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Letters JAOA • Vol 102 • No 4 • April 2002 • 203 LETTERS Follow-up on “Symptoms associated with anthrax exposure: Suspected ‘aborted’ anthrax” To the Editor: Case reports are the front line of evidence in the evolution of medical practice. Despite the obvious weakness of case reports (ie, they deal with a small number of patients, even as low as a single person), they have great value as the starting point of discov-ery. 1 Although we cannot predict whether the ideas presented in our January 2002 case report (JAOA 2002;102:41-43) will be sustained after further study—or after addi-tional evidence is revealed—the clinical observations included in that case report continue to be of interest. The patient we presented, a 37-year-old man with a high level of exposure to the spores of Bacillus anthracis, has improved since publication of the report. On presen-tation, he had a low PO2 level, pleural effu-sions, and abnormal lesions on imaging of the chest. Blood culture results and anti-body tests for exposure to anthrax were negative. After 3 months of triple antibiot-ic treatment, the patient’s PO2 level is now 108; his fevers have subsided, but his strength has not returned. The patient was noted to be anergic to measles and Candida albicans, and the results of histo titers whole complement test have also come back neg-ative. We have received many questions about our decision to relate the patient’s illness to anthrax exposure. Our intention was to present a single case for primary care clin-icians that would begin to explore the expe-riences of clinicians who have patients with similar findings. None of the clinicians at our facility has seen a case of anthrax dis-ease. This patient was cultured for anthrax and tested for antispore antibody and anti-toxin antibody by the Centers for Disease Control and Prevention, and all results were negative. Therefore, the patient presented in the case report does not have anthrax dis-ease. But there should be an explanation as to why a healthy 37-year-old male with no medical problems suddenly has fevers, shortness of breath with a PO2 of 67, pleural effusions, and abnormal lymph nodes. The fact is, thus far, we have failed to produce an explanation for the distress occurring in this patient. The temporal relationship between his exposure to B anthracis and his symp-toms— and the fact that the symptoms were relieved with antibiotic treatment—make an infectious etiology high on our list of possible causes. If anthrax exposure does prove to be the cause of this patient’s distress, our patient would not be the first to have symptoms from an anthrax exposure without being culture- or antibody-positive. A fact sheet on three laboratory occupational deaths includ-ed in a government report, “Report of Demilitarization of Fort Detrick,”2 includes the 1951 case of William Allen Boyles, whose death was classified as caused by anthrax, despite the fact that “the microorganism could not be (and never was) cultivated from blood, sputum, nose and throat, or skin taken at any time during the illness, nor from tissue and fluids taken at autopsy.” The diagnosis was made postmortem be-cause of a small number of gram-positive bacilli resembling B anthracis found only in the pacconian granulations of the brain. Arthur M. Friedlander et al3 reported the findings of a study of 60 rhesus monkeys exposed to B anthracis to test the effectiveness of antibiotics. In that study, one animal given ciprofloxacin died 5 days after exposure, presumably from an aspiration pneumonia diagnosed because of negative blood cul-tures for anthrax. Another monkey died 73 days after antibiotics were stopped; this time the death was attributed to urethral obstruc-tion— again because blood samples were culture-negative for anthrax. A third mon-key died 5 days after antibiotics were dis-continued. Similarly, no cause could be found for that animal’s death.3 The anthrax bacterium causes damage through extensive replication in the blood. Its ability to expand so successfully is helped by proteins it secretes that “intoxicate” the cells it is invading. The proteins are benign until they bind to the surface of the cell where an enzyme trims off its outermost tip. Protective antigen, edema factor, and lethal factor are the proteins involved in cel-lular damage, allowing the spores to enter the cytosol of the cells.4 Without knowing what caused our pa-tient’s illness, we have to take care of him. Granted, the temporal relationship to the exposure does not automatically mean there is a causal relationship. The patient’s con-dition has improved while on triple intra-venous antibiotic therapy and became worse when intravenous antibiotics were discon-tinued. This report gives clinicians an indication as to treatment options. Limited experience with anthrax disease makes all clinical infor-mation, including our patient’s presenta-tion, important to share. TYLER C. CYMET, DO Section Head Department of Family Medicine Sinai Hospital Baltimore, Maryland Assistant Professor Internal Medicine The Johns Hopkins University School of Medicine Baltimore, Maryland GARY J. KERKVLIET, MD Director Residence Practice Office Program of Internal Medicine Sinai Hospital Baltimore, Maryland Assistant Professor Associate Program Director Internal Medicine The Johns Hopkins University School of Medicine Baltimore, Maryland References 1. Vandenbroucke JP. In defense of case reports and case series. Ann Intern Med. 2001;134:330- 334. 