 17727436] 2. Garcia-Tsao G, Bosch J. Management of varices and variceal hemorrhage in cirrhosis. N Engl J Med. 2010;362:823-32. [PMID: 20200386] 3. Martı´ M, Artigas JM, Garzo´n G, Alvarez-Sala R, Soto JA. Acute lower intestinal bleeding: feasibility and diagnostic performance of CT angiography. Radiology. 2012; 262:109-16. [PMID: 22084211]
The 2013 Lung Allocation Controversy TO THE EDITOR: Halpern (1) refers to the temporary restraining
orders issued on 5 and 6 June 2013 by Judge Michael M. Baylson, a federal judge in Philadelphia, as “a troubling precedent,” “circumvention of due process,” and “legal wrongs.” He says that the temporary restraining orders suggest “either failure to recognize that preferential treatment for some recipients will adversely affect others (who may not be much older than 12) or that the court considered these 2 children’s lives more valuable than others.” His assertions are incorrect. I assume that he is aware that a specific federal regulation, a binding law, requires that organs be allocated on the basis of medical urgency, with no exception for children younger than 12 years. He may not know that the legal complaint filed on behalf of Sarah Murnaghan and Javier Acosta asked only that they receive access to adult lungs on the basis of the medical urgency of their conditions and that they sought no special preference. Certainly no suggestion was made at any time that their lives were more valuable than those of others. To the contrary, their parents took the position that each life is equally valuable and that Murnaghan and Acosta should be treated equally with persons aged 12 years and older absent some compelling reason. They questioned whether there was any compelling reason for treating their children differently when it would probably result in the deaths of both children. As it turned out, we never learned through the legal system whether any compelling reason was present in the circumstances of Murnaghan and Acosta—that is, children younger than 12 years who are closer to age 12 than infancy and who
have fatal diseases that present in children and adults where their physicians have expressed confidence in a lobar transplant procedure— because 4 days after the second temporary restraining order, the Organ Procurement and Transplantation Network (OPTN) authorized the OPTN Lung Review Board to waive the “Under 12 Rule” in certain cases and the Board decided to waive it in these 2 cases. We can all agree that organ allocation systems are complicated and that we do not want to make a habit of second-guessing the physicians responsible for them. But we do have a legal system that provides for review of the OPTN’s policies by the Secretary of Health and Human Services and by a court, if necessary. The possibility of baseless claims is not a reason to reject meritorious claims. In this case, the failure of the system to allocate adult lungs to persons younger than 12 years in the circumstances of Murnaghan and Acosta on the basis of the allocation principle of medical urgency presented an important legal issue that deserved the attention of a federal court authorized to decide it. Without question, one or both children could have died before that decision could have been thoughtfully made. Under these circumstances, the court acted appropriately and well within its power to prevent the possible deaths of 2 children pending the outcome of the OPTN’s decision. Stephen G. Harvey, JD Pepper Hamilton LLP Philadelphia, Pennsylvania Potential Conflicts of Interest: Disclosures can be viewed at www .acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum ⫽L13-1069. Reference 1. Halpern SD. Turning wrong into right: the 2013 lung allocation controversy. Ann Intern Med. 2013;159:358-9. [PMID: 23797998]
IN RESPONSE: Mr. Harvey raises issue with my characterization of the judicial review process in the cases of Murnaghan and Acosta because of a specific rule commonly referred to as the OPTN “Final Rule” (or 42 CFR 121) (1) dictating that medical urgency be a basis for organ allocation. The relevant sections of this rule state that “transplant candidates shall be grouped by status categories ordered from most to least medically urgent” and that “criteria for status designations shall contain explicit thresholds for differentiating among patients and shall be expressed, to the extent possible, through objective and measurable medical criteria.” Current lung allocation policies in adults and children meet these criteria. Existing policies categorize children as Priority 1 or Priority 2 on the basis of explicit criteria reflecting medical urgency. The Final Rule is silent on the question of what, if any, special priority should be accorded to patients of different ages. Thus, the fact that the urgency-based prioritization in children differs from that in adults in no way violates the Final Rule. Indeed, the multivariable prediction models included in the Lung Allocation Score, which gauge urgency and anticipated benefit in ranking adults on the waiting list, cannot be applied with any confidence or statistical precision to children because the paucity of children requiring lung transplantation led to their exclusion from these complex models when they were developed (2). Applying these models to children might therefore cause inequitable prioritization, conflicting with the Final Rule’s mandate.
