Volume 8, Number 2, Winter 2002

In This Issue:

Telemedicine: Emerging Medical Technology for the Present and Future

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Background

According to the American Telemedicine Association (ATA), telemedicine is defined as "the use of medical information exchanged from one site to another via electronic communications, for the health and education of the patient or healthcare provider, and for the purpose of improving patient care." Examples of telemedicine include teleradiology and telepathology, where, for the most part, images (x-rays, lab slides) are sent electronically to a distant site for viewing and interpretation by others. There are some more active uses of this technology as well, such as telesurgery, where real-time operations can be conducted with the patient and surgeon in two different locations. The latter is obviously still in an experimental phase.

A Brief History of Telemedicine

The first documented use of telemedicine was at the University of Nebraska College of Medicine in 1959. The psychiatry department conducted group therapy and instructed medical students by connecting clinics and classrooms using telemedicine. In 1968, the INTERACT project of the University of Vermont College of Medicine and Dartmouth Medical School started providing medical and educational services to ten sites in rural Vermont and New Hampshire. This was one of the first projects to link rural clinics with tertiary care through telemedicine. Also in 1968, the Massachusetts General Hospital established a link between the hospital and Boston's Logan Airport. This telemedicine application provided immediate access to a doctor without requiring one to be permanently assigned to the airport. Consults included radiology, dermatology, and cardiology.

Since then, telemedicine applications have grown tremendously and have included many international efforts. An example of a cross-continent collaboration is Project SHARE, between Canada and East Africa, which in 1986 established a satellite network between medical facilities in Canada, Kenya, and Uganda. Project SHARE not only included consults but was also utilized for physician medical education and collaboration on research.

Telemedicine Today

In the U.S. and elsewhere, government-funded programs have supported the creation of "hub and spoke" telemedicine systems linking an academic medical center at the hub with primary care clinics at the spokes. These systems have been beneficial in demonstrating the effectiveness of telemedicine. They have also shown that the real costs of telemedicine lie not in equipment and hardware, but rather in other components, such as telecommunication/transmission, training of staff, and integrating telemedicine into existing health care systems.

The uses of telemedicine within primary care as well as subspecialty care remain diverse and numerous. Tele-interactions may involve live audio and video "virtual visits" between patients and medical professionals and sending patient monitoring data, such as blood sugar levels, blood pressure, or other information, from the patient's home to a clinic.

A growing number of medical specialties use telemedicine, including dermatology, oncology, radiology, surgery, cardiology, and mental health. Some examples include:

Radiology: This involves the transmission of medical images (x-rays, CT scans, MRIs, etc.) to a radiologist for interpretation. This was one of the first uses of telemedicine to receive full reimbursement under Medicare and is the most popular application for telemedicine in the country.

Psychiatry: Telemedicine was first demonstrated by this discipline, and since then has experienced wider acceptance by mental health professionals. Psychiatrists can converse with patients located in a remote location while observing their behavior as well. Mental health services can thus be made available to patients in regions that may not be able to retain these specialists.

Dermatology: While this discipline requires the use of specialized equipment, such as dermatoscopes or high-resolution examination cameras, this visually oriented field can make use of the resulting still images to aid in diagnosing and treating skin conditions.

Cardiology: Cardiologists have utilized telemedicine technology to perform remote auscultations as well as to transmit and view patient data, such as EKG and ultrasound information.

Surgery: Telesurgery applications are useful in pre-operative situations, such as in screening surgical candidates and preparing patients for surgery. Telesurgery can also be used to consult with a colleague during a procedure and have observers visualize a procedure for educational purposes. Post-operative follow-up, wound care, and other tasks can be carried out remotely as well. In the future, one can imagine an entirely remote operation being performed, where a surgeon in a different location operates on a patient at a distant OR.

Pathology: The use of telemedicine has been a crucial technology for many pathology departments. The transmission of visual information on a slide or from a specimen can allow for collaborative analysis and diagnosis.

Patient monitoring: Remote patient monitors allow the patient to remain at home and transmit monitoring data to the health professional through the telephone.

Correctional care: Prison-based populations in the U.S. receive guaranteed health care coverage. However, the cost and difficulty in transporting prisoners from remote facilities to medical facilities makes telemedicine an attractive alternative.

Other uses: Federal agencies have been heavily involved in using telemedicine in the delivery of care. These agencies include the U.S. Department of Defense, Veterans Administration, and National Aeronautics and Space Administration, who fund research in the development of telemedicine applications for use with military, veteran, and even astronaut populations.

