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 with the letter 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 only if their letter is accepted. Unpublished letters cannot be returned.
Disseminated Candidiasis after Intravenous Use of Oral Methadone To the Editors: Fresh lemon juice, used as a solvent for the brown "Iranian" heroin and other poorly soluble drugs, is a recognized source of disseminated candidiasis in intravenous drug users (1). Candida albicans has also been isolated from lemon juice preserved in plastic lemon-shaped containers from which the sulfur-dioxide preservative had evaporated because the juice was kept beyond the recommended consumption date (2, 3). We report the cases of two drug users who presented with disseminated candidiasis and who had apparently not used lemon juice. A 36-year-old, HIV-negative heroin user who was receiving oral methadone presented with lesions characteristic of candidal vitritis (4). Three weeks earlier, he had intravenously injected methadone that had been prepared for oral administration by dilution in orange juice. A few hours later, he experienced chills and fever, followed within 2 days by a self-limiting episode of disseminated folliculitis, predominantly of the hair-bared skin. A diagnosis of probable candidal vitritis was made, and a 10-day course of ketoconazole treatment led to the gradual resolution of symptoms. The original undiluted methadone solution was sterile. The orange juice used as the methadone dilutent was unavailable for testing. A 27-year-old, HIV-negative former heroin user who had been receiving methadone treatment for 3 years was regularly given a 7-day supply of methadone that was diluted in raspberry syrup and sterile water. The used glass bottles were usually boiled before refilling. Occasionally, the patient intravenously injected one prepared dose of diluted methadone. After one such injection, he developed signs of disseminated candidiasis with fever, skin lesions, and bilateral panophthalmitis. Candida albicans was cultured in three pairs of blood samples and from plucked hairs. Candida albicans was also isolated from the remaining drops of diluted methadone that the patient had injected. All isolates were identical by DNA fingerprinting (5). Panophthalmitis was successfully treated with a 20-day course of amphotericin B (total dose, 820 g) plus flucytosine. Further laboratory tests showed that C. albicans grows readily in both orange juice and raspberry syrup (unpublished data). As methadone maintenance programs expand to counter the AIDS epidemic, more patients may be tempted to use oral methadone preparations intravenously. Patients and doctors 576
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should be aware of the risk for disseminated candidiasis posed by this practice. Claude Scheidegger, MD Jolanta Pietrzak, MD Reno Frei, MD University Hospital of Basel 4031 Basel, Switzerland
References 1. Newton-John HF, Wise K, Looke DF. Role of the lemon in disseminated candidiasis of heroin abusers. Med J Austr. 1984;140:780-1. 2. Shankland GS, Richardson MD. Possible role of preserved lemonjuice in the epidemiology of Candida endophthalmitis in heroin addicts. Eur J Clin Microbiol Infect Dis. 1989;8:87-9. 3. Scheidegger C, Frei R. Disseminated candidiasis in a drug addict not using heroin. J Infect Dis. 1989;159:1007-8. 4. Servant JB, Dutton GN, Ong-Tone L, Barrie T, Davey C. Candidal endophthalmitis in Glaswegian heroin addicts: report of an epidemic. Trans Ophthalmol Soc UK. 1985;104:297-308. 5. Scherer S, Stevens DA. Application of DNA typing methods to epidemiology and taxonomy of Candida species. J Clin Microbiol. 1987; 25:675-9.
Standardizing Fecal Occult Blood Testing To the Editors: In their recent article, Fleisher and colleagues (1) stressed the need to pay careful attention to visual interpretation of the fecal occult blood test using Hemoccult II slides (SmithKline Diagnostics, Inc., San Jose, California). We request clarification of the following points: What were the volumes of blood and stool used to yield ''moderately positive" and "strongly positive" results? What were the specific "instructions" given to the evaluators who were asked to read the samples? Were evaluators shown color pictures of "negative," "moderately positive," and "strongly positive" specimens? We feel it would be beneficial to have these data published in the journal. It would be interesting to know if these "instructions for interpretation" would reduce the number of false-negative test results in subsequent studies. Siva Maran, MD Thomas P. Short, MD Eapen Thomas, MD James H. Quillen College of Medicine Johnson City, TN 37601
Reference 1. Fleisher M, Winawer SJ, Zauber AG, Smith C, Schwartz MK. Accuracy of fecal occult blood test interpretation. Ann Intern Med. 1991; 114:875-6. In response: The questions posed by Drs. Maran, Short, and Thomas raise important points that should be helpful to users of the Hemoccult II slides. As indicated in our article (1), instructional intervention should improve clinical efficacy of fecal occult blood testing. Negative guaiac stool samples were used as the test matrix. Simulated guaiac-positive stool samples were prepared by add-
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ing normal human whole blood with a hemoglobin concentration that ranged from 12 to 15 g/dL after hemolysis by freezethawing. Aliquots of blood were added to 5 to 10 g of stool, homogenized, and tested for the degree of guaiac positivity. Blood was added to the stool sample in amounts sufficient to achieve the desired degree of positivity. Each program coordinator attended a 45-minute instructional seminar on the development and interpretation of Hemoccult slides that consisted of a description of the mechanism of the test, the appropriate method for adding the developing reagent, the way in which to discern the blue color characteristic of a moderately positive reaction from the color variation due to the stool itself. Instead of color pictures, actual slides with positive blue color variations were used to show color intensity and variability. Immediately after the instructional seminar, each program coordinator was given a set of three Hemoccult II slides and was asked to develop each slide and to record the results. Problems in interpretation were discussed as they arose. The instructional seminar was followed by a discussion period. Each coordinator reported that this type of instruction was extremely useful in standardizing the interpretation of Hemoccult II slides and in pointing out the pitfalls of the test. Martin Fleisher, PhD Sidney J. Winawer, MD Ann Graham Zauber, PhD Memorial Sloan-Kettering Cancer Center New York, NY 10021
Reference 1. Fleisher M, Winawer SJ, Zauber AG, Smith C, Schwartz MK. Accuracy of fecal occult blood test interpretation. Ann Intern Med. 1991; 114:875-6.
