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Governor's Newsletter, Fall 1999

"I would say that two contrary laws seem to be wrestling with each other nowadays: the one a law of blood and death, ever imagining new means of destruction and forcing nations to be constantly ready for the battlefield - the other a law of peace, work and health, ever evolving new means of delivering man from the scourges that beset him. Which one of these two laws will ultimately prevail God alone knows."

This statement appears in a recent volume of the Textbook of Military Medicine, and is attributed by managing editor Ron Bellamy, COL USA MC (retired), to Louis Pasteur at the turn of the last century. It defines clearly a role for modern medicine and our medical corps - to be expert in the ways of "peace, work and health" and to be ready to provide the best, compassionate care for the victims of "blood and death" due to new - and old - "means of destruction." As internists, our role centers around the medical care of adults, and our actions as consultants and primary care specialists largely define the quality of medical care they receive in peace or war, or in the increasing number of operations in between peace and war.

Many things have changed in the way the medical corps and medicine are structured since Pasteur made these comments. Peace time medicine throughout the United States continues to experience an explosion of technological advances, while patients and physicians have become increasingly active forces in the organization of health care delivery systems. Because of the intermittent nature of armed conflicts, much of our operational medical planning and doctrine remains untested in real time settings, when the expert use of the current and most recent medical technology will be critical to treat those injured or at risk of injury from the environment and weapons of modern technology.

Present day medicine as practiced in modern health care systems, is extremely challenging. It is also very likely that the next chapteral or full scale conflict, large or small, will provide medical challenges that far surpass those faced by Pasteur's colleagues when they cared for those injured in the First World War by what were then considered, unimaginable weapons of mass destruction. At that time, physicians deployed with their brigades and battalions, or in reserve units from some of the finest hospital systems in the world. Tremendous medical advances were made, but many, many patients did not benefit from these advances because of the steep learning curve required to acclimate physicians to their environment, the delay in bringing these units to the field, and the delay in matching their clinical and research skills to the new injuries they were treating. Our present day medical corps, active duty and reserves - trained and practicing largely in our own residencies and hospitals - is the sole legacy of those that have served before. We have the considerable responsibility of being expert in the daily practice of modern Internal Medicine and in bringing everything possible to the care of those injured and at risk of injury in the conflicts of the next century.

This newsletter will catch up on some of the columns that have been submitted since the last meeting in Reston, Virginia. Soon, the Army Chapter Council will meet at the Fall 99 Meeting, which is sponsored by Brooke Army Medical Center in San Antonio, Texas. The following newsletter will have updates from that meeting, the Consultant and other council members.

Army ACP-ASIM Chapter Newsletter Addition - Awards and Recognition Committee

I would like to officially announce the 1998 winners of the Army Chapter ACP-ASIM awards, which were presented at our fall meeting in Reston, VA. The Fall 1999 selections have been made and we encourage everyone to use our web site and begin now to plan for year 2000 submissions. The awards are listed below with the respective winners. A complete discussion, including the seven standardized categories summarizing each award, along with the name of its Chair, is contained on our Army Chapter Web site. Congratulations to these distinguished physicians, who exemplify the qualities of our Army ACP-ASIM membership.

The 1998 award winners included:

  • COL Robert H. Moser Award - Stephen M. Salerno, MAJ MC
  • ACP-ASIM Laureate Awards - Barbara M. Alving, COL (ret) MC; Lawrence F. Johnson, COL (ret) MC; Kurt Kroenke, COL (ret) MC; and Joseph I. Matthews, COL (ret) MC
  • Master Teacher Award - Louis N. Pangaro, COL MC
  • Excellence in Operational Medicine - John A. Powell, LTC MC
  • COL William Crosby Award for Superiority in Research - Nancy A. Dawson, COL MC
  • ACP-ASIM Army Chapter Associate Awards (podium presentations) -

    1st - Bret A. Purcell, MAJ MC, BAMC
    2nd - Eric A. Shry, CPT MC, MAMC
    3rd - Stuart Roop, CPT MC, WRAMC

  • ACP-ASIM Army Chapter Associate Awards (poster presentations) -

    1st - David E. Katz, CAPT MC, WRAMC
    2nd - Eric Robert E. Jeschke, CPT MC, TAMC
    3rd - S J Thomas, CPT MC, WRAMC

I may be reached at (253) 968-1290 [phone], (253) 968-1168 [fax], or col_lester_reed@smtplink.mamc.amedd.army.mil. The Committee extends its hearty thanks to all those members and support staff who helped make this award program a success.

COL H. Lester Reed, MD, FACP
Chair, Army Chapter ACP-ASIM Awards and Recognition Committee
Chief, Department of Medicine
Madigan Army Medical Center
MCHJ-M
Tacoma, WA 98431

Army Chapter 1998 Fall Meeting

The Fall 98 Meeting in Reston was outstanding. Our representative from the national ACP-ASIM, Executive Vice President, Dr. Walt McDonald, was especially impressed with the excellent organization of the meeting, and the extremely high quality of our staff and associate presentations. On behalf of the entire Chapter, I extend our sincere thanks and appreciation to the WRAMC organizers - COL Yancy Phillips, Program Chair, Ms. Daisy Word, Meeting Planner, and many, many consultants and breakout session planners. Our Chapter meetings have surpassed their original purpose to provide CME, and have become an excellent and extremely cost efficient vehicle to maintain and improve readiness of the Army Internal Medicine Community. More on this aspect of meetings past and present after the meeting sponsored by BAMC.