Some Benefits of Telemedicine

Remote populations

Since it is not always possible to have general or specialized medical expertise available, both routine and emergency uses of telemedicine can reduce the distance needed to travel for help. Linking health centers, medical departments, and remote clinics in the hub and spoke model of telemedicine has proven to be a cost-effective way to maintain quality.

Medical education

Distance learning has been a popular use of telemedicine technology, whether for undergraduate, graduate, or postgraduate medical training. Grand rounds and case presentations are routinely video-conferenced to remote locations.

Community-based care

One of the most well-received benefits of providing health care centers with access to video conferencing is the response from the community. People like to receive high-quality care in their local communities. This reduces travel time and related stresses associated with many referrals. It also provides patients a greater continuity of care. By allowing local practitioners to access medical consults, they become partners with both the patient, for whom they are ultimately responsible, and the distant specialist as they collaborate on the patient's medical problem and develop a professional relationship. The provision of community-based care is a positive experience for all involved.

The Future of Telemedicine

The major obstacles to widespread use of telemedicine include some of the administrative structures of medical care. Changing laws and regulations, as well as the attitudes of some involved in the traditional delivery of medicine, present challenges to newer modes of health care delivery. A major hurdle is financial reimbursement to physicians. At present, Medicare may reimburse for several different types of telemedicine services, such as teleradiology, remote monitoring, and video-conferencing with patients in remote or shortage areas. However, broader reimbursement for other telemedicine uses is still unavailable. HMOs are also variable in their coverage of such services. At present, each state requires separate medical licenses for physicians practicing within their borders. This does not equate perfectly with the telemedicine mode of working across state or even national boundaries, and some states have enacted laws to restrict health professionals who are licensed in other states.

Another hurdle is the lack of physician familiarity with high technology. This can equate to reluctance to invest in equipment, or even to participate in consults which do not allow for a face-to-face interaction. Patient trust in such a system is also far from complete, due to concerns about maintaining privacy and confidentiality.

Despite the significant issues that have been touched on, telemedicine remains a promising mode of health care delivery, not to replace but to supplement quality health care being provided already. The obstacles facing widespread implementation of telemedicine technology are real, and they are guiding the development of solutions. The potential of telemedicine is to transform the delivery of quality care and to improve the health of many more people than possible at present.

Useful Internet Resources

American Telemedicine Association:
http://www.atmeda.org

Telemedicine Information Exchange:
http://www.telemed.org

UK National Database of Telemedicine:
http://www.dis.port.ac.uk/ndtm/

University of Vermont/Fletcher Allen Health Care Telemedicine Program:
http://www.fahc.org/telemedicine

Department of Defense Telemedicine Site:
http://www.matmo.org

NASA Telemedicine:
http://www.hq.nasa.gov/office/olmsa/ aeromed/telemed

Omar A. Khan
Council of Student Members
Representative, New England Region
University of Vermont College of Medicine, 2003
E-mail: omar.khan@vtmednet.org

References

1. Callas PW, Leslie KO, Mattia AR, et al. Diagnostic accuracy of a rural live video telepathology system. Am J Surg Path. 1997;21:812.

2. Ricci MA, Callas PW and Montgomery W. The Vermont telemedicine project: the first six months. Telemed J. 1997;3:94.

3. Ricci MA, Callas PW, Montgomery WL. The Vermont telemedicine project: initial implementation phases. Telemed J. 1997;3:197-205.

4. Reid JG, McGowan JJ, Ricci MA, McFarlane G. Desktop teleradiology in support of rural orthopedic trauma care. J Am Med Informatics Assoc. 1997:403.

5. Bashshur RL, Armstrong PA, Youssef ZI. Telemedicine: explorations in the use of telecommunications in health care. Springfield, IL: C.C. Thomas; 1975:354.

6. Park B. An introduction to telemedicine. New York: The Alternative Media Center at the School of the Arts New York University; 1974:129-35.

Focus on Subspecialties: General Internal Medicine

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Internists are doctors for adults. Their primary responsibilities include heath maintenance and disease screening; the diagnosis and care of acute and chronic medical conditions; management of patients with multiple, complex medical problems; and serving as a consultant to other disciplines including surgery, obstetrics, and family medicine.