Octreotide for Diarrhea in Amyloidosis To the Editors: The somatostatin analog octreotide acetate (Sandostatin, Sandoz Pharmaceuticals, East Hanover, New Jersey) has been used to treat diarrhea associated with various disorders (1). We report the successful use of octreotide to treat intractable diarrhea in a patient with amyloidosis secondary to multiple myeloma. A 53-year-old man with multiple myeloma of the immunoglobulin G-kappa type was treated with melphalan-prednisone, and his hematologic status became stable. He was found to have polyneuropathy 14 months after the diagnosis of myeloma was made. Diarrhea, hepatomegaly, congestive heart failure, polyserositis, orthostatic hypotension, and periorbital bleeding were subsequently noted. Amyloidosis was diagnosed on the basis of bone marrow biopsy results. Although most symptoms were treated successfully, the patient's diarrhea did not respond to treatment with diphenoxylate hydrochloride, atropine sulfate, loperamide hydrochloride, codeine phosphate, antibiotics, or other supportive measures. The patient denied experiencing any abdominal cramps, fever, or chills. He reported urgency and 6 to 20 bowel movements per day, half of which were nocturnal. The stool was described as watery and mixed with solids. No blood or mucus was noted. Microscopic examination of the stool failed to show neutral fat, fatty acids, ova, or parasites. Although a gram stain of the stool sample showed many gram-positive cocci and gram-negative rods, substantial numbers of leukocytes were not seen. Stool cultures showed normal fecal flora and no pathogens. A 24-hour stool sample that weighed 508 g contained 3.6 g of lipids (normal, 0 to 7 g/d). A 5-hour xylose absorption test showed a blood D-xylose level of 6 mg/dL (normal, > 25 mg/dL) and a urine D-xylose level of 1.0 g/5 h (normal, 4.1 to 8.2 g/5 h). The excretion of paraminobenzoic acid in a 6-hour urine sample (chymex test) was 11% (normal, > 50%). Examination of stool electrolytes and osmolality were ordered, but the specimen was unsatisfactory for study. The patient was treated with octreotide acetate, 100 /ug three times per day, and the diarrhea quickly ceased. He reported
soft, formed stools within 2 days after the start of therapy and was able to "sleep undisturbed at night for the first time in 1 year." Treatment with octreotide was discontinued, and the diarrhea promptly recurred. Reinstitution of octeotide therapy was followed by resolution of the diarrhea. The patient was discharged to a nursing home, and he continued to receive treatment with octreotide acetate, 50 /ig three times per day. The patient had occasional soft stools occurring three to four times per day that were effectively treated by adding paragoric to the regimen. One month later, the patient suddenly died. The cause of death remains unknown but is presumed to have been caused by cardiac arrthymia resulting from amyloid cardiomyopathy. The most likely cause of the diarrhea experienced by one patient was amyloidosis. Although diarrhea occurs frequently in amyloidosis, severe cases, such as that seen in our patient, are uncommon (2). The diarrhea may be due to either neuropathy or amyloid infiltration of the gastrointestinal tract that results in malabsorption, inhibition of ion absorption, and stimulation of ion secretion. The condition may also be caused by immobility of the gastrointestinal tract accompanied by bacterial overgrowth. Because insufficient data were available for analysis, we cannot accurately identify the mechanism responsible for the diarrhea our patient had. We were able to locate only one other report of a patient with systemic amyloidosis who was treated with octreotide acetate (3). Although this patient had primary, not secondary, amyloidosis, the clinical features and treatment results of these two patients are similar. Octreotide acetate may be an effective treatment for diarrhea associated with amyloidosis. Lung T. Yam, MD Socorro B. Oropilla, MD Veterans Affairs Medical Center University of Louisville School of Medicine Louisville, KY 40206-1499 References 1. Gorden P, Comi RJ, Maton PN, Go VL. Somatostatin and somatostatin analogue (SMS 201-995) in treatment of hormone-secreting tumors of the pituitary and gastrointestinal tract and non-neoplastic diseases of the gut. Ann Intern Med. 1989;110:35-50. 2. Kyle RA, Greipp PR. Amyloidosis (AL): clinical and laboratory features in 229 cases. Mayo Clin Proc. 1983;58:665-83. 3. O'Connor CR, O'Dorisio TM. Amyloidosis, diarrhea, and a somatostatin analogue. Ann Intern Med. 1989;110:665-6. Diagnosing Lyme Disease To the Editors: Borrelia burgdorferi is considered to be the causative agent in Lyme borreliosis, a tick-borne zoonosis that afflicts both humans and domestic mammals. In the last 10 years, however, the diversity of clinical manifestations assumed to be the result of infection with B. burgdorferi has continued to increase, and Lyme borreliosis is sometimes difficult to diagnose. Why do only 70% of patients develop erythema migrans, the characteristic annular red rash that develops around the infective site? Why does a "flu-like syndrome" characterized by fever, headaches, and cough develop in only a portion of infected patients? Why do some patients appear to have no acute or early disease, but later develop severe cardiac, arthritic, or neurologic manifestations? Why do some patients become ill following the bite of the tick Ixodes dammini but do not develop Lyme disease? Early researchers looking for the etiologic agent of Lyme disease attempted to isolate viruses from infected humans, wild animals, and ticks but were unable to do so (1). Attempts to identify in patients with Lyme disease antibodies to a large number of known viruses also produced disappointing results (2). The discovery and identification of B. burgdorferi ended the search for other infectious agents in /. dammini. Since these first studies in the 1970s, however, when Lyme arthritis appeared to be restricted to a few communities in south-central Connecticut, cases in humans have been reported from most of the continental United States, although most occur in a few hyperendemic regions (3). Ixodes dammini has apparently in-
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creased in abundance and distribution, resulting in increased human contact. Ticks are known to be infected with and may transmit 126 or more of the 504 registered arboviruses, many of which cause substantial morbidity and mortality among humans (4). In Eurasia, /. ricinus and /. persulcatus have long been known to be important vectors of tick-borne encephalitis (TBE) virus, and these ticks can simultaneously transmit B. burgdorferi and TBE virus (E. Korenberg. Personal communication) in the same way that /. dammini can simultaneously transmit B. burgdorferi and Babesia microti, a causative agent of human babesiosis (5). Given the increased contact of humans with /. dammini, it seems reasonable to ask again whether viruses or other bacteria might be transmitted by these ticks and might contribute to an increasingly complex clinical picture. The discovery of B. burgdorferi has helped to define many previously undefined clinical disorders, but is the spirochete responsible for every malady that results from the bites of /. dammini or other ticks known to transmit the spirochete? We suggest not. Nadelman and colleagues presented the results of a prospective study of 132 persons exposed to /. dammini', 16 (12%) developed flu-like symptoms after being bitten by these ticks but none was confirmed by laboratory findings to have Lyme disease (Conference Abstract Book B, p. 34). Although these patients may have coincidentally been bitten by ticks and later acquired an illness through another route of exposure, the possibility exists that Ixodes ticks may be transmitting viruses or other bacteria, alone or simultaneously, with B. burgdorferi. Viral infection may help to explain why persons who become ill after a tick bite may believe that they have Lyme disease despite negative serologic tests. In such cases, there is nothing wrong with the test; these persons do not have Lyme disease. Concomitant infections with viruses and spirochetes or infections with the spirochete alone may also explain, in part, the wide array and variable clinical manifestations presently ascribed solely to Lyme disease. Tom G. Schwan, PhD Warren J. Simpson, PhD Rocky Mountain Laboratories, NIAID Hamilton, MT 59840 References 1. Wallis RC, Brown SE, Klotter KO, Main AJ Jr. Erythema chronicum migrans and Lyme arthritis: field study of ticks. Am J Epidemiol. 1978;108:322-7. 2. Steere AC, Malawista SE, Snydman DR, Shope RE, Andiman WA, Ross MR, et al. Lyme arthritis: an epidemic of oligoarticular arthritis in children and adults in three Connecticut communities. Arthritis Rheum. 1977;20:7-17. 3. Centers for Disease Control. National secular trends in Lyme disease 1982-1989. Lyme Disease Surveillance Summary. 1990;1:1. 4. Karabotsos N; ed. International Catalogue of Arboviruses, Including Certain Other Viruses of Vertebrates. San Antonio: American Society of Tropical Medicine and Hygiene. 1985:1-1147. 5. Piesman J, Hicks TC, Sinsky RJ, Obiri G. Simultaneous transmission of Borrelia burgdorferi and Babesia microti by individual nymphal Ixodes dammini ticks. J Clin Microbiol. 1987;25:2012-3.