ACP-ASIM Master

Dr. Barbara Alving, COL USA MC (ret), was awarded a Mastership by the national ACP-ASIM Awards Committee and received her honor at the Spring 1999 Annual Session in New Orleans. Dr. Alving served for many years as Chief of the WRAIR Coagulation Laboratory, and was known throughout the AMEDD and international medical community for her clinical consultative and research expertise in hematology and coagulation disorders. She also served as Chair of the Department of Hematology/Oncology at USUHS and of the Division of Medicine at WRAIR. She is presently the Director of Blood Resources, National Heart, Lung and Blood Institute. Dr. Alving was also awarded a Laureate by the Army Chapter at the Fall 1998 Reston meeting, and will be speaking at the Plenary Session of the Fall 1999 meeting in San Antonio.

Army ACP-ASIM Chapter: Clinical Corner

Everything we do that impacts on our patients is important. The clinical corner section of the newsletter is provided by the Chief Resident Representative to the Army Chapter Council, and is designed to bring into focus relevant clinic topics similar to a "morning report" type of format. The following clinical corner was submitted early this year by CPT Cecily Peterson, Chief of Medical Residents at Madigan Army Medical Center, 1998-99.

This issue's "Clinical Corner" ventures into the realm of "Complementary Alternative Medicine (CAM)." The growing popularity of CAM in this country has been well documented (1). Whereas there is great controversy astir in this arena, there are specific interventions that have well studied efficacy, and can readily augment the repertoire of the practicing internist. Two recently seen illustrative cases are presented below.

Case 1

A 28-year-old medical intern with a history of weekly-to-monthly migraine without aura since age 16 presented with severe nausea (graded 7-8/10) on a post-call morning. He had had his typical right retro-orbital migraine the night before, which he had successfully aborted with two Extra Strength Excedrin. After a leisurely two hours sleep, he found that his headache was minimal (pain<3/10), but his usual accompanying nausea was worse than the night before. He was treated by his intrepid chief resident with the insertion of a single acupuncture needle at point Pericardium 6 (P6) in his left forearm. The needle was left in place for 20 minutes, then removed. Immediately following treatment, his nausea subsided with minimal residua (grade 1-2/10). It remained abated for 3-4 hrs., then returned to a more moderate degree (grade 4-5/10). He then stimulated the point for 30 seconds with digital pressure, and the nausea ceased entirely.

Consideration 1

The use of acupuncture point P6 for nausea has been well documented, particularly to quash the side effects of post-operative opiate analgesia or cancer chemotherapy (2). Its use, however, has been described to treat nausea of a variety of etiologies, from motion sickness to hyperemesis gravidarum. This point is located between the palmaris longus and flexor carpi radialis tendons, approximately 4.5 cm proximal to the true transverse wrist crease. It may be needled 0.5-1.0 cm deep with a 28-30 gauge acupuncture needle. The needle is advanced until the patient experiences either a deep achy grabbing sensation, or paresthesia from the underlying median nerve. The needle is then left in place for 10-20 minutes. The treatment may be repeated as needed (generally q 3-4 hours).

Case 2

A 59-year-old man presented with obstructive uropathy from benign prostatic hypertrophy (BPH). On terazosin 5mg hs, he had partial relief of his nocturia, down to 3 times nightly from q 30-45 minutes without medication. However, the terazosin caused side effects, including partial erectile dysfunction and orthostatic dizziness. Lower dosages of the medication were ineffective at ameliorating his nocturia, and still caused erectile dysfunction. He was switched to saw palmetto (Serenoa repens/Sabal serrulata) extract 160 mg bid. At his next visit 3 months later, he reported that his nocturia on the saw palmetto was comparable to the 5mg terazosin dose, and he noted a subjectively stronger urinary stream as well. He had no dizziness on the herbal extract; and, when inquired about the status of his erectile dysfunction, he pumped his fist in the air and gleamingly proclaimed, "like a rock!" These salubrious results were present at his 6 month follow-up as well.

Consideration 2

Saw palmetto extract is the lipophilic resinous concentrate of the ripe berries of related dwarf pine species native to the Southeastern United States. Six of seven double blind placebo controlled trials have shown saw palmetto to significantly improve BPH over the short term (3 months), using both subjective and objective criteria (3). Additionally, this preparation is similar in efficacy to, but has fewer side effects than other available agents, such as finasteride or alpha-blockers (4). Initial experiments suggested that the extract may function as an androgen antagonist, but further studies have left the mechanism of action unclear. Though long term clinical trials have not yet been concluded, the short term data are very encouraging.

References

Eisenberg DM, et.al.: Trends in Alternative Medicine Use in the United States, 1990-1997. JAMA. 1998;280:1569-1575.

Dundee JW, McMillan CM: Clinical Uses of P6 Acupuncture Antiemesis. Acupuncture & Electro-Therapeutics Research. 1990;15(3-4):211-5.

Lowe FC, Ku JC: Phytotherapy in Treatment of Benign Prostatic Hyperplasia: A Critical Review. Urology 1996;48(1):12-20.

Wilt TJ, et.al.: Saw Palmetto Extracts for Treatment of Benign Prostatic Hyperplasia. JAMA. 1998;280:1604-1609.

The Internist and Complementary Alternative Medicine
Daniel I. Newman, MD
E-mail: Daniel_Newman_at_MEDCEN7-MAMC@smtplink.mamc.amedd.army.mil

I thank all the contributors to this newsletter, as well as many, many, many Army ACP-ASIM members and council members for their contributions throughout the year. The meeting at San Antonio promises to be exciting.

Lt. Col. Charles D. Bolan, MD, FACP
ACP-ASIM Governor for Army
10015 Portland Road
Silver Spring, MD 20901
Phone: (301) 496-4506; Fax: (301) 402-1360
E-mail: cbolan@mail.cc.nih.gov