2. Report on the Demilitarization of Fort Detrick (MD), including case report of the death of William Boyles. Document of US Government 1977. 3. Friedlander AM, Welkos SL, Pitt ML, Ezzell JW, Worsham PL, Rose KJ, et al. Postexposure pro-phylaxis against experimental inhalation anthrax. J Infect Dis. 1993;167:1239-1243. 4. Young AT, Collier RJ. Attacking anthrax. Sci Am. 2002;286:48-50, 54-59. 204 • JAOA • Vol 102 • No 4 • April 2002 LETTERS Letters Unity between osteopathic and allopathic medicine only answer to preserving osteopathic uniqueness To the Editor: This letter is an addition to the ongoing dialog regarding the uniqueness of osteo-pathic medicine and addresses, in particu-lar, the comments of Brent Hutson, MSII, “DOs must preserve their uniqueness” (The DO 2001;42:15-16). I will discuss the effects of disturbing trends in the current health-care environment that certainly challenge the DO “uniqueness.” Mr. Hutson, while passionate and well-meaning, emphasizes the differences be-tween allopathic and osteopathic medicine, rather than finding their commonalities. He implies that it is impossible to unite the two professions under a single representa-tive body or to test the two professions with a unified testing structure. His arguments on both accounts are neither convincing nor unique. Let us first examine the elements that create the need for unity. Medicine today is under assault on many fronts. Frivolous lawsuits led by lawyers wishing to cash in on the current litigious trend in American culture are driving the cost of malpractice insurance upward, making it nearly impos-sible for small groups of physicians to afford group insurance at reasonable rates. One terrible result of this trend is that a portion of students no longer wish to practice obstetrics-gynecology because of the cost of malpractice insurance. It is unimagin-able that the choice of one’s profession is dictated by insurance malpractice rates, rather than sincere desire! On another front are the problems of insurance reimbursement and Medicare and Medicaid cost cutting. This is our bread and butter, folks; this is how we survive. Reimbursement is guided by Medicare, which is, in turn, set by the government. When the government, in its infinite wis-dom, cuts Medicare reimbursement, pri-vate insurance cuts reimbursement as well. Not only do reimbursement cuts affect pay but affect how a hospital staffs each depart-ment. If General Medical Center receives a cut in Medicare reimbursement, it can no longer fully staff the emergency depart-ment with an adequate number of aides to transport patients to other floors or to the x-ray department in a timely manner. The poor distribution of patients to their next step in care creates a glut in an already-overcrowded department. This is just one example of the effect of reimbursement cuts that occurs every day! A more dangerous example of the effects of reimbursement cuts is the virtual unchecked growth of mid-level practition-ers, so-called “physician extenders.” While Mr. Hutson and others are busy arguing that “OMT [osteopathic manipulative treat-ment] is an art” and “rational treatment is based on an understanding of the basic principles of body unity...,” nurse practi-tioners (NPs) are practicing medicine in primary care offices! To add insult to injury, many nurse practitioners work in the offices of osteopathic physicians. The harm appar-ent in this scenario is that a patient deemed by an NP to have otitis media will not understand the benefit that is possible from receiving lymphatic treatment. Lost also is the possibility of a patient presenting with congestion and cough who is triaged to an NP, who does not see the benefit of thera-py that includes rib-raising. These are the diagnoses that have made osteopathic medicine unique, yet reimbursement drives the diagnosis and treatment of these types of problems. It takes more physician visits to maintain the same income, resulting in health maintenance organizations pushing for the cheaper alternative of physician-extenders. This is what strips osteopathic physicians of their unique identity. So how can we fight back? How can the battle be won? Unity is the answer—the unity of a combined representative