Cardiopulmonary Resuscitation in Teaching Hospitals To the Editors: Although cardiopulmonary resuscitation (CPR) was originally conceived as an intervention to reverse acute cardiac arrest in otherwise healthy patients, it has recently evolved into a desperate attempt to revive the dying. Because of its low success rate and its great potential for harm, CPR should not be initiated thoughtlessly. Decisions to resuscitate patients, like decisions to withhold CPR, should reflect thoughtful discussion, deliberate analysis, and serious consideration. Unfortunately, despite widespread attention devoted to this issue in the academic literature and in the popular press, explicit resuscitation directives such as do-not-resuscitate (DNR) orders are still often absent when they are needed (1). Resuscitation directives are sometimes omitted because the attending physician and the patient agree that CPR would be appropriate therapy in the event of cardiac arrest. In many instances, however, the absence of such directives is simply 578
the result of neglect and reflects the attending physician's difficulty in discussing "code status." In the absence of resuscitation directives, the prevailing practice among housestaff in teaching hospitals is to "do everything," that is, to initiate resuscitation as if the patient would desire (and the situation would warrant) such activity. Although such practices are generally done to prevent avoidable mortality, patients frequently do not want to be resuscitated, particularly when their clinical conditions preclude any reasonable hope for recovery (2). Further, there is a growing consensus among physicians and philosophers that the use of CPR in medically "futile" situations is unwarranted, because ineffective therapy should not be offered to patients (3, 4). When attending physicians in teaching hospitals fail to discuss resuscitation in advance, not only are patients put at increased risk for avoidable iatrogenic harm, but resident physicians who are asked to perform CPR are put in a position in which they may inadvertently override patient wishes for nonaggressive treatment. Therefore, if attending physicians cannot or will not attempt to learn a patient's preference regarding resuscitation, then other care givers should be trained and empowered to do so. Because housestaff are burdened with the technical and emotional responsibility for resuscitation, they are ideal candidates for assessing patients' "code status." Housestaff have ample opportunity to learn patients' desires and fears, are trained to appreciate prognostic and therapeutic factors, and are available at all hours. It seems appropriate that housestaff physicians receive formal training in the ethical as well as technical use of CPR and that they be empowered to use such training to assess the appropriate use of such treatment. Housestaff should not routinely make DNR decisions—this task remains the duty of attending physicians. When attending physicians are unavailable during emergency situations in which a patient's CPR status is unknown, trained housestaff could make DNR decisions and thus spare patients and their families the consequences of inappropriate CPR. Michael Green, MD Evanston Hospital Evanston, IL 60201 References 1. Gleeson K, Wise S. The do-not resuscitate order: still too little too late. Arch Intern Med. 1990;150:1057-60. 2. Wagner A. Cardiopulmonary resuscitation in the aged: a prospective survey. N Engl J Med. 1984;310:1129-30. 3. Tomlinson T, Brody H. Futility and the ethics of resuscitation. JAMA. 1990;264:1276-80. 4. Council on Ethical and Judicial Affairs, American Medical Association. Guidelines for the appropriate use of do-not-resuscitate orders. JAMA. 1991;265:1868-71.
Aspergillosis and Marijuana To the Editors: We read with interest the letter by Doblin and Kleiman stating that nearly half of all oncologists polled reported having recommended illegal use of marijuana for the control of chemotherapy-induced emesis (1). Although reports of benefits from marijuana treatment are anecdotal, many patients with the acquired immunodeficiency syndrome (AIDS) have experimented with marijuana to combat anorexia and weight loss, and the United States government supplies marijuana cigarettes to a small number of patients on a compassionate-use basis. Despite the availability, on a prescription basis, of oral synthetic tetrahydrocannabinol (THC; Marinol, Roxane Laboratories, Inc., Columbus, Ohio), the active ingredient in marijuana, many patients choose to smoke marijuana. Patients should be aware that this practice may involve unforeseen risks. Studies have shown that most illegally obtained marijuana is contaminated with Aspergillus species—most often A. flavus and A. fumigatus (2). Aspergillus spores easily pass through contaminated marijuana that is smoked (2, 3). For immunocompetent individuals, such exposure is unlikely to be associated with disease; however, in immunocompromised patients, invasive pulmonary aspergillosis may ensue (4). Given
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the widespread recreational use of marijuana, as well as the use of marijuana for medical indications, the number of cases of invasive aspergillosis associated with smoking marijuana may be substantial. Although patients who receive chemotherapy are advised to use the prescription form of THC, some continue to use nonsterilized, illicit marijuana. For that reason, simple conditions were defined that would result in the removal from marijuana of Aspergillus spores (and probably of most other pathogens). Because of difficulties in obtaining marijuana legally, oregano, parsley, and tea (substances physically similar to marijuana) were each heavily inoculated with spores of A. fumigatus, A. flavus, and A. niger. The herbs were then baked at varying temperatures and times and were later cultured for fungi. The conditions required to consistently kill all fungi were a temperature of 135 °C (275 °F) of dry heat for 5 minutes. Allowing for variations in home ovens, marijuana users could assume elimination of Aspergillus in marijuana that is baked at a minimum temperature of 150 °C (300 °F) for 15 minutes before smoking. Similar conditions have been shown not to degrade tetrahydrocannabinol (5). Because heating may not degrade Aspergillus antigens, sensitized patients may develop bronchospasm after smoking contaminated marijuana (2). Education on this simple method for sterilizing marijuana of Aspergillus may, however, reduce a major potential risk in patients who remain convinced that they obtain unique benefits from smoking marijuana. Stuart M. Levitz, MD Richard D. Diamond, MD Boston University School of Medicine Boston, MA 02118
References 1. Doblin R, Kleiman MA. Medical use of marijuana [Letter]. Ann Intern Med. 1991;114:809-10. 2. Kagen SL, Kurup VP, Sohnle PG, Fink JN. Marijuana smoking and fungal sensitization. J Allergy Clin Immunol. 1983;71:389-93. 3. Kurup VP, Resnick A, Kagen SL, Cohen SH, Fink JN. Allergenic fungi and actinomycetes in smoking materials and their health implications. Mycopathologia. 1983;82:61-4. 4. Chusid MJ, Gelfand JA, Nutter C, Fauci AS. Pulmonary aspergillosis, inhalation of contaminated marijuana smoke, and chronic granulomatous disease. Ann Intern Med. 1975;82:682-3. 5. Mechoulam R, McCallum NK, Burstein S. Recent advances in the chemistry and biochemistry of cannabis. Chem Rev. 1976;76:75-112.