The following is an interview with a general internist, James Reuler, MD, FACP, conducted by Kavita Patel, MD. Dr. Reuler is Chief of the Section of General Medicine at the Veterans Affairs Medical Center and Professor of Medicine at Oregon Health Sciences University in Portland, Oregon. Dr. Patel is an internal medicine resident at the Veterans Affairs Medical Center in Portland, Oregon.

IMpact: What is your current job?

Dr. Reuler: I am Chief of the Section of General Medicine at the Veterans Affairs Medical Center and Professor of Medicine at Oregon Health Sciences University in Portland. In addition to having my own practice, I have the privilege of working with students who are applying for medical school admissions and precepting and mentoring medical students in all years of their education. I supervise internal medicine residents on the wards and in the clinics. I also co-attend with physicians who are pursuing advanced fellowship training in general medicine, women's health, and informatics. Such opportunities provide wonderful variety, stimulation, and rewards.

IMpact: What does a general internist do? How does a generalist differ from a specialist?

Dr. Reuler: The practice of general internal medicine is characterized by the development of long-term, continuous relationships with patients and their families. A general internist coordinates care and services for his or her patients and participates as a member of a team, often including other health care professionals and community agencies. General internal medicine encompasses adolescence through the end of life and the entire spectrum of symptoms, illnesses, and diseases seen in these age groups, and delivery of preventive services.

A specialist frequently sees patients in consultation who are referred by a general internist. If a patient has organ-specific (a nephrologist would be consulted for a patient who has kidney disease) or disease-specific (an endocrinologist would be consulted for a patient who has complicated diabetes) disorders, or the need for specific procedures (such as cardiac catheterization), a specialist may be consulted. For some of the specialties, more time is spent caring for patients in the hospital than in the office.

IMpact: How did you come to the decision to specialize in general internal medicine?

Dr. Reuler: At the completion of my residency training, I realized that I found long-term doctor-patient relationships, the coordination of care, and the intellectual stimulation inherent in the uncertainty and problem-solving aspects of generalizing most fulfilling. Also, there was no single subspecialty in internal medicine that attracted me, I did not have a strong desire to do procedures, and I saw that my love of teaching would be a good fit with general medicine.

IMpact: What are some myths and falsehoods surrounding general internal medicine? What are some common mistakes that medical students make about your specialty?

Dr. Reuler: One myth is that it is impossible to keep up with all areas of internal medicine as a generalist. With the continued evolution of information technology and CME programs such as those offered by the College, the challenge of keeping current across the broad spectrum of conditions is made easier. This is part of the development of life-long learning skills.

Another misconception is that dealing with chronic illnesses, for which there are no cures, will not provide for a rewarding career. Just the opposite! The challenges of maintaining effective doctor-patient communication, assessing health beliefs, and helping patients to achieve maximal quality of life and dignity at the end of life are extremely rewarding and satisfying.

IMpact: What advice do you have for students interested in internal medicine or general internal medicine?

Dr. Reuler: General internal medicine is an office-based specialty. Therefore, as a student exploring this career option, seek out preceptorships and rotation experiences based in office settings and with a variety of populations. Frequently, clinic experiences in an academic health center or hospital are different than experiences at practices based in community or rural settings. Try to get a view from several vantage points and seek out practicing general internists who can serve as mentors and tell you about their careers. Your College chapter can be helpful in connecting you to such resources.

IMpact: Students are so busy these days, but there are still a number of worthwhile extracurricular activities in which students can participate. Do you feel that these activities are important to continue into residency and beyond?

Dr. Reuler: All of us have obligations and responsibilities to fulfill our social contract with society and to be contributing citizens in our larger community. Community and professional organization service carry with them tremendous rewards and will make you a better doctor. Appreciating historical perspectives, developing a better understanding of current events in your community, and having the opportunity to serve as role models for our children are just a few of these benefits. Non-profit, voluntary agencies are looking for people just like you--educated, organized, able to evaluate information critically, and able to work effectively as a member of a team. And through community service, you will meet new and fascinating people with whom you never would have come in contact.

IMpact: What other passions and interests do you have?

Dr. Reuler: The most important aspect of my life is my family. Attending our children's activities, volunteering at their schools, and sharing in household responsibilities--complex equations when two parents have full-time jobs and three children--are absolute priorities for me. Regular exercise and volunteer work with an agency providing health care to the homeless, where we have a large program for third- and fourth-year medical students, help me maintain balance, health, and a positive frame of mind.