body speaking to legislatures demonstrating the strength that can be found when two groups with common issues put aside their differences and acknowledge what really matters to the practice of medicine. Will it be difficult? Yes. Must it occur? Absolutely. Putting together a winning plan is not easy, so it is imperative that we begin by solidifying our common interests and goals. Sharing and teaching OMT to our allopathic peers is only the start. Combining the Unit-ed States Medical Licensing Examination and the Comprehensive Osteopathic Med-ical Licensing Examination is certainly pos-sible. Moreover, the addition of an OMT section to the current USMLE format would further demonstrate that osteopathic physi-cians have treatment options in addition to allopathic medicine, rather than care that is viewed as different. It is my view, and certainly the view of others, that for all branches of medicine to survive in today’s threatening environment, we must unify our voices so they can be heard louder than they have ever been heard before. ETHAN E. WAGNER, MSIV University of Health Services College of Medicine Kansas City, Missouri Herbal medications should undergo rigorous evaluation To the Editor: In his case report, “Digoxin toxicity in a 26- year-old woman taking a herbal dietary supplement” (JAOA 2001;101:444-446), Michael E. Scheinost, DO, points out some of the often-overlooked risks associated with herbal supplements and should be commended for addressing this important public health issue. The following are relat-ed issues that we believe warrant further attention. One of the dangers associated with herbal products is their classification as dietary supplements. Since the Dietary Sup-plement Health and Education Act of 1994 was passed, herbal products (medications) have been exempt from the regulatory over-sight and the safety and efficacy regula-tions established for other biologically active products used in healthcare, namely pre-scription and over-the-counter medica-tions. 1,2 As a result, the public, and to a less-er degree, clinicians view herbal med-ications as relatively harmless and may not be aware of their biologic activity. This may explain why patients frequently attribute their physicians’ concerns to anti-herbal sentiments. Herbal medications, similar to some foods and traditional medications, can trigger interactions and allergic reac-tions and should be taken with caution by certain populations. Unknown cardiac gly-coside activity in herbal medications is only JAOA • Vol 102 • No 4 • April 2002 • 205 LETTERS Letters one example of the potential risks and bio-logic activity of these products. The public may not be aware that some herbal companies do not use good manu-facturing practices. As a result, contaminants and unsafe adulterants such as mercury and arsenic may be in some of these products. Although many physicians are inade-quately educated about herbal products and nutritional supplements, it still remains wor-risome that patients follow the “medical” advice of a health store clerk over that of a clinician. Our poison control center held an herbal information day and invited the pub-lic to ask related questions. A random survey of a portion of the callers indicated that fewer than 20% volunteered their use of herbal medications to their clinicians, and fewer than 33% were asked by their clinicians about taking such products. As professionals, we need to become educated about nutriceuticals and under-stand why patients turn to herbal medica-tions and to alternative medicine, then pro-vide a nonjudgmental atmosphere for patients so they feel comfortable discussing their healthcare choices. As there are still rel-atively few well-designed, randomized, con-trolled clinical trials establishing the safety, clinical benefit, or effectiveness of many herbal products, we need to promote rigor-ous evaluation of such products, as well as communicate the message to patients that herbal supplements are not inert, but rather biologically active chemicals that should be considered medications. As osteopathic physicians and students, we may be tempted to automatically accept the use of herbal medicines, as our profession is often considered a complementary modal-ity. This is, however, exactly what we should avoid. It was, in fact, concern about the safe-ty and effectiveness of medications and med-ical practices that served as a major impetus for Andrew Taylor Still, MD, DO, to devel-op osteopathic medicine. ANDREW FARBER, MSII New York College of Osteopathic Medicine Old Westbury, New York ROBIN B. MCFEE, DO Clinical Assistant Professor of Medicine New York College of Osteopathic Medicine Consultant to the LI Regional Poison Control Center Winthrop University Hospital Mineola, New York References 1. Ang-Lee MK, Moss J, Yuan CS. Herbal medicines and perioperative care. JAMA. 2001;286:208-216. 