A Library for Internists To the Editors: The article by Ludmerer (1), "A Library for Internists VII," was indeed informative. I recognize that Dr. Ludmerer coordinated a multidisciplinary effort to complete the seventh edition of this work. As a practitioner of general internal medicine and a teacher of residents and medical students for over 20 years, I offer a slightly different model (Table 1). In this revision I have included several additional subcategories that I feel are worthy of note: Anesthesia; Obstetrics and Gynecology; Pathology; and Surgery grouped under "Other Specialties of Clinical Medicine"; Medical Malpractice; Quality Assurance; Symptoms, Signs, and (patient) Problems (for example, headache, backache, and edema) grouped under "Related Clinical Fields"; and Clinical Competence, Counseling; Management; Medical Interviewing; Physical Diagnosis; and Teaching/Training (for example, clerkships) grouped under a new heading called "Professional Skills." A survey of members of the American College of Physicians may be conducted as the eighth revision is being considered. Others have considerable expertise in this area and can be called on to contribute (2-5). David A. Nardone, MD Veterans Affairs Medical Center Portland, OR 97207
Table 1. Proposed Model for a Library for Internists Basic sciences Biochemistry Biophysics Molecular biology Pharmacology Clinical medicine Internal medicine Ambulatory care/primary care Cardiology Dermatology Endocrinology and metabolism Gastroenterology General medicine Genetics Geriatrics Hematology Immunology and allergy Infectious diseases Intensive care Nephrology Neurology Oncology Pulmonary medicine Rheumatology Other specialties Anesthesia Adolescent medicine Emergency medicine Nuclear medicine Obstetrics and gynecology Occupational medicine Pathology Physical medicine and rehabilitation Psychiatry Radiology Sports medicine Surgery Tropical medicine Related clinical fields Clinical consultation Epidemiology History of medicine Informatics Medical economics Medical ethics Medical malpractice Quality assurance Symptoms, signs, and patient problems Professional skills Clinical competence Counseling Decision making Management Medical interviewing Physical diagnosis Teaching and training Reference works Dictionaries Directories Indexes Computer-based information systems CD-ROM products
References 1. Ludmerer KM. A library for internists VII: recommendations from the American College of Physicians. Ann Intern Med. 1991;114:811-32. 2. Fuller EA. A system for filing medical literature: based on a method developed by Dr. Maxwell M. Wintrobe. Ann Intern Med. 1968;68: 684-93. 3. Singer K. Where did I see that article? JAMA. 1979;241:1492-3. 4. Classification Committee of the World Organization of National Colleges, Academies, and Academic Associations of General Practitioners/ Family Physicians. ICHPPC-2-defined: International Classification of
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Health Problems in Primary Care. 3d ed. New York: Oxford University Press; 1983. 5. Haynes RB, McKibbon KA, Fitzgerald D, Guyatt GH, Walker CJ, Sackett DL. How to keep up with the medical literature: VI. How to store and retrieve articles worth keeping. Ann Intern Med. 1986;105:978-84. Additional references available from the author on request. In response: Dr. Nardone's constructive suggestions regarding the Library for Internists are welcome. One of the most difficult issues in the development of an outline concerned the areas outside internal medicine to be included. Certainly, no one would deny the importance of many related fields to internal medicine; however, the task of creating an internal medicine bibliography without allowing that bibliography to become unmanageably long posed a difficult challenge. I am sure that the next Library for Internists committee will profit from Dr. Nardone's suggestions. Kenneth M. Ludmerer, MD Washington University School of Medicine St. Louis, MO 63110
A patient was dying of colon cancer. The hospice nurse and I made a home visit to do a paracentesis and to adjust the dose of analgesics. After the visit, the patient's wife and son and I were standing outside in the yard. Their neat cottage was tucked into the edge of the woods adjacent to a large upland swamp, or pocosin. The pocosin was teaming with bears, deer, and other wildlife. The grounds of the cottage were tidy and well kept. A chicken house, however, was in serious disrepair. "Why have you stopped raising chickens?" I asked. "Too many varmints, and the government won't let us kill them," replied the son. (It seems that restrictions on trapping foxes had made keeping chickens impossible in that location.) Rather than abandon our carefully crafted strategies for avoiding lawsuits, I suggest that we reform our tort system. As Dr. Welch points out, diversion of resources away from patient care is an important argument for such a practice. Without control of predators or the protection of defensive medicine, doctors are like chickens at the edge of the pocosin.
Defensive Medicine: A Form of "Varmint" Control?
E. Rodney Hornbake, MD Eastern Carolina Internal Medicine, P.A. 532 Webb Boulevard Havelock, NC 28532
To the Editors: The recent article by Welch (1) is an important contribution to the issue of physician participation in costcontainment efforts. His second recommendation, the abandonment of clinical strategies that are designed primarily to avoid lawsuits, reminds me of an incident from my practice.
Reference 1. Welch HG. Should the health care forest be selectively thinned by physicians or clear cut by payers? Ann Intern Med. 1991;115:223-6.