Common Procedures Performed in General Internal Medicine

Lumbar puncture; flexible sigmoidoscopy; bladder catherization; arthrocentesis; thoracentesis; Gram stain of fluids and secretions; insertion of intravenous catheters; nasogastric intubation; breast, pelvic, and pap smears including wet mounts; arterial puncture; interpretation of chest and plain abdominal x-rays; arterial blood gases; urinalysis; peripheral blood smears; electrocardiograms; office spirometry.

Training for General Internal Medicine

General internal medicine training requires three years of accredited training following medical school. The three years of training must include 30 months of internal medicine rotations in general internal medicine, subspecialty internal medicine, critical care medicine, geriatric medicine, and emergency medicine. The 30 months may include up to four months of non-internal medicine primary skill areas such as dermatology, neurology, and office gynecology. A third of the total training time must be in the ambulatory setting.

Some internal medicine training programs have primary care tracts and special women's medicine tracts. Combined internal medicine training programs with pediatrics, family medicine, psychiatry, emergency medicine, neurology, preventive medicine, and physical medicine and rehabilitation are available. These combined programs require four to five years of training. A list of these programs is available on www.acponline.org.

Reprinted from IMpact, Vol. 5, No. 4, Summer 1999 issue.

17&szlig:-estradiol Reduced Depressive and Somatic Symptoms in Perimenopausal Women

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ACP Journal Club. 2002 Jan-Feb;136:26.

Soares CN, Almeida OP, Joffe H, Cohen LS. Efficacy of estradiol for the treatment of depressive disorders in perimenopausal women. A double-blind, randomized, placebo-controlled trial. Arch Gen Psychiatry. 2001 Jun;58:529-34. [PubMed ID: 11386980]

Question: In perimenopausal women with clinically important depressive disorders, does 17&szlig:-estradiol decrease depressive symptoms?

Design: 12-week randomized (allocation concealed*), blinded (clinicians, patients, outcome assessors, and statisticians),*† placebo-controlled trial.

Setting: A gynecologic clinic and psychiatric outpatient clinic in Săo Paulo, Brazil.

Patients: 50 women who were 40 to 55 years of age (mean age 50 y); had a history of menstrual-cycle irregularity or amenorrhea for < 12 months; had a serum level of follicle-stimulating hormone > 25 IU/L; and had been diagnosed with major depressive disorder, dysthymic disorder, or minor depressive disorder. Exclusion criteria were medical illness; hormone replacement therapy or psychoactive drug use in the previous 3 months; or presence of psychotic features or suicidal or severe aggressive behavior. Follow-up was 90%.

Intervention: Patients were allocated to a 17&szlig:-estradiol patch, 100 µg (Systen/Evorel, Janssen-Cilag Laboratories, Săo Paulo, Brazil) (n = 25), or a placebo patch (n = 25).

Main outcome measures: Severity of depressive symptoms measured by the Montgomery-Asberg Depression Rating Scale (MADRS) and severity of perimenopausal symptoms measured by the Blatt-Kupperman Menopausal Index (BKMI). Remission of depression was achieved if the MADRS score was < 10. A decrease of >= 50% from the baseline BKMI score was considered a significant improvement in somatic symptoms.

Main results: Analysis was by intention to treat. At 12 weeks, MADRS scores decreased more from baseline in women who received 17&szlig:-estradiol than in those who received placebo (-16.36 vs -4.16, {95% CI for the 12.2 difference in change from baseline 8.4 to 16.0}‡, P < 0.001). More women who received estradiol had remission of depression (P = 0.001) and a >= 50% decrease in BKMI scores (P = 0.005) than did women who received placebo (Table). The groups did not differ for adverse events. At the end of a 4-week washout period, MADRS scores remained lower than those at baseline in the estradiol group (P < 0.001) but were as severe as those at baseline in the placebo group (P = 0.07).

Conclusion: In perimenopausal women with clinically important depressive disorders, 17&szlig:-estradiol decreased depressive and somatic symptoms.

Source of funding: Fundaçăo de Amparo ŕ Pesquisa do Estado de Săo Paulo (FAPESP)--Săo Paulo Research Foundation.

For correspondence: Dr. C. N. Soares, Perinatal and Reproductive Psychiatry Clinical Research Program, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, WACC 812, Boston, MA 02114, USA. FAX 617-724-3028.

*See Glossary.
† Information provided by author.
‡CI calculated from data in article.