794 3 December 2013 Annals of Internal Medicine Volume 159 • Number 11
Downloaded From: https://annals.org/ by a Kaohsiung Medica University User on 11/23/2018
www.annals.org
Letters These facts raise serious questions about the merits of Mr. Harvey’s case. He is correct that, as it happened, the step in the judicial process where the merits of the Murnaghan case would be considered was never reached because Murnaghan received a transplant within the 10-day window of the temporary restraining order. He is also correct that Murnaghan might have experienced irreparable harm without the restraining order. In most legal circumstances, this would make issuance of a restraining order appropriate until the merits could be fully evaluated. However, issuing a restraining order that interferes with national organ allocation policy differs from nearly all contexts in which restraining orders have been used to date because the order protects 1 identifiable person while causing direct disadvantage to 1 or more others awaiting transplantation. This conflict creates unusually broad responsibilities for Judge Baylson in contemplating a restraining order, making him ethically (if not also legally) obliged to seriously consider the merits of the claim before intervening. Had such prudent steps been taken, the claims that existing policies violated the Final Rule or discriminated against children probably could not have been sustained. There may, indeed, be ways to improve the existing allocation system, but granting one-off waivers to well-resourced patients and families is not the path to such improvement. Scott D. Halpern, MD, PhD University of Pennsylvania Philadelphia, Pennsylvania Potential Conflicts of Interest: Disclosures can be viewed at www .acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum ⫽M13-1487. References 1. Department of Health and Human Services. The Final Rule. 2 April 1998. Accessed at www.gaonet.gov/special.pubs/organ/appendd.pdf on 1 July 2013. 2. Egan TM, Murray S, Bustami RT, Shearon TH, McCullough KP, Edwards LB, et al. Development of the new lung allocation system in the United States. Am J Transplant. 2006;6:1212-27. [PMID: 16613597]
OBSERVATION
horizontal nystagmus and intention tremor in both women and a fractured tibia in one. Nothing in their medical histories seemed relevant. Questioning revealed that the women had been conducting a traditional Eritrean coffee ceremony in a small, unventilated kitchen. Arterial blood gas analysis performed 20 minutes after symptom onset showed a pH of 7.41, PO2 of 84.8 mm Hg, PCO2 of 39.8 mm Hg, carboxyhemoglobin of 24.2%, and oxyhemoglobin of 74.5% in 1 woman and similar results in the other. With continued high-flow oxygen, the carboxyhemoglobin decreased to less than 3% within 3 hours in both women. At 4-week follow-up, neither woman had neurologic sequelae. Discussion: Coffee ceremonies are an integral part of Eritrean and Ethiopian cultures and are practiced at festivities and everyday social occasions. Typically, green coffee beans are roasted in a pan over hot charcoal; participants then purposefully and repeatedly inhale the coffee’s aromatic smoke. The darkened beans are then finely ground and boiled while incense is burned. A cup of coffee is served to each person and refilled twice, and the human spirit is believed to be transformed. Our patients started to develop symptoms after grinding the coffee. The charcoal, incense, and coffee involved in the ceremony contain carbon monoxide (4). A study in Ethiopia found that domestic coffee ceremonies moderately increase chronic inhalational exposure to indoor air pollution, including carbon monoxide (4). The lack of cases of acute carbon monoxide poisoning may be attributable to the natural ventilation that many Eritrean and Ethiopian homes provide; for example, the common Ethiopian tukul features open windows and gas-permeable roofing (Figure). These aspects of traditional housing could contribute to decreased awareness of potential carbon monoxide poisoning in other types of housing, putting the emigrant community and residents of East Africa who live in nontraditional housing at risk. Among 32 members of the London Ethiopian community, 20 said that they practiced coffee ceremonies indoors on occasion, only 12 considered ventilation essential, and only 2 had installed carbon monoxide detectors. Clinicians who care for these communities should be alert to this scenario
Figure. The traditional round hut of rural Ethiopia “smokes” as breakfast is cooked inside.