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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 with the letter 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 only if their letter is accepted. Unpublished letters cannot be returned.
Disseminated Candidiasis after Intravenous Use of Oral Methadone To the Editors: Fresh lemon juice, used as a solvent for the brown "Iranian" heroin and other poorly soluble drugs, is a recognized source of disseminated candidiasis in intravenous drug users (1). Candida albicans has also been isolated from lemon juice preserved in plastic lemon-shaped containers from which the sulfur-dioxide preservative had evaporated because the juice was kept beyond the recommended consumption date (2, 3). We report the cases of two drug users who presented with disseminated candidiasis and who had apparently not used lemon juice. A 36-year-old, HIV-negative heroin user who was receiving oral methadone presented with lesions characteristic of candidal vitritis (4). Three weeks earlier, he had intravenously injected methadone that had been prepared for oral administration by dilution in orange juice. A few hours later, he experienced chills and fever, followed within 2 days by a self-limiting episode of disseminated folliculitis, predominantly of the hair-bared skin. A diagnosis of probable candidal vitritis was made, and a 10-day course of ketoconazole treatment led to the gradual resolution of symptoms. The original undiluted methadone solution was sterile. The orange juice used as the methadone dilutent was unavailable for testing. A 27-year-old, HIV-negative former heroin user who had been receiving methadone treatment for 3 years was regularly given a 7-day supply of methadone that was diluted in raspberry syrup and sterile water. The used glass bottles were usually boiled before refilling. Occasionally, the patient intravenously injected one prepared dose of diluted methadone. After one such injection, he developed signs of disseminated candidiasis with fever, skin lesions, and bilateral panophthalmitis. Candida albicans was cultured in three pairs of blood samples and from plucked hairs. Candida albicans was also isolated from the remaining drops of diluted methadone that the patient had injected. All isolates were identical by DNA fingerprinting (5). Panophthalmitis was successfully treated with a 20-day course of amphotericin B (total dose, 820 g) plus flucytosine. Further laboratory tests showed that C. albicans grows readily in both orange juice and raspberry syrup (unpublished data). As methadone maintenance programs expand to counter the AIDS epidemic, more patients may be tempted to use oral methadone preparations intravenously. Patients and doctors 576
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should be aware of the risk for disseminated candidiasis posed by this practice. Claude Scheidegger, MD Jolanta Pietrzak, MD Reno Frei, MD University Hospital of Basel 4031 Basel, Switzerland
References 1. Newton-John HF, Wise K, Looke DF. Role of the lemon in disseminated candidiasis of heroin abusers. Med J Austr. 1984;140:780-1. 2. Shankland GS, Richardson MD. Possible role of preserved lemonjuice in the epidemiology of Candida endophthalmitis in heroin addicts. Eur J Clin Microbiol Infect Dis. 1989;8:87-9. 3. Scheidegger C, Frei R. Disseminated candidiasis in a drug addict not using heroin. J Infect Dis. 1989;159:1007-8. 4. Servant JB, Dutton GN, Ong-Tone L, Barrie T, Davey C. Candidal endophthalmitis in Glaswegian heroin addicts: report of an epidemic. Trans Ophthalmol Soc UK. 1985;104:297-308. 5. Scherer S, Stevens DA. Application of DNA typing methods to epidemiology and taxonomy of Candida species. J Clin Microbiol. 1987; 25:675-9.
Standardizing Fecal Occult Blood Testing To the Editors: In their recent article, Fleisher and colleagues (1) stressed the need to pay careful attention to visual interpretation of the fecal occult blood test using Hemoccult II slides (SmithKline Diagnostics, Inc., San Jose, California). We request clarification of the following points: What were the volumes of blood and stool used to yield ''moderately positive" and "strongly positive" results? What were the specific "instructions" given to the evaluators who were asked to read the samples? Were evaluators shown color pictures of "negative," "moderately positive," and "strongly positive" specimens? We feel it would be beneficial to have these data published in the journal. It would be interesting to know if these "instructions for interpretation" would reduce the number of false-negative test results in subsequent studies. Siva Maran, MD Thomas P. Short, MD Eapen Thomas, MD James H. Quillen College of Medicine Johnson City, TN 37601
Reference 1. Fleisher M, Winawer SJ, Zauber AG, Smith C, Schwartz MK. Accuracy of fecal occult blood test interpretation. Ann Intern Med. 1991; 114:875-6. In response: The questions posed by Drs. Maran, Short, and Thomas raise important points that should be helpful to users of the Hemoccult II slides. As indicated in our article (1), instructional intervention should improve clinical efficacy of fecal occult blood testing. Negative guaiac stool samples were used as the test matrix. Simulated guaiac-positive stool samples were prepared by add-
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ing normal human whole blood with a hemoglobin concentration that ranged from 12 to 15 g/dL after hemolysis by freezethawing. Aliquots of blood were added to 5 to 10 g of stool, homogenized, and tested for the degree of guaiac positivity. Blood was added to the stool sample in amounts sufficient to achieve the desired degree of positivity. Each program coordinator attended a 45-minute instructional seminar on the development and interpretation of Hemoccult slides that consisted of a description of the mechanism of the test, the appropriate method for adding the developing reagent, the way in which to discern the blue color characteristic of a moderately positive reaction from the color variation due to the stool itself. Instead of color pictures, actual slides with positive blue color variations were used to show color intensity and variability. Immediately after the instructional seminar, each program coordinator was given a set of three Hemoccult II slides and was asked to develop each slide and to record the results. Problems in interpretation were discussed as they arose. The instructional seminar was followed by a discussion period. Each coordinator reported that this type of instruction was extremely useful in standardizing the interpretation of Hemoccult II slides and in pointing out the pitfalls of the test. Martin Fleisher, PhD Sidney J. Winawer, MD Ann Graham Zauber, PhD Memorial Sloan-Kettering Cancer Center New York, NY 10021
Reference 1. Fleisher M, Winawer SJ, Zauber AG, Smith C, Schwartz MK. Accuracy of fecal occult blood test interpretation. Ann Intern Med. 1991; 114:875-6.