Commentary

In the landmark study from Brazil by Soares and colleagues, of the 50 perimenopausal women enrolled, 52% met the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), criteria for major depressive disorder, 26% for minor depressive disorder, and 22% for dysthymic disorder. The study had a 12-week treatment phase and a 4-week washout phase. A relatively high dose of estrogen (100 µg) alone was used. Progesterone (which is the standard of care in women with a uterus or endometrium) was not used. 68% of women treated with transdermal 17&szlig:-estradiol had remission of depression, regardless of DSM-IV diagnosis, compared with 20% of women in the placebo group.

The Massachusetts Women's Health Study, a prospective 5-year observational trial, found no link between the onset of natural menopause and an increased risk for depression (1). However, women with a lengthy perimenopause apparently had moderately increased rates of depressive symptoms. Therefore, it is not surprising that mood disturbances, which may be higher in symptomatic perimenopausal women, would respond to estrogen.

We need to determine which women with depressive symptoms benefit from estrogen alone, estrogen with a conventional antidepressant, or antidepressant therapy alone. Transdermal estradiol may be the best initial first-line therapy in women who have perimenopausal symptoms and minor mild-to-moderate mood symptoms, particularly if they do not have a uterus and do not need a progestin. Standard antidepressant therapy remains the first line of treatment for perimenopausal women with major depressive disorders alone.

We are moving beyond viewing estrogen as only a reproductive hormone to viewing it as a neural hormonal agent with effects on mood and cognition.

Holly L. Thacker, MD
Cleveland Clinic Foundation
Cleveland, Ohio, USA

Reference

1. Avis NE, Brambilla D, McKinlay SM, Vass K. A longitudinal analysis of the association between menopause and depression. Results from the Massachusetts Women's Health Study. Ann Epidemiol. 1994;4:214-20.

17&szlig:-estradiol vs placebo patch for depressive disorders
in perimenopausal women

  17&szlig:-   RBI NNT
Outcomes at 12 wk estradiol Placebo (95% CI) (CI)
Remission of depression 68% 20% 71% 3
      (38 to 87) (1 to 5)
>=50% decrease from baseline
in BKMI score		 68% 28% 59% 3
      (23 to 80) (2 to 8)

Review: Placebo is Better Than No Treatment for Subjective Continuous Outcomes and for Treatment of Pain

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ACP Journal Club. 2002 Jan-Feb;136:20.

Hróbjartsson A, Gřtzsche PC. Is the placebo powerless? An analysis of clinical trials comparing placebo with no treatment. N Engl J Med. 2001 May 24;344:1594-602. [PubMed ID: 11372012]

Questions: In patients with various clinical conditions, what is the clinical effect of placebo as a treatment for disease? Does the effect differ for subjective and objective outcomes?

Data sources: Trials published before the end of 1998 were identified by searching MEDLINE, EMBASE/Excerpta Medica, PsycLIT, Biological Abstracts, and the Cochrane Controlled Trials Register. Reference lists were reviewed, and experts were contacted.

Study selection: Studies were selected if patients were randomly allocated to a placebo group or an untreated group. Exclusion criteria were unconcealed randomization, a sample of paid or healthy volunteers, nonblinding of assessors of objective outcomes, a >50% dropout rate, or if the alleged placebo had a clinical effect not associated with the treatment ritual alone.

Data extraction: The primary outcome was that defined by the trial author or, if not defined, the most clinically relevant outcome.

Main results: 114 trials were included. The typical pharmacologic placebo was a lactose tablet, the typical physical placebo was a procedure done with a machine turned off, and the typical psychological placebo was an attention placebo (a nondirectional neutral discussion). 40 clinical conditions were investigated.

Placebo did not differ from no treatment for binary outcomes (32 trials, n = 3795), regardless of whether outcomes were subjective (23 trials) or objective (9 trials) (Table); significant heterogeneity existed among trials (P = 0.003). Placebo did not differ from no treatment in trials assessing nausea (3 trials), smoking cessation relapse (6 trials), or depression (3 trials).

Placebo was more effective than no treatment for continuous outcomes overall (82 trials, n = 4730; pooled standardized mean difference [SMD] -0.28, 95% CI -0.38 to -0.19) and for subjective continuous outcomes only (53 trials, pooled SMD -0.36, CI -0.47 to -0.25); placebo did not differ from no treatment when considering objective continuous outcomes only (29 trials) (Table). Significant heterogeneity existed among trials (P < 0.001), and the magnitude of placebo effect decreased with an increasing sample size (P = 0.05). For trials assessing continuous outcomes, placebo was better than no treatment for pain (27 trials, pooled SMD -0.27, CI -0.40 to -0.15) but not for obesity (5 trials), asthma (3 trials) hypertension (7 trials), insomnia (5 trials), or anxiety (6 trials).