Carbon Monoxide From Domestic Coffee Roasting: A Case Report Background: During roasting, coffee beans generate substantial carbon monoxide, much of which is released during grinding (1). Fatal and near-fatal acute carbon monoxide exposures have occurred in industrial coffee-processing plants (2, 3). Purpose: To describe the first reported cases to our knowledge of acute carbon monoxide poisoning from domestic coffee roasting. Case Report: In March 2013, 2 women aged 47 and 48 years of Eritrean origin arrived at a London hospital by ambulance. They had developed vomiting, abdominal cramps, headache, and vertigo while preparing coffee together. When symptoms began, 1 woman opened a window hoping for symptomatic relief. The other woman soon lost consciousness, fell, and injured her leg. Upon arrival, both women had Glasgow Coma Scores of 15 with normal pulse rates and blood pressures and an SaO2 of 100% on room air. Physical examinations were normal except for sustained www.annals.org
Photograph courtesy of Apollo Habtamu. 3 December 2013 Annals of Internal Medicine Volume 159 • Number 11 795
Downloaded From: https://annals.org/ by a Kaohsiung Medica University User on 11/23/2018
Letters because carbon monoxide poisoning is notorious for its nonspecific presentation and patients may not volunteer participation in the coffee ceremony unless specifically asked. The mainstay of treatment is high-flow oxygen, and the value of hyperbaric oxygen remains controversial (5). We also think that public health organizations should target emigrant communities from Ethiopia and Eritrea with carbon monoxide awareness campaigns that include the value of adequate ventilation, abstaining from smoke inhalation, and installing carbon monoxide alarms where coffee ceremonies are performed. Joel B. Raffel, BMBCh Joanne Thompson, BA, MB BChir Imperial College London London, United Kingdom
Potential Conflicts of Interest: None disclosed.
References 1. Clarke RJ. Roasting and grinding. In: Clarke RJ, Macrae R, eds. Coffee Technology. vol. 2. New York: Elsevier Science; 1987:73-89. 2. Newton J. Carbon monoxide exposure from coffee roasting. Appl Occup Environ Hyg. 2002;17:600-2. [PMID: 12216587] 3. Nishimura F, Abe S, Fukunaga T. Carbon monoxide poisoning from industrial coffee extraction [Letter]. JAMA. 2003;290:334. [PMID: 12865373] 4. Keil C, Kassa H, Brown A, Kumie A, Tefera W. Inhalation exposures to particulate matter and carbon monoxide during Ethiopian coffee ceremonies in Addis Ababa: a pilot study. J Environ Public Health. 2010;2010:213960. [PMID: 20886061] 5. Hampson NB, Piantadosi CA, Thom SR, Weaver LK. Practice recommendations in the diagnosis, management, and prevention of carbon monoxide poisoning. Am J Respir Crit Care Med. 2012;186:1095-101. [PMID: 23087025]
Where is that article I read in Annals?
Search archives of Annals — articles since 1927 available o printing or for online reading
Interested? Go to www.annals.org
796 3 December 2013 Annals of Internal Medicine Volume 159 • Number 11
Downloaded From: https://annals.org/ by a Kaohsiung Medica University User on 11/23/2018
www.annals.org
Annals of Internal Medicine COMMENTS
AND
RESPONSES
Acute Gastrointestinal Bleeding TO THE EDITOR: We compliment Kerlin and Tokar (1) for a good,
thorough review of acute gastrointestinal bleeding. However, we would like to point out a few areas of discrepancy in the literature. We disagree with their recommendation that colonoscopy be done within 12 to 24 hours of presentation for lower gastrointestinal bleeding. The only study indicating that colonoscopy altered outcomes in diverticular bleeding episodes was by Jensen and colleagues (2). Follow-up studies by Green and associates (3) and Laine and coworkers (4) did not show any reduction in need for colectomy, change in clinical outcome, or reduction in cost. As a result, early endoscopy within 24 hours has not been shown to be superior to elective colonoscopy within 72 hours (3, 4). Furthermore, the authors do not indicate that the currently more used test of choice for diverticular hemorrhage is emergent computed tomography angiography. With the improvement in computed tomography angiography, localization of the lesion is feasible, with subsequent interventional angiography successfully treating any bleeding vessel (5, 6). In addition, the authors comment that to prevent gastrointestinal bleeding in patients with chronic liver disease, nonselective -blockers can reduce portal pressure, thereby reducing variceal bleeding. However, the current American Association for the Study of Liver Diseases guideline does not recommend -blockers for all patients with chronic liver disease (7). Primary prophylaxis is indicated in patients with underlying cirrhosis who have medium or large varices or small varices with high-risk stigmata on endoscopy (for example, red wale marks). Alternatively, -blockers can be used in patients with cirrhosis without high-risk features, but as the American Association for the Study of Liver Diseases (AASLD) guidelines note, long-term benefit has not been established. Secondary prophylaxis is indicated after any variceal bleeding (7). In addition, the authors advise that if balloon tamponade is used to treat variceal hemorrhage, the balloon should be inflated for no more than 12 hours. Published trials of the Sengstaken–Blakemore or Minnesota tube effectively use the gastric balloons inflated for up to 24 hours (8, 9). In the rare situation that an esophageal balloon is used, then deflating it every 6 to 12 hours is indicated to avoid pressure necrosis of the esophagus (9). We do commend Kerlin and Tokar for writing a good summary of this broad topic of gastrointestinal bleeding. Joseph D. Feuerstein, MD Daniel A. Leffler, MD, MS Beth Israel Deaconess Medical Center Boston, Massachusetts Potential Conflicts of Interest: Dr. Leffler: Consultancy and grants/ grants pending: Prometheus Diagnostics, Alba Pharmaceuticals, Alvine Therapeutics, Shire Therapeutics. References 1. Prasad Kerlin M, Tokar JL. Acute gastrointestinal bleeding. Ann Intern Med. 2013; 159:ITC2-15. [PMID: 23922080]
2. Jensen DM, Machicado GA, Jutabha R, Kovacs TO. Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage. N Engl J Med. 2000;342: 78-82. [PMID: 10631275] 3. Green BT, Rockey DC, Portwood G, Tarnasky PR, Guarisco S, Branch MS, et al. Urgent colonoscopy for evaluation and management of acute lower gastrointestinal hemorrhage: a randomized controlled trial. Am J Gastroenterol. 2005;100:2395-402. [PMID: 16279891] 4. Laine L, Shah A. Randomized trial of urgent vs. elective colonoscopy in patients hospitalized with lower GI bleeding. Am J Gastroenterol. 2010;105:2636-41. [PMID: 20648004] 5. Martı´ M, Artigas JM, Garzo´n G, Alvarez-Sala R, Soto JA. Acute lower intestinal bleeding: feasibility and diagnostic performance of CT angiography. Radiology. 2012; 262:109-16. [PMID: 22084211] 6. Loffroy R. Multidetector CT angiography for the detection of colonic diverticular bleeding: when, how, and why? [Editorial]. Dig Dis Sci. 2013;58:1822-4. [PMID: 23695874] 7. Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W; Practice Guidelines Committee of the American Association for the Study of Liver Diseases. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007;46: 922-38. [PMID: 17879356] 8. Feneyrou B, Hanana J, Daures JP, Prioton JB. Initial control of bleeding from esophageal varices with the Sengstaken-Blakemore tube. Experience in 82 patients. Am J Surg. 1988;155:509-11. [PMID: 3257849] 9. Vlavianos P, Gimson AE, Westaby D, Williams R. Balloon tamponade in variceal bleeding: use and misuse. BMJ. 1989;298:1158. [PMID: 2500170]
IN RESPONSE: Regarding management of patients with varices, Drs.
Feuerstein and Leffler accurately point out that the AASLD does not advocate nonselective -blockers for primary prophylaxis of variceal bleeding for all patients with chronic liver disease, only those with higher-risk varices. We agree that, in our practices, many patients with small, low-risk varices typically do not routinely receive these agents for primary prophylaxis. That said, the AASLD guidelines (1) do not recommend that patients with small varices should never receive -blockers but state that “prophylaxis with beta-blockers should be used in patients with small varices who are at high risk for bleeding; that is, those with advanced liver disease and the presence of red wale marks on varices” and that “other patients with small varices can receive beta-blockers to prevent variceal growth, although their long-term benefit has not been well established.” A subsequent expert review recommends that “these agents are considered optional” in patients with low-risk varices (2). Our article also states that the balloon for tamponade in acute management of variceal hemorrhage should not be inflated for more than 12 hours. We were referring to the esophageal balloon, which can induce pressure necrosis of the esophagus. Indeed, the gastric balloon can safely be inflated for up to 24 hours. Our intent was to reduce the risk for misinterpretation and inadvertent inflation of the esophageal balloon continuously for 24 hours. The comments about management of patients with acute lower gastrointestinal bleeding are also valuable. Drs. Feuerstein and Leffler accurately point out that performing colonoscopy within 12 to 24 hours remains controversial. We stated this viewpoint in our article and that the opportunity for intervention may be limited, hoping to highlight these limitations of colonoscopy. Although colonoscopy is still performed within 24 hours at many institutions, we agree that existing data are inadequate to make absolute recommendations. We also appreciate the reminder that computed tomography angiography is a useful diagnostic test for lower gastrointestinal bleeding, although we are unaware of data supporting their assertion © 2013 American College of Physicians 793
Downloaded From: https://annals.org/ by a Kaohsiung Medica University User on 11/23/2018
Letters that it is “the currently more used test of choice.” The article that they reference, albeit encouraging, had a relatively small sample size and was recognized by its authors as a feasibility study (3). Furthermore, we believe that urgent computed tomography angiography is not always available, there remains a paucity of comparative data, and professional guidelines advocating its use as the initial test are lacking. Meeta Prasad Kerlin, MD, MSCE The Perelman School of Medicine at the University of Pennsylvania Philadelphia, Pennsylvania Jeffrey L. Tokar, MD Fox Chase Cancer Center Philadelphia, Pennsylvania Potential Conflicts of Interest: Dr. Kerlin: Consulting fee or honorarium: American College of Physicians; Grants/grants pending: National Heart, Lung, and Blood Institute, Centers for Disease Control and Prevention. References 1. Garcia-Tsao G, Sanyal AJ, Grace ND, Carey WD; Practice Guidelines Committee of American Association for Study of Liver Diseases. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Am J Gastroenterol. 2007;102:2086-102. [PMID: 17727436] 2. Garcia-Tsao G, Bosch J. Management of varices and variceal hemorrhage in cirrhosis. N Engl J Med. 2010;362:823-32. [PMID: 20200386] 3. Martı´ M, Artigas JM, Garzo´n G, Alvarez-Sala R, Soto JA. Acute lower intestinal bleeding: feasibility and diagnostic performance of CT angiography. Radiology. 2012; 262:109-16. [PMID: 22084211]
The 2013 Lung Allocation Controversy TO THE EDITOR: Halpern (1) refers to the temporary restraining
orders issued on 5 and 6 June 2013 by Judge Michael M. Baylson, a federal judge in Philadelphia, as “a troubling precedent,” “circumvention of due process,” and “legal wrongs.” He says that the temporary restraining orders suggest “either failure to recognize that preferential treatment for some recipients will adversely affect others (who may not be much older than 12) or that the court considered these 2 children’s lives more valuable than others.” His assertions are incorrect. I assume that he is aware that a specific federal regulation, a binding law, requires that organs be allocated on the basis of medical urgency, with no exception for children younger than 12 years. He may not know that the legal complaint filed on behalf of Sarah Murnaghan and Javier Acosta asked only that they receive access to adult lungs on the basis of the medical urgency of their conditions and that they sought no special preference. Certainly no suggestion was made at any time that their lives were more valuable than those of others. To the contrary, their parents took the position that each life is equally valuable and that Murnaghan and Acosta should be treated equally with persons aged 12 years and older absent some compelling reason. They questioned whether there was any compelling reason for treating their children differently when it would probably result in the deaths of both children. As it turned out, we never learned through the legal system whether any compelling reason was present in the circumstances of Murnaghan and Acosta—that is, children younger than 12 years who are closer to age 12 than infancy and who
have fatal diseases that present in children and adults where their physicians have expressed confidence in a lobar transplant procedure— because 4 days after the second temporary restraining order, the Organ Procurement and Transplantation Network (OPTN) authorized the OPTN Lung Review Board to waive the “Under 12 Rule” in certain cases and the Board decided to waive it in these 2 cases. We can all agree that organ allocation systems are complicated and that we do not want to make a habit of second-guessing the physicians responsible for them. But we do have a legal system that provides for review of the OPTN’s policies by the Secretary of Health and Human Services and by a court, if necessary. The possibility of baseless claims is not a reason to reject meritorious claims. In this case, the failure of the system to allocate adult lungs to persons younger than 12 years in the circumstances of Murnaghan and Acosta on the basis of the allocation principle of medical urgency presented an important legal issue that deserved the attention of a federal court authorized to decide it. Without question, one or both children could have died before that decision could have been thoughtfully made. Under these circumstances, the court acted appropriately and well within its power to prevent the possible deaths of 2 children pending the outcome of the OPTN’s decision. Stephen G. Harvey, JD Pepper Hamilton LLP Philadelphia, Pennsylvania Potential Conflicts of Interest: Disclosures can be viewed at www .acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum ⫽L13-1069. Reference 1. Halpern SD. Turning wrong into right: the 2013 lung allocation controversy. Ann Intern Med. 2013;159:358-9. [PMID: 23797998]
IN RESPONSE: Mr. Harvey raises issue with my characterization of the judicial review process in the cases of Murnaghan and Acosta because of a specific rule commonly referred to as the OPTN “Final Rule” (or 42 CFR 121) (1) dictating that medical urgency be a basis for organ allocation. The relevant sections of this rule state that “transplant candidates shall be grouped by status categories ordered from most to least medically urgent” and that “criteria for status designations shall contain explicit thresholds for differentiating among patients and shall be expressed, to the extent possible, through objective and measurable medical criteria.” Current lung allocation policies in adults and children meet these criteria. Existing policies categorize children as Priority 1 or Priority 2 on the basis of explicit criteria reflecting medical urgency. The Final Rule is silent on the question of what, if any, special priority should be accorded to patients of different ages. Thus, the fact that the urgency-based prioritization in children differs from that in adults in no way violates the Final Rule. Indeed, the multivariable prediction models included in the Lung Allocation Score, which gauge urgency and anticipated benefit in ranking adults on the waiting list, cannot be applied with any confidence or statistical precision to children because the paucity of children requiring lung transplantation led to their exclusion from these complex models when they were developed (2). Applying these models to children might therefore cause inequitable prioritization, conflicting with the Final Rule’s mandate.
794 3 December 2013 Annals of Internal Medicine Volume 159 • Number 11
Downloaded From: https://annals.org/ by a Kaohsiung Medica University User on 11/23/2018
www.annals.org
Letters These facts raise serious questions about the merits of Mr. Harvey’s case. He is correct that, as it happened, the step in the judicial process where the merits of the Murnaghan case would be considered was never reached because Murnaghan received a transplant within the 10-day window of the temporary restraining order. He is also correct that Murnaghan might have experienced irreparable harm without the restraining order. In most legal circumstances, this would make issuance of a restraining order appropriate until the merits could be fully evaluated. However, issuing a restraining order that interferes with national organ allocation policy differs from nearly all contexts in which restraining orders have been used to date because the order protects 1 identifiable person while causing direct disadvantage to 1 or more others awaiting transplantation. This conflict creates unusually broad responsibilities for Judge Baylson in contemplating a restraining order, making him ethically (if not also legally) obliged to seriously consider the merits of the claim before intervening. Had such prudent steps been taken, the claims that existing policies violated the Final Rule or discriminated against children probably could not have been sustained. There may, indeed, be ways to improve the existing allocation system, but granting one-off waivers to well-resourced patients and families is not the path to such improvement. Scott D. Halpern, MD, PhD University of Pennsylvania Philadelphia, Pennsylvania Potential Conflicts of Interest: Disclosures can be viewed at www .acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum ⫽M13-1487. References 1. Department of Health and Human Services. The Final Rule. 2 April 1998. Accessed at www.gaonet.gov/special.pubs/organ/appendd.pdf on 1 July 2013. 2. Egan TM, Murray S, Bustami RT, Shearon TH, McCullough KP, Edwards LB, et al. Development of the new lung allocation system in the United States. Am J Transplant. 2006;6:1212-27. [PMID: 16613597]
OBSERVATION
horizontal nystagmus and intention tremor in both women and a fractured tibia in one. Nothing in their medical histories seemed relevant. Questioning revealed that the women had been conducting a traditional Eritrean coffee ceremony in a small, unventilated kitchen. Arterial blood gas analysis performed 20 minutes after symptom onset showed a pH of 7.41, PO2 of 84.8 mm Hg, PCO2 of 39.8 mm Hg, carboxyhemoglobin of 24.2%, and oxyhemoglobin of 74.5% in 1 woman and similar results in the other. With continued high-flow oxygen, the carboxyhemoglobin decreased to less than 3% within 3 hours in both women. At 4-week follow-up, neither woman had neurologic sequelae. Discussion: Coffee ceremonies are an integral part of Eritrean and Ethiopian cultures and are practiced at festivities and everyday social occasions. Typically, green coffee beans are roasted in a pan over hot charcoal; participants then purposefully and repeatedly inhale the coffee’s aromatic smoke. The darkened beans are then finely ground and boiled while incense is burned. A cup of coffee is served to each person and refilled twice, and the human spirit is believed to be transformed. Our patients started to develop symptoms after grinding the coffee. The charcoal, incense, and coffee involved in the ceremony contain carbon monoxide (4). A study in Ethiopia found that domestic coffee ceremonies moderately increase chronic inhalational exposure to indoor air pollution, including carbon monoxide (4). The lack of cases of acute carbon monoxide poisoning may be attributable to the natural ventilation that many Eritrean and Ethiopian homes provide; for example, the common Ethiopian tukul features open windows and gas-permeable roofing (Figure). These aspects of traditional housing could contribute to decreased awareness of potential carbon monoxide poisoning in other types of housing, putting the emigrant community and residents of East Africa who live in nontraditional housing at risk. Among 32 members of the London Ethiopian community, 20 said that they practiced coffee ceremonies indoors on occasion, only 12 considered ventilation essential, and only 2 had installed carbon monoxide detectors. Clinicians who care for these communities should be alert to this scenario
Figure. The traditional round hut of rural Ethiopia “smokes” as breakfast is cooked inside.
Carbon Monoxide From Domestic Coffee Roasting: A Case Report Background: During roasting, coffee beans generate substantial carbon monoxide, much of which is released during grinding (1). Fatal and near-fatal acute carbon monoxide exposures have occurred in industrial coffee-processing plants (2, 3). Purpose: To describe the first reported cases to our knowledge of acute carbon monoxide poisoning from domestic coffee roasting. Case Report: In March 2013, 2 women aged 47 and 48 years of Eritrean origin arrived at a London hospital by ambulance. They had developed vomiting, abdominal cramps, headache, and vertigo while preparing coffee together. When symptoms began, 1 woman opened a window hoping for symptomatic relief. The other woman soon lost consciousness, fell, and injured her leg. Upon arrival, both women had Glasgow Coma Scores of 15 with normal pulse rates and blood pressures and an SaO2 of 100% on room air. Physical examinations were normal except for sustained www.annals.org
Photograph courtesy of Apollo Habtamu. 3 December 2013 Annals of Internal Medicine Volume 159 • Number 11 795
Downloaded From: https://annals.org/ by a Kaohsiung Medica University User on 11/23/2018
Letters because carbon monoxide poisoning is notorious for its nonspecific presentation and patients may not volunteer participation in the coffee ceremony unless specifically asked. The mainstay of treatment is high-flow oxygen, and the value of hyperbaric oxygen remains controversial (5). We also think that public health organizations should target emigrant communities from Ethiopia and Eritrea with carbon monoxide awareness campaigns that include the value of adequate ventilation, abstaining from smoke inhalation, and installing carbon monoxide alarms where coffee ceremonies are performed. Joel B. Raffel, BMBCh Joanne Thompson, BA, MB BChir Imperial College London London, United Kingdom
Potential Conflicts of Interest: None disclosed.
References 1. Clarke RJ. Roasting and grinding. In: Clarke RJ, Macrae R, eds. Coffee Technology. vol. 2. New York: Elsevier Science; 1987:73-89. 2. Newton J. Carbon monoxide exposure from coffee roasting. Appl Occup Environ Hyg. 2002;17:600-2. [PMID: 12216587] 3. Nishimura F, Abe S, Fukunaga T. Carbon monoxide poisoning from industrial coffee extraction [Letter]. JAMA. 2003;290:334. [PMID: 12865373] 4. Keil C, Kassa H, Brown A, Kumie A, Tefera W. Inhalation exposures to particulate matter and carbon monoxide during Ethiopian coffee ceremonies in Addis Ababa: a pilot study. J Environ Public Health. 2010;2010:213960. [PMID: 20886061] 5. Hampson NB, Piantadosi CA, Thom SR, Weaver LK. Practice recommendations in the diagnosis, management, and prevention of carbon monoxide poisoning. Am J Respir Crit Care Med. 2012;186:1095-101. [PMID: 23087025]
Where is that article I read in Annals?
Search archives of Annals — articles since 1927 available o printing or for online reading
Interested? Go to www.annals.org
796 3 December 2013 Annals of Internal Medicine Volume 159 • Number 11
Downloaded From: https://annals.org/ by a Kaohsiung Medica University User on 11/23/2018
www.annals.org