Octreotide for Diarrhea in Amyloidosis To the Editors: The somatostatin analog octreotide acetate (Sandostatin, Sandoz Pharmaceuticals, East Hanover, New Jersey) has been used to treat diarrhea associated with various disorders (1). We report the successful use of octreotide to treat intractable diarrhea in a patient with amyloidosis secondary to multiple myeloma. A 53-year-old man with multiple myeloma of the immunoglobulin G-kappa type was treated with melphalan-prednisone, and his hematologic status became stable. He was found to have polyneuropathy 14 months after the diagnosis of myeloma was made. Diarrhea, hepatomegaly, congestive heart failure, polyserositis, orthostatic hypotension, and periorbital bleeding were subsequently noted. Amyloidosis was diagnosed on the basis of bone marrow biopsy results. Although most symptoms were treated successfully, the patient's diarrhea did not respond to treatment with diphenoxylate hydrochloride, atropine sulfate, loperamide hydrochloride, codeine phosphate, antibiotics, or other supportive measures. The patient denied experiencing any abdominal cramps, fever, or chills. He reported urgency and 6 to 20 bowel movements per day, half of which were nocturnal. The stool was described as watery and mixed with solids. No blood or mucus was noted. Microscopic examination of the stool failed to show neutral fat, fatty acids, ova, or parasites. Although a gram stain of the stool sample showed many gram-positive cocci and gram-negative rods, substantial numbers of leukocytes were not seen. Stool cultures showed normal fecal flora and no pathogens. A 24-hour stool sample that weighed 508 g contained 3.6 g of lipids (normal, 0 to 7 g/d). A 5-hour xylose absorption test showed a blood D-xylose level of 6 mg/dL (normal, > 25 mg/dL) and a urine D-xylose level of 1.0 g/5 h (normal, 4.1 to 8.2 g/5 h). The excretion of paraminobenzoic acid in a 6-hour urine sample (chymex test) was 11% (normal, > 50%). Examination of stool electrolytes and osmolality were ordered, but the specimen was unsatisfactory for study. The patient was treated with octreotide acetate, 100 /ug three times per day, and the diarrhea quickly ceased. He reported
soft, formed stools within 2 days after the start of therapy and was able to "sleep undisturbed at night for the first time in 1 year." Treatment with octreotide was discontinued, and the diarrhea promptly recurred. Reinstitution of octeotide therapy was followed by resolution of the diarrhea. The patient was discharged to a nursing home, and he continued to receive treatment with octreotide acetate, 50 /ig three times per day. The patient had occasional soft stools occurring three to four times per day that were effectively treated by adding paragoric to the regimen. One month later, the patient suddenly died. The cause of death remains unknown but is presumed to have been caused by cardiac arrthymia resulting from amyloid cardiomyopathy. The most likely cause of the diarrhea experienced by one patient was amyloidosis. Although diarrhea occurs frequently in amyloidosis, severe cases, such as that seen in our patient, are uncommon (2). The diarrhea may be due to either neuropathy or amyloid infiltration of the gastrointestinal tract that results in malabsorption, inhibition of ion absorption, and stimulation of ion secretion. The condition may also be caused by immobility of the gastrointestinal tract accompanied by bacterial overgrowth. Because insufficient data were available for analysis, we cannot accurately identify the mechanism responsible for the diarrhea our patient had. We were able to locate only one other report of a patient with systemic amyloidosis who was treated with octreotide acetate (3). Although this patient had primary, not secondary, amyloidosis, the clinical features and treatment results of these two patients are similar. Octreotide acetate may be an effective treatment for diarrhea associated with amyloidosis. Lung T. Yam, MD Socorro B. Oropilla, MD Veterans Affairs Medical Center University of Louisville School of Medicine Louisville, KY 40206-1499 References 1. Gorden P, Comi RJ, Maton PN, Go VL. Somatostatin and somatostatin analogue (SMS 201-995) in treatment of hormone-secreting tumors of the pituitary and gastrointestinal tract and non-neoplastic diseases of the gut. Ann Intern Med. 1989;110:35-50. 2. Kyle RA, Greipp PR. Amyloidosis (AL): clinical and laboratory features in 229 cases. Mayo Clin Proc. 1983;58:665-83. 3. O'Connor CR, O'Dorisio TM. Amyloidosis, diarrhea, and a somatostatin analogue. Ann Intern Med. 1989;110:665-6. Diagnosing Lyme Disease To the Editors: Borrelia burgdorferi is considered to be the causative agent in Lyme borreliosis, a tick-borne zoonosis that afflicts both humans and domestic mammals. In the last 10 years, however, the diversity of clinical manifestations assumed to be the result of infection with B. burgdorferi has continued to increase, and Lyme borreliosis is sometimes difficult to diagnose. Why do only 70% of patients develop erythema migrans, the characteristic annular red rash that develops around the infective site? Why does a "flu-like syndrome" characterized by fever, headaches, and cough develop in only a portion of infected patients? Why do some patients appear to have no acute or early disease, but later develop severe cardiac, arthritic, or neurologic manifestations? Why do some patients become ill following the bite of the tick Ixodes dammini but do not develop Lyme disease? Early researchers looking for the etiologic agent of Lyme disease attempted to isolate viruses from infected humans, wild animals, and ticks but were unable to do so (1). Attempts to identify in patients with Lyme disease antibodies to a large number of known viruses also produced disappointing results (2). The discovery and identification of B. burgdorferi ended the search for other infectious agents in /. dammini. Since these first studies in the 1970s, however, when Lyme arthritis appeared to be restricted to a few communities in south-central Connecticut, cases in humans have been reported from most of the continental United States, although most occur in a few hyperendemic regions (3). Ixodes dammini has apparently in-
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creased in abundance and distribution, resulting in increased human contact. Ticks are known to be infected with and may transmit 126 or more of the 504 registered arboviruses, many of which cause substantial morbidity and mortality among humans (4). In Eurasia, /. ricinus and /. persulcatus have long been known to be important vectors of tick-borne encephalitis (TBE) virus, and these ticks can simultaneously transmit B. burgdorferi and TBE virus (E. Korenberg. Personal communication) in the same way that /. dammini can simultaneously transmit B. burgdorferi and Babesia microti, a causative agent of human babesiosis (5). Given the increased contact of humans with /. dammini, it seems reasonable to ask again whether viruses or other bacteria might be transmitted by these ticks and might contribute to an increasingly complex clinical picture. The discovery of B. burgdorferi has helped to define many previously undefined clinical disorders, but is the spirochete responsible for every malady that results from the bites of /. dammini or other ticks known to transmit the spirochete? We suggest not. Nadelman and colleagues presented the results of a prospective study of 132 persons exposed to /. dammini', 16 (12%) developed flu-like symptoms after being bitten by these ticks but none was confirmed by laboratory findings to have Lyme disease (Conference Abstract Book B, p. 34). Although these patients may have coincidentally been bitten by ticks and later acquired an illness through another route of exposure, the possibility exists that Ixodes ticks may be transmitting viruses or other bacteria, alone or simultaneously, with B. burgdorferi. Viral infection may help to explain why persons who become ill after a tick bite may believe that they have Lyme disease despite negative serologic tests. In such cases, there is nothing wrong with the test; these persons do not have Lyme disease. Concomitant infections with viruses and spirochetes or infections with the spirochete alone may also explain, in part, the wide array and variable clinical manifestations presently ascribed solely to Lyme disease. Tom G. Schwan, PhD Warren J. Simpson, PhD Rocky Mountain Laboratories, NIAID Hamilton, MT 59840 References 1. Wallis RC, Brown SE, Klotter KO, Main AJ Jr. Erythema chronicum migrans and Lyme arthritis: field study of ticks. Am J Epidemiol. 1978;108:322-7. 2. Steere AC, Malawista SE, Snydman DR, Shope RE, Andiman WA, Ross MR, et al. Lyme arthritis: an epidemic of oligoarticular arthritis in children and adults in three Connecticut communities. Arthritis Rheum. 1977;20:7-17. 3. Centers for Disease Control. National secular trends in Lyme disease 1982-1989. Lyme Disease Surveillance Summary. 1990;1:1. 4. Karabotsos N; ed. International Catalogue of Arboviruses, Including Certain Other Viruses of Vertebrates. San Antonio: American Society of Tropical Medicine and Hygiene. 1985:1-1147. 5. Piesman J, Hicks TC, Sinsky RJ, Obiri G. Simultaneous transmission of Borrelia burgdorferi and Babesia microti by individual nymphal Ixodes dammini ticks. J Clin Microbiol. 1987;25:2012-3.
Cardiopulmonary Resuscitation in Teaching Hospitals To the Editors: Although cardiopulmonary resuscitation (CPR) was originally conceived as an intervention to reverse acute cardiac arrest in otherwise healthy patients, it has recently evolved into a desperate attempt to revive the dying. Because of its low success rate and its great potential for harm, CPR should not be initiated thoughtlessly. Decisions to resuscitate patients, like decisions to withhold CPR, should reflect thoughtful discussion, deliberate analysis, and serious consideration. Unfortunately, despite widespread attention devoted to this issue in the academic literature and in the popular press, explicit resuscitation directives such as do-not-resuscitate (DNR) orders are still often absent when they are needed (1). Resuscitation directives are sometimes omitted because the attending physician and the patient agree that CPR would be appropriate therapy in the event of cardiac arrest. In many instances, however, the absence of such directives is simply 578
the result of neglect and reflects the attending physician's difficulty in discussing "code status." In the absence of resuscitation directives, the prevailing practice among housestaff in teaching hospitals is to "do everything," that is, to initiate resuscitation as if the patient would desire (and the situation would warrant) such activity. Although such practices are generally done to prevent avoidable mortality, patients frequently do not want to be resuscitated, particularly when their clinical conditions preclude any reasonable hope for recovery (2). Further, there is a growing consensus among physicians and philosophers that the use of CPR in medically "futile" situations is unwarranted, because ineffective therapy should not be offered to patients (3, 4). When attending physicians in teaching hospitals fail to discuss resuscitation in advance, not only are patients put at increased risk for avoidable iatrogenic harm, but resident physicians who are asked to perform CPR are put in a position in which they may inadvertently override patient wishes for nonaggressive treatment. Therefore, if attending physicians cannot or will not attempt to learn a patient's preference regarding resuscitation, then other care givers should be trained and empowered to do so. Because housestaff are burdened with the technical and emotional responsibility for resuscitation, they are ideal candidates for assessing patients' "code status." Housestaff have ample opportunity to learn patients' desires and fears, are trained to appreciate prognostic and therapeutic factors, and are available at all hours. It seems appropriate that housestaff physicians receive formal training in the ethical as well as technical use of CPR and that they be empowered to use such training to assess the appropriate use of such treatment. Housestaff should not routinely make DNR decisions—this task remains the duty of attending physicians. When attending physicians are unavailable during emergency situations in which a patient's CPR status is unknown, trained housestaff could make DNR decisions and thus spare patients and their families the consequences of inappropriate CPR. Michael Green, MD Evanston Hospital Evanston, IL 60201 References 1. Gleeson K, Wise S. The do-not resuscitate order: still too little too late. Arch Intern Med. 1990;150:1057-60. 2. Wagner A. Cardiopulmonary resuscitation in the aged: a prospective survey. N Engl J Med. 1984;310:1129-30. 3. Tomlinson T, Brody H. Futility and the ethics of resuscitation. JAMA. 1990;264:1276-80. 4. Council on Ethical and Judicial Affairs, American Medical Association. Guidelines for the appropriate use of do-not-resuscitate orders. JAMA. 1991;265:1868-71.
Aspergillosis and Marijuana To the Editors: We read with interest the letter by Doblin and Kleiman stating that nearly half of all oncologists polled reported having recommended illegal use of marijuana for the control of chemotherapy-induced emesis (1). Although reports of benefits from marijuana treatment are anecdotal, many patients with the acquired immunodeficiency syndrome (AIDS) have experimented with marijuana to combat anorexia and weight loss, and the United States government supplies marijuana cigarettes to a small number of patients on a compassionate-use basis. Despite the availability, on a prescription basis, of oral synthetic tetrahydrocannabinol (THC; Marinol, Roxane Laboratories, Inc., Columbus, Ohio), the active ingredient in marijuana, many patients choose to smoke marijuana. Patients should be aware that this practice may involve unforeseen risks. Studies have shown that most illegally obtained marijuana is contaminated with Aspergillus species—most often A. flavus and A. fumigatus (2). Aspergillus spores easily pass through contaminated marijuana that is smoked (2, 3). For immunocompetent individuals, such exposure is unlikely to be associated with disease; however, in immunocompromised patients, invasive pulmonary aspergillosis may ensue (4). Given
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the widespread recreational use of marijuana, as well as the use of marijuana for medical indications, the number of cases of invasive aspergillosis associated with smoking marijuana may be substantial. Although patients who receive chemotherapy are advised to use the prescription form of THC, some continue to use nonsterilized, illicit marijuana. For that reason, simple conditions were defined that would result in the removal from marijuana of Aspergillus spores (and probably of most other pathogens). Because of difficulties in obtaining marijuana legally, oregano, parsley, and tea (substances physically similar to marijuana) were each heavily inoculated with spores of A. fumigatus, A. flavus, and A. niger. The herbs were then baked at varying temperatures and times and were later cultured for fungi. The conditions required to consistently kill all fungi were a temperature of 135 °C (275 °F) of dry heat for 5 minutes. Allowing for variations in home ovens, marijuana users could assume elimination of Aspergillus in marijuana that is baked at a minimum temperature of 150 °C (300 °F) for 15 minutes before smoking. Similar conditions have been shown not to degrade tetrahydrocannabinol (5). Because heating may not degrade Aspergillus antigens, sensitized patients may develop bronchospasm after smoking contaminated marijuana (2). Education on this simple method for sterilizing marijuana of Aspergillus may, however, reduce a major potential risk in patients who remain convinced that they obtain unique benefits from smoking marijuana. Stuart M. Levitz, MD Richard D. Diamond, MD Boston University School of Medicine Boston, MA 02118
References 1. Doblin R, Kleiman MA. Medical use of marijuana [Letter]. Ann Intern Med. 1991;114:809-10. 2. Kagen SL, Kurup VP, Sohnle PG, Fink JN. Marijuana smoking and fungal sensitization. J Allergy Clin Immunol. 1983;71:389-93. 3. Kurup VP, Resnick A, Kagen SL, Cohen SH, Fink JN. Allergenic fungi and actinomycetes in smoking materials and their health implications. Mycopathologia. 1983;82:61-4. 4. Chusid MJ, Gelfand JA, Nutter C, Fauci AS. Pulmonary aspergillosis, inhalation of contaminated marijuana smoke, and chronic granulomatous disease. Ann Intern Med. 1975;82:682-3. 5. Mechoulam R, McCallum NK, Burstein S. Recent advances in the chemistry and biochemistry of cannabis. Chem Rev. 1976;76:75-112.