Conclusions: Placebo is more effective than no treatment for continuous subjective outcomes and for treatment of pain. Placebo and no treatment do not differ in trials assessing objective or subjective binary outcomes or objective continuous outcomes.

Source of funding: No external funding.

For correspondence: Dr. A. Hróbjartsson, Department of Medical Philosophy and Clinical Theory, University of Copenhagen, Panum Institute, Blegdamsvej 3, DK-2200 Copenhagen N, Denmark. FAX 45-3545-7007.

Commentary

The meta-analysis by Hróbjartsson and Gřtzsche is controversial both theoretically and practically. Theoretical difficulties are highlighted by the fact that the authors once argued that placebo was undefinable (1) and that the placebo effect was uncontrollable (i.e., any comparison would underestimate it) (2). The sweeping nature of the conclusions in the original paper is also questionable: A meta-analytic summary is justified insofar as a more or less similar magnitude of effect can be expected across a range of patients, interventions, and outcomes for the included studies. May we expect similar effects of comparisons of placebo and no treatment for smoking, nausea, infertility, infection, or Parkinson's disease? In my opinion, the abstract above, independently prepared by the editorial office of this journal, is a better summary.

In practical terms, it seems wise to concentrate on the substantive areas in which practicing clinicians may be interested. For pain, the pooled SMD was -0.27 (95% CI -0.40 to -0.15); the point estimate suggests a small effect, but the CI is such that one cannot rule out the possibility of a moderate effect. For other conditions, the CIs are too wide to rule out a large-to-moderate effect. For hypertension, for example, the SMD was -0.32 (CI -0.78 to 0.13). For insomnia, it was -0.26 (CI -0.66 to 0.13), and for anxiety, it was -0.06, (CI -0.31 to 0.18).

On the basis of current knowledge, we cannot claim that we could use "placebo treatment" for depression or anxiety (3). Nor should we talk about maximizing placebo effects in treatment unless good evidence exists to show that we really can do so (4).

Toshi A. Furukawa, MD, PhD
Nagoya City University
Nagoya, Japan

References

1. Gřtzsche PC. Is there logic in the placebo? Lancet. 1994;344:925-6.

2. Hróbjartsson A. The uncontrollable placebo effect. Eur J Clin Pharmacol. 1996;50:345-8.

3. Enserink M. Can the placebo be the cure? Science. 1999;284:238-40.

4. Kleijnen J, de Craen AJ, van Everdingen J, et al. Placebo effect in double-blind clinical trials: a review of interactions with medications. Lancet. 1994;344:1347-9.

Placebo vs no treatment for various conditions

Outcomes at end of treatment Binary outcomes Pooled relative risk (95% CI) Continuous outcomes Pooled standardized mean difference (CI)*
Laboratory data 0.92 (0.73 to 1.17)† 0.18 (0.02 to 0.33)
Objective, without patient cooperation 0.89 (0.66 to 1.20)† -0.25 (-0.5 to -0.01)
Objective, with patient cooperation 0.84 (0.52 to 1.36)† -0.21 (-0.44 to 0.02)
Subjective and observable 0.93 (0.77 to 1.11)† -0.41 (-0.61 to -0.20)
Subjective and nonobservable 0.97 (0.89 to 1.07)† -0.35 (-0.48 to -0.22)

*Negative values favor placebo. † Not significant.

Internal Medicine Interest Group Activity Ideas

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Bioterrorism in Our Midst

It was late October and the United States was facing an anthrax bioterrorist attack of unknown proportions. While the media accounts were fascinating, members of the University of Vermont College of Medicine's Internal Medicine Student Interest Group were interested in a more systematic and scientific explanation of the current events and how they may affect us as future clinicians. Dr. W. Kemper Alston, an infectious disease attending, as well as hospital epidemiologist at nearby Fletcher Allen Health Care, agreed to hold a brown bag lunch session to discuss the details and walk us through the topic of bioterrorism.

What followed was an engaging dialogue that included the role of biowarfare throughout history, critical surveillance items that can indicate a bioterrorist attack, and how organisms can be used as weapons. Since anthrax was not a disease covered to any great extent within our normal curriculum, the basic facts of Bacillis anthracis were discussed, as well as typical disease presentation, methods of diagnosis, and treatment options. Many of us were surprised to learn that some forms of cutaneous anthrax are treatable with ordinary penicillin or doxycycline, a fact that had been overshadowed in the lay press amidst exponential ciprofloxacin prescriptions. Anthrax that has been weaponized, however, is less likely to be susceptible to penicillin. Following a systematic review of the facts as they related to anthrax outbreaks up to that time, concerns for the future were addressed.

It was a sobering but enlightening session. The immense scope and ramifications of bioterrorist attacks are daunting, especially to those of us who will be called upon to treat future victims. Despite the lack of easy solutions, those of us present left with an increased awareness of the events taking place around us, as well as a better understanding of what may be expected from us in future medical practice.

Nicole Piscatelli
University of Vermont College of Medicine, 2004

MKSAP Question 1

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A 43-year-old woman complains of itching that keeps her awake at night. Physical examination is normal, except for the liver, which is felt 7 cm below the right costal margin.

The blood count is normal; the results of serum chemistry tests are as follows:

  • Creatinine 0.8 mg/dL
  • Bilirubin 0.6 mg/dL
  • Alanine aminotransferase 78 U/L
  • Albumin 4.2 g/dL
  • Alkaline phosphatase 450 U/L

Which test would you order next in order to diagnose the underlying disorder?

(A) Serum protein electrophoresis
(B) Anti­smooth-muscle antibody
(C) Antimitochondrial antibody
(D) Technetium-99m liver-spleen scan
(E) Endoscopic retrograde cholangiopancreatography (ERCP)

MKSAP Question 2

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A 25-year-old woman living in Washington, DC, describes "rose fever" each year starting in early May and continuing through the end of June. Her symptoms consist of sneezing, nasal and conjunctival pruritus, rhinorrhea, and nasal congestion. Smears of nasal secretions reveal eosinophils in great number. Both her mother and sibling have "hay fever."

To which of the following allergens is this patient most likely to be allergic?

(A) Ragweed pollen
(B) Alternaria spores
(C) Rose pollen
(D) Beech pollen
(E) Grass pollen

MKSAP Question 3

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A patient presents to your office with complaints of severe earache and decreased hearing on the left side. Examination confirms left otitis media. You prescribe an oral cephalosporin and an analgesic. The next day the patient is brought to the emergency room with a rash and moderate bronchospasm. Reviewing his office record you are horrified to discover that he is known to have a severe allergic reaction to penicillin.

What should you tell the patient at this point?

(A) Apologize and explain what happened.
(B) Apologize and offer to compensate him financially.
(C) Attribute the rash and the bronchospasm to his infection.
(D) Explain to the patient that he is allergic to cephalosporin as well as penicillin.
(E) No explanations are necessary.

MKSAP Question 4

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A 16-year-old girl presents with a history of recurrent intensely pruritic skin lesions. They commonly occur after minor skin irritation in areas of her skin where her mother has noted brownish 0.2- to 1.0-cm maculopapular spots on her chest and trunk. On examination, you note that rubbing one of these areas produces an immediate flare.

Biopsy of one of the spots would be characterized by a marked accumulation of which of the following cell types?

(A) Eosinophils
(B) Neutrophils
(C) Basophils
(D) Mast cells
(E) Monocytes

Answer - Question 1

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Answer: C

Educational Objective: Recognize primary biliary cirrhosis and the most efficacious way of diagnosing it.

This is the classic description of primary biliary cirrhosis. Itching is the most common specific symptom of early primary biliary cirrhosis. Approximately 70% of affected patients have enlarged livers. The best screening test for suspected primary biliary cirrhosis is the antimitochondrial antibody test. It is positive in 95% of affected patients and has a 98% specificity if newer enzyme-linked immunosorbent assay (ELISA) tests are used. Serum protein electrophoresis might show a diffuse increase in immunoglobulins. However, this finding is nonspecific and may be found in many chronic liver diseases. Anti­smooth-muscle antibody tests are positive in some patients with autoimmune chronic hepatitis. However, the test is nonspecific and not terribly useful. The sulfur colloid technetium liver-spleen scan is useful for detecting portal hypertension and hypersplenism. However, it is not specific and would not be helpful in diagnosing primary biliary cirrhosis. Endoscopic retrograde cholangiopancreatography (ERCP) is typically normal in patients with primary biliary cirrhosis. Its only role in the diagnosis of primary biliary cirrhosis is in the patient who presents with a similar syndrome but who has a negative antimitochondrial antibody test. ERCP would then be performed to look for other causes of disease such as primary sclerosing cholangitis.

Bibliography

1. Kaplan MM. Primary biliary cirrhosis. N Engl J Med. 1987;316:521-8.

2. Kaplan MM. Primary biliary cirrhosis. In: Schiff L, Schiff ER, eds. Diseases of the Liver. 7th edition. Philadelphia: J.B. Lippincott Co.; 1993:377-410.

3. Van de Water J, Cooper A, Surh CD, Coppel R, Danner D, Ansari A, et al. Detection of autoantibodies to recombinant mitochondrial proteins in patients with primary biliary cirrhosis. N Engl J Med. 1989;320:1377-80.

Answer - Question 2

.

Answer: E

Educational Objective: Recognize the timing of pollen seasons for the Northeastern United States.

"Rose fever," like "hay fever," is named for the predominant feature of the garden during the pollination season, not for the source of allergens. Grasses in the spring and early summer and ragweed in the fall are the major allergens throughout much of the United States, although in addition each locale has its own unique allergens. The primary allergens are proteins found in the outer coat of the pollen grain. These proteins must be water-soluble, readily eluted, and potent allergens. In order for a plant to be a source of allergen, it must pollinate profusely, the pollen must be small and float in the air, and it must be widely distributed. For example, pine pollens are heavy and fall to the ground, whereas oak pollens are light and readily airborne. Because flowers have heavier pollens not distributed by the wind, they are not allergens. Alternaria is the most common outdoor mold-derived allergen and generally causes summer-long symptoms.

Bibliography

1. Solomon WR, Mathews KP. Aerobiology and inhalant allergens. In: Middleton E Jr, Reed CE, Ellis EF. Allergy: Principles and Practice. 2nd ed. St. Louis: C.V. Mosby Co.; 1983:1143-202.

Answer - Question 3

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Answer: A

Educational Objective: Understand the importance of informing patients of medical errors.

Medical errors are common but are infrequently reported to patients. The fear is that acknowledging a mistake may lead to litigation. Nevertheless, there is no excuse for a physician not to admit a mistake, which is an inevitable part of medical practice. Apologizing and explaining is not only ethical, but also has been shown to decrease the risk of litigation. There is no need or obligation to offer financial compensation. Trying to attribute your mistake to other causes, or attempting to blame the patient for your negligence is not only unethical, but will increase your risk of litigation. Finally, nothing will anger a patient more than no explanation at all.

Bibliography

1. Finkelstein D, Wu AW, Holtzman NA, Smith MK. When a physician harms a patient by a medical error: ethical, legal, and risk-management considerations. J Clin Ethics. 1997;8:330-5. UI: 98163811.

2. Witman AB, Park DM, Hardin SB. How do patients want physicians to handle mistakes? A survey of internal medicine patients in an academic setting. Arch Intern Med. 1996;156:2565-9. UI: 97109019.

3. Ethics manual. Fourth edition. American College of Physicians. Ann Intern Med. 1998;128:576-94. UI: 98175284.

Answer - Question 4

.

Answer: D

Educational Objective: Know that mast cells are concentrated in the lesions of urticaria pigmentosa.

The description of the brownish maculopapular spots on the chest and trunk coupled with the information that rubbing the area produces an immediate flare characterizes the lesions of urticaria pigmentosa. The irritation on rubbing (Darier's sign) characteristically occurs because of the release of histamine from mast cells, which are concentrated in the upper dermis along with dermal macrophages. Increased melanotic pigmentation in the adjacent cells, however, accounts for the brownish discoloration.

Characteristically, urticaria pigmentosa lesions begin in the first years of life and are widely dispersed over the trunk. In about half of these children, lesions may recede spontaneously. However, lesions that appear later in adolescence usually persist into adult life and represent a more severe variant of the condition. Systemic mastocytosis may also appear in infancy but more commonly arises later in life. Approximately half of these patients are asymptomatic, and 10% to 15% develop bone lesions, hepatosplenomegaly associated with intense pruritus, headache, flushing, tachycardia, and hypotension.

Bibliography

1. Czarnetski BM, Behrendt H. Urticaria pigmentosa: clinical picture and response to oral disodium cromoglycate. Br J Dermatol. 1981;105:563.

2. Caplan RM. Urticaria pigmentosa and systemic mastocytosis. JAMA. 1965;194:1077.

3. Fine J. Mastocytosis. Int J Dermatol. 1980;19:117.

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