Pamela Hartzband

Off the record--avoiding the pitfalls of going electronic.

The ultimate goal of the electronic medical record is to make all patient information immediately accessible and easily transferable and to allow its essential elements to be held by both physician and patient. Drs. Pamela Hartzband and Jerome Groopman write that before blindly embracing electronic records, we should consider their current limitations and potential downsides.

Untangling the Web — Patients, Doctors, and the Internet

The Web is profoundly changing communication between doctor and patient. Drs. Pamela Hartzband and Jerome Groopman write that, nonetheless, the core relationship should not change.

Keeping the patient in the equation--humanism and health care reform.

Drs. Pamela Hartzband and Jerome Groopman write that two major movements, the medical humanism movement and evidence-based practice, will now play out in the context of national health care reform. Today, when it is most important for these two movements to coalesce, they are poised to collide.

Money and the changing culture of medicine.

Drs. Pamela Hartzband and Jerome Groopman argue that assigning a monetary value to every aspect of a physicians time and effort may actually reduce productivity, impair the quality of performance, and thereby even increase costs.

Assessment of hypothalamic-pituitary-adrenal (HPA) axis dysfunction: comparison of ACTH stimulation, insulin-hypoglycemia and metyrapone

The response to ACTH stimulation, insulin-hypoglycemia and metyrapone in patients with suspected HPA axis dysfunction due to corticosteroid therapy (Group I, n = 10), or pituitary surgery (Group II, n = 7) and in a control population (Group III, n = 8) was studied. Group I patients had been maintained on a stable low dose of prednisone 5.0–7.5 mg/day for 1 month-16 yr (mean = 31 mos) prior to testing. Basal 08:00 h cortisol levels in this group were not different from control values. However, the mean responses to all three testing procedures were suppressed (Group I vs III, ACTH p < 0.001, insulin p< 0.01, metyrapone p< 0.05). Group II patients had undergone surgery 1–26 months (mean = 10 mo) prior to testing and had been maintained subsequently on a stable dose of prednisone 5.0–7.5 mg/day. In this group basal mean 08:00 h cortisol and the cortisol response to ACTH and insulin-hypoglycemia were not significantly different from control values while the response to metyrapone was suppressed (Group II vs III p< 0.02). Basal serum DHEA-S levels were suppressed in both Groups I and II when compared to Group III (p< 0.001 ). Discordant responses to the three testing procedures were noted in 6 patients with suspected HPA dysfunction with abnormal test results in 1/6 using cortrosyn, 3/6 using insulin-hypoglycemia and 4/6 using metyrapone. We conclude that: (1) Low doses of prednisone cause subtle, but significant HPA axis suppression, (2) DHEA-S levels do not correlate with standard tests of the HPA axis, and (3) Although no single test identified every subject with an abnormal HPA axis, metyrapone was more useful in detecting subtle degrees of HPA dysfunction than ACTH or insulin-hypoglycemia. Metyrapone is simple, safe and may be the test of choice in assessing patients with suspected secondary adrenal insufficiency.

The New Language of Medicine

In the new language of medicine, patients are “customers” or “consumers”; doctors and nurses are “providers.” The words we use to explain our roles set expectations and shape behavior. This change in the language of medicine has important and deleterious consequences.

Is there a therapeutic role for octreotide in patients with ectopic Cushing’s syndrome?

Cushing’s syndrome (CS) due to ectopic ACTH secretion (EAS) has a high morbidity and mortality, because of the underlying tumor and the sequelae of severe hypercortisolemia. Therefore, rapid treatment of ectopic CS is mandatory. Scintigraphy shows that up to 80% of ectopic ACTH-producing tumors have somatostatin receptors. While this suggests that somatostatin analogs may reduce ACTH production and treat patients with EAS, the therapeutic role of these agents is still evolving. Here we demonstrate the spectrum of responses to octreotide therapy in 3 patients with EAS. Diagnostic imaging with the 111In-pentetreotide scan did not predict the therapeutic response to octreotide. Two patients with positive somatostatin receptor scintigraphy failed to respond to octreotide, while one with a negative scan reached eucortisolemia on a maintenance dose of 75 μg octreotide twice daily or octreotide LAR 30 mg per month. We conclude that octreotide is not a first line agent to control hypercortisolemia but may be a useful agent when other inhibitors of steroidogenesis fail or parenteral administration is required. Before therapy an octreotide challenge test may predict therapeutic response. Cortisol levels should be monitored regularly on somatostatin analog therapy, because of its unpredictable long-term pharmacodynamic profile.

There Is More to Life Than Death

In classic medical decision analysis, when outcomes are uncertain and risk is involved, the “best” choice is the one with the “highest expected utility.” The outcome usually measured is death, which is readily determined and quantified. But what of other key outcomes?

SYNCHRONOUS PARATHYROID CARCINOMA, PARATHYROID ADENOMA, AND PAPILLARY THYROID CARCINOMA IN A PATIENT WITH SEVERE AND LONG-STANDING HYPERPARATHYROIDISM

OBJECTIVE To describe a patient presenting with the rare constellation of synchronous parathyroid carcinoma, parathyroid adenoma, and papillary thyroid carcinoma. METHODS We summarize the clinical presentation, diagnostic work-up, surgical management, and pathologic features of our patient and review the pertinent literature. RESULTS The patient was a 59-year-old man who presented with severe clinical manifestations of long-standing primary hyperparathyroidism, a serum calcium concentration of 14.4 mg/dL, and a parathyroid hormone level of 2,023 pg/mL. He was found to have a 3.4-cm parathyroid carcinoma on the left side and a 3.2-cm papillary carcinoma in the right thyroid lobe. In addition, a 917-mg parathyroid adenoma was found on the right side. CONCLUSION Synchronous parathyroid and thyroid carcinomas are extremely rare. To our knowledge, our patient is the first documented case with a parathyroid adenoma in addition to synchronous parathyroid and thyroid carcinomas. The presence of concurrent parathyroid carcinoma and parathyroid adenoma can cause diagnostic confusion and should be considered in patients presenting with severe hyperparathyroidism. Any concomitant thyroid nodules must be investigated to rule out thyroid carcinoma.

Hypercalcemia in an AIDS patient treated with growth hormone

Method:Recombinant human growth hormone (rhGH) is a newly approved treatment for weight loss and wasting in patients with AIDS. We report a male patient with advanced AIDS who developed hypercalcemia 2 weeks after institution of rhGH therapy. Results:Parathyroid hormone, parathyroid hormone-related peptide and 1,25-dihydroxyvitamin D levels were suppressed, suggesting that hypercalcemia was mediated through alternative mechanisms. The hypercalcemia responded to discontinuation of rhGH and a single dose of intravenous pamidronate disodium and has not recurred in 8 months of follow-up. Conclusion:We believe this to be the first reported case of rhGH-induced hypercalcemia in an HIV-infected patient.