A Library for Internists To the Editors: The article by Ludmerer (1), "A Library for Internists VII," was indeed informative. I recognize that Dr. Ludmerer coordinated a multidisciplinary effort to complete the seventh edition of this work. As a practitioner of general internal medicine and a teacher of residents and medical students for over 20 years, I offer a slightly different model (Table 1). In this revision I have included several additional subcategories that I feel are worthy of note: Anesthesia; Obstetrics and Gynecology; Pathology; and Surgery grouped under "Other Specialties of Clinical Medicine"; Medical Malpractice; Quality Assurance; Symptoms, Signs, and (patient) Problems (for example, headache, backache, and edema) grouped under "Related Clinical Fields"; and Clinical Competence, Counseling; Management; Medical Interviewing; Physical Diagnosis; and Teaching/Training (for example, clerkships) grouped under a new heading called "Professional Skills." A survey of members of the American College of Physicians may be conducted as the eighth revision is being considered. Others have considerable expertise in this area and can be called on to contribute (2-5). David A. Nardone, MD Veterans Affairs Medical Center Portland, OR 97207
Table 1. Proposed Model for a Library for Internists Basic sciences Biochemistry Biophysics Molecular biology Pharmacology Clinical medicine Internal medicine Ambulatory care/primary care Cardiology Dermatology Endocrinology and metabolism Gastroenterology General medicine Genetics Geriatrics Hematology Immunology and allergy Infectious diseases Intensive care Nephrology Neurology Oncology Pulmonary medicine Rheumatology Other specialties Anesthesia Adolescent medicine Emergency medicine Nuclear medicine Obstetrics and gynecology Occupational medicine Pathology Physical medicine and rehabilitation Psychiatry Radiology Sports medicine Surgery Tropical medicine Related clinical fields Clinical consultation Epidemiology History of medicine Informatics Medical economics Medical ethics Medical malpractice Quality assurance Symptoms, signs, and patient problems Professional skills Clinical competence Counseling Decision making Management Medical interviewing Physical diagnosis Teaching and training Reference works Dictionaries Directories Indexes Computer-based information systems CD-ROM products
References 1. Ludmerer KM. A library for internists VII: recommendations from the American College of Physicians. Ann Intern Med. 1991;114:811-32. 2. Fuller EA. A system for filing medical literature: based on a method developed by Dr. Maxwell M. Wintrobe. Ann Intern Med. 1968;68: 684-93. 3. Singer K. Where did I see that article? JAMA. 1979;241:1492-3. 4. Classification Committee of the World Organization of National Colleges, Academies, and Academic Associations of General Practitioners/ Family Physicians. ICHPPC-2-defined: International Classification of
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Health Problems in Primary Care. 3d ed. New York: Oxford University Press; 1983. 5. Haynes RB, McKibbon KA, Fitzgerald D, Guyatt GH, Walker CJ, Sackett DL. How to keep up with the medical literature: VI. How to store and retrieve articles worth keeping. Ann Intern Med. 1986;105:978-84. Additional references available from the author on request. In response: Dr. Nardone's constructive suggestions regarding the Library for Internists are welcome. One of the most difficult issues in the development of an outline concerned the areas outside internal medicine to be included. Certainly, no one would deny the importance of many related fields to internal medicine; however, the task of creating an internal medicine bibliography without allowing that bibliography to become unmanageably long posed a difficult challenge. I am sure that the next Library for Internists committee will profit from Dr. Nardone's suggestions. Kenneth M. Ludmerer, MD Washington University School of Medicine St. Louis, MO 63110
A patient was dying of colon cancer. The hospice nurse and I made a home visit to do a paracentesis and to adjust the dose of analgesics. After the visit, the patient's wife and son and I were standing outside in the yard. Their neat cottage was tucked into the edge of the woods adjacent to a large upland swamp, or pocosin. The pocosin was teaming with bears, deer, and other wildlife. The grounds of the cottage were tidy and well kept. A chicken house, however, was in serious disrepair. "Why have you stopped raising chickens?" I asked. "Too many varmints, and the government won't let us kill them," replied the son. (It seems that restrictions on trapping foxes had made keeping chickens impossible in that location.) Rather than abandon our carefully crafted strategies for avoiding lawsuits, I suggest that we reform our tort system. As Dr. Welch points out, diversion of resources away from patient care is an important argument for such a practice. Without control of predators or the protection of defensive medicine, doctors are like chickens at the edge of the pocosin.
Defensive Medicine: A Form of "Varmint" Control?
E. Rodney Hornbake, MD Eastern Carolina Internal Medicine, P.A. 532 Webb Boulevard Havelock, NC 28532
To the Editors: The recent article by Welch (1) is an important contribution to the issue of physician participation in costcontainment efforts. His second recommendation, the abandonment of clinical strategies that are designed primarily to avoid lawsuits, reminds me of an incident from my practice.
Reference 1. Welch HG. Should the health care forest be selectively thinned by physicians or clear cut by payers? Ann Intern Med. 1991;115:223-6.
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