2. Dietary Supplement Health and Education Act, Public Law No. 103-417 (1994). Available at http://www.fda.gov/opacom/laws/dshea.html. To kill, or not to kill... To the Editor: When a physician considers the issue of physician-assisted suicide (PAS), the under-lying question if whether to end another’s life. To many lay people, the question may not seem so difficult to answer. Is the patient’s prognosis “terminal”? Is this per-son’s quality of life unbearable? Is the patient so depressed that he or she has lost the will to live? These questions might seem straightforward, cut-and-dried, or black-and- white, but this could not be farther from the truth. Physicians, patients, and their loved ones know the agony in at-tempting to cope with PAS. Therefore, physicians need to take a stand and be heard as experts on the issue. Medicine is an art, not an exact science—yet lawmakers set exact criteria that enable patients to kill themselves. This demonstrates the degree to which we have allowed our society to dete-riorate. Physician-assisted suicide is an emo-tionally charged, subjective issue that can-not be converted into an objective, exact referendum to be decided at the voting booth. How did we get to this point? What happened to place us in such a difficult sit-uation? The issue of PAS first appeared on the Washington ballot in 1991 and was defeated. California voters considered the issue in 1992, and it was again defeated. In 1994, Oregon’s Death with Dignity Act passed despite the fact that the Oregon Medical Association and the Oregon Osteo-pathic Association were strongly opposed to PAS. The American Medical Associa-tion, the American Osteopathic Associa-tion, and the American Nursing Association continue to maintain strong opposition to PAS. Is anybody listening out there? Osteo-pathic physicians have taken an oath to “first do no harm” and to “give no drugs for deadly purposes.” But these patients are voluntary, terminal patients, right? In 1996, Lee et al1 found that 50% of physicians could not predict confidently that a patient’s condition was terminal. Further, surveyed physicians were unable to definitively rec-ognize depression 33% of the time. So much for the objective criteria to qualify for PAS. The voting public is unaware of that side of the story. To date, only one state—Oregon— has legalized PAS. Michigan and California have had the issue on the ballot, only to be defeated. A poll of California citizens showed that most were in favor of volun-tary PAS for terminally-ill patients. Cali-fornia is expected to again ask its voters to decide this issue, styling the proposed law after the Oregon statute. California’s law would allow the physician to provide, but not administer, the lethal drugs to the ter-minal patient—a hair-splitting point but critical for passage of the proposal. This is, after all, the technicality that got renegade pathologist, [Jack] Kevorkian, convicted of murder in Michigan after he successfully assisted in the killing of nearly 130 human beings. In 1992, D.C. Clark of the Center for Sui-cide Research and Prevention2 stated that patients with terminal illness and intractable pain are usually grateful that no one facil-itated their suicide while they were tem-porarily depressed or having difficulties with pain. Clark also stated that 95% of sui-cide patients suffered from depression, yet only 2% to 4% of suicides were in termi-nally- ill patients. We must concentrate on effectively treat-ing pain and depression in terminally-ill patients. Hospice can provide this service. The suicide rate among hospice patients is generally less than one tenth of 1%. That is because hospice manages pain and pro-vides emotional and spiritual support for the patient and family. Rather than help-ing to facilitate the suicides of terminally-ill patients who are desperate and afraid, we should support the peaceful completion of their journey. JOHN G. HORTON, DO Director of Medical Education Selby General Hospital Marietta, Ohio 206 • JAOA • Vol 102 • No 4 • April 2002 LETTERS Letters References 1. Lee MA, Nelson HD, Tilden VP, Ganzini L, Schmidt TA, et al. Legalizing assisted suicide–views of physicians in Oregon. N Engl J Med. 1996; 334: 310-315. 2. Clark DC. “Rational” suicide and people with terminal conditions or disabilities. Issues Law Med. 1192;8:147-66. Defining the three-column spine To the Editor: The article by Maurizio A. Miglietta, DO, et al, “Evaluation of spine injury in blunt trau-ma” (JAOA 2002;102:87-91) is an excellent discussion of the difficulties physicians face trying to “clear” the spine. In the “Indica-tions for subspecialty consultation” section of the article, however, the authors define the three-column theory as consisting of (1) the anterior half of the vertebral body and anterior longitudinal ligament; (2) the pos-terior half of the vertebral body, posterior longitudinal ