Paul M. Wallach

Breast irradiation in the older woman: a toxicity study.

Objective: To establish the tolerance of breast irradiation by women aged 65 and older.

A Case of the Eosinophilia-Myalgia Syndrome Associated with Use of an L-Tryptophan Product

Excerpt L-Tryptophan has been used as a sedative hypnotic for insomnia and as an antidepressant for many years. Previously reported toxicity has included nausea, vomiting, ataxia, hyperreflexia, po...

Medical Students' Perspectives on and Responses to Abuse During the Internal Medicine Clerkship

Background: The abuse of medical students on clinical rotations is a recognized problem, but the effects on students and their responses warrant further study. Purpose: To determine the severity of student abuse and the effects of abuse on students during the internal medicine clerkship. Methods: Internal medicine clerks at 11 medical schools (N = 1,072) completed an exit survey. Students were asked whether they had been abused. If they had, they were asked about the severity of the abuse, whether they reported it, and its effects on them. Results: Of the responding students, 123 (11%) believed they had been abused. Only 31% of the students who felt abused reported the episodes to someone. The most common consequences of the events included poor learning environments, lack of confidence, and feelings of depression, anger, and humiliation. Conclusion: Students described a variety of personal and educational effects of abuse. They generally did not report abuse because of fear of retaliation and the belief that reporting is pointless.

Recurrent Pneumothorax in a Patient With Rheumatoid Arthritis

ABSTRACT Rheumatoid arthritis is a multisystem disease. Pulmonary manifestations and complications include pleural disease, pulmonary infections, pneumonitis and interstitial pulmonary fibrosis, bronchogenic carcinoma, arteritis with pulmonary hypertension, obliterative bronchiolitis, bronchiectasis, and amyloidosis. Pulmonary rheumatoid nodules, including rheumatoid pneumoconiosis (Caplan’s Syndrome), can result in spontaneous pneumothorax. In this article, the authors present a patient with rheumatoid arthritis and recurrent spontaneous pneumothorax. Through investigation, a bronchopleural fistula caused by a rheumatoid nodule was revealed. The authors also discuss the potential pitfalls caused by a lung nodule in a patient with rheumatoid arthritis, including the overlap with bronchogenic carcinoma and confusion with tuberculosis.

Treatment of the eosinophilia-myalgia syndrome☆

The eosinophilia-myalgia syndrome (EMS) is a unique entity associated with products that contain L-tryptophan (L-trp). Studies of the underlying etiopathogenic processes are underway. EMS is a distinct syndrome, but shares features with eosinophilic fasciitis and other variants of systemic sclerosis. A wide spectrum of clinical manifestations has been described, but there is no consensus regarding treatment. We report the clinical and laboratory features of 12 patients. All were treated with nonsteroidal antiinflammatory drugs (NSAIDs) and analgesics with transient or minimal effect. Two received D-penicillamine (DP) and colchicine, with minimal improvement; one had no response to azathioprine (AZA). Eleven received corticosteroids and had improvement of general symptoms, arthralgias, arthritis, myalgias, skin changes, eosinophilia, and leukocytosis. Nevertheless, all but the latter two findings recurred when corticosteroids were tapered. Seven patients who were unresponsive to the former treatments received low-dose pulse oral methotrexate. Six exhibited continued improvement after a mean follow-up of 4.5 months, with good drug tolerance. Corticosteroids were tapered and, in some instances, discontinued without relapse or complications. One patient improved but later died of aspiration pneumonia. We conclude that methotrexate (MTX) is a therapeutic alternative for patients with severe or refractory EMS.

Octreotide for gastrointestinal bleeding of obscure origin in an anticoagulated patient.

To The Editor: Gastrointestinal bleeding from an unknown site can be frustrating to evaluate and treat. Hospitalization with multiple transfusions and numerous diagnostic procedures, each of which carries its own risks and expense, are often required. Treatments have included hormonal therapy and DDAVP with limited success (1, 2). Somatostatin and its analog octreotide have been reported in the literature to be beneficial in arresting bleeding from varices and bleeding peptic ulcers (2–8). The use of anticoagulation complicates gastrointestinal bleeding. Anticoagulation is typically stopped at the first sign of gastrointestinal bleeding; however, certain conditions do not allow its discontinuation. Patients with prosthetic mitral heart valves are at increased risk for thromboembolic complications when not anticoagulated. We evaluated a 49-year-old male with a one-week history of progressive fatigue, dyspnea on exertion, and melena. Three years ago the patient underwent a coronary artery bypass surgery and required prosthetic aortic and mitral heart valves. He has required anticoagulation since. On exam, the patient appeared pale. His abdominal exam was benign. The stool hemoccult test was positive. His hemoglobin was 6.8 g/dl and the platelet count was 481,000. The INR was 3.6. One week prior to admission, the patient’s hemoglobin level was reported as 11.0 g/dl. The patient’s warfarin therapy was discontinued; however his anticoagulation was continued with intravenous heparin therapy. Colonoscopy revealed diverticulosis and internal hemorrhoids, but no site of bleeding. An upper endoscopy was normal. A bleeding scan demonstrated active gastrointestinal bleeding which appeared to be in the area of the distal small bowel. A visceral angiogram revealed no site of active bleeding. Finally, enteroclysis and enteroscopy of the proximal 70 cm of small bowel beyond the pyloric sphincter, were both normal. The hemoglobin continued to decrease approximately 1 g/day, requiring packed red blood cell transfusions daily. On hospital day 6, the patient was started on a continuous drip of octreotide at 50 g/hr. The next day the patient’s hemoglobin level stabilized at 11.5 g/dl. Over the next five days, the patient continued on the octreotide therapy, and his hemoglobin increased daily despite anticoagulation therapy. After five days of octreotide, the therapy was discontinued, and the patient was monitored. His hemoglobin level continued to increase to 13.8 g/dl at the time of discharge with no signs or symptoms of continued blood loss. Five months after discharge, his hemoglobin remained stable. Somatostatin is a polypeptide found in highest concentrations in the gastrointestinal tract and the pancreas (9). It is known to have inhibitory effects on growth hormone and multiple gastrointestinal hormones, including gastrin CCK, VIP, insulin, secretin, motilin, and intestinal glucagon (9). It reduces the volume of splanchnic blood flow and increases vascular resistance (9). Somatostatin has also been shown to enhance human platelet aggregation in vitro (10). Octreotide acetate is a somatostatin analog marketed with the benefit of a longer half-life (T1/2 100 min), thus allowing its use as an outpatient treatment (9). Somatostatin and octreotide have been used since 1980, and both have been reported to be successful in stopping gastrointestinal bleeding secondary to bleeding peptic ulcers up to 80–100% of cases (2–8). Gastrointestinal bleeding of obscure origin and arteriovenous malformations are problematic to manage and need to be treated pharmacologically when bleeding persists and can not be localized. Estrogens, progestins, danazol, desmopressin, and aminocaproic acid have been studied with varying results (1). Octreotide has been used with favorable responses. Nardone et al evaluated the treatment of gastrointestinal bleeding of obscure origin with subcutaneous octreotide (6). Seventeen patients who were resistant to previous treatments, received octreotide 100 g subcutaneously for six months. Bleeding was arrested in 10 patients, a transient success was observed in four patients who required repeated treatment, and no effect was observed in three patients. Bowers et al reported using octreotide successfully in two patients with von Willebrand’s disease and angiodysplasia causing severe gastrointestinal hemorrhage (2). These patients had previously received red cell transfusions, clotting factor replacement, antifibrinolytic agents, hormonal replacement therapy and steroids. Subcutaneous octreotide was started, bleeding was controlled, transfusion support was unnecessary, and outpatient management became possible. Our case of gastrointestinal bleeding of unknown origin was complicated by the necessity for continued Digestive Diseases and Sciences, Vol. 47, No. 7 (July 2002), pp. 1514–1515 (© 2002)

D-penicillamine-induced myasthenia gravis: Diagnosis obscured by coexisting chronic obstructive pulmonary disease

D-penicillamine, a drug used to treat rheumatoid arthritis, Wilsons disease, and cystinuria, can cause myasthenia gravis. Fortunately, the myasthenia typically resolves after discontinuation of the drug. The diagnosis may be missed if weakness is blamed on a patients underlying disease(s), in particular, rheumatoid arthritis. Reported here are the cases of two patients with chronic obstructive lung disease who were taking D-penicillamine for rheumatoid arthritis, then experienced increasing respiratory failure. At first, their problem seemed to stem from chronic lung disease, but further evaluation revealed the cause of the hypoventilation to be D-penicillamine-induced myasthenia gravis.

Internal Medicine Clerkship Directors' Opinion Regarding Clinical Input in the Preclinical Years: The 2002 CDIM Basic Science Survey Results

Background: Input from both basic science and clinical faculty members is needed to promote further integration of medical curricula. Purpose: To assess current views of clerkship directors about the role and relationship of the basic sciences to clinical years in medical education. Methods: As part of the 2002 Annual CDIM Survey, questions regarding basic science curriculum were included; 89 of 123 CDIM members responded (72%). Results: Overall, respondents felt participation from both basic science and clinical faculty members is necessary to define basic science course content. Nearly 89% of clerkship directors indicated curricular review should be collaborative and interdepartmental; 93% felt that this review effort should occur frequently. Supporting the growing philosophy that the structure of the preclinical years should involve increased clinically relevant integration, 58% favored an integrated organ system approach rather than the traditional departmental structure (18%). In addition, in order of ranking, respondents felt that small group (M = 2.0 ± 0.9) and problem-based learning (M = 2.1 ± 1.1) are better approaches than the standard lecture format (M = 2.8 ± 1.2). Although clerkship directors recognized the need for increased clinical input in the preclinical years, many reported a lack of knowledge regarding the amount of clinical exposure students received in the basic science years (33%), frequency of peer review of the basic science courses (20%), and who performed peer review of the basic science courses at their institution (36%). Conclusion: Medical clerkship directors believe that basic science education should be developed collaboratively, organized by organ system, and presented in small groups.

Pyogenic Thalamic Brain Abscess in the Setting of a Ventricular Septal Defect

Congenital heart disease occurs in 8 of 1,000 live births, with ventricular septal defects comprising 30% of these. Although many are now corrected surgically in infancy or childhood, persisting septal defects in adulthood increase the risk of congestive heart failure. irreversible pulmonary hypertension with resulting Eisenmengers physiology, infective endocarditis, aortic insufficiency, systemic abscesses, and polycythemia. The acute onset of fever and meningeal signs in a 38‐year‐old man led to the discovery of a pyogenic thalamic brain abscess associated with a large ventricular septal defect and a tricuspid vegetation. To date, only 19 similar solitary pyogenic thalamic abscesses have been reported, and 5 were associated with ventricular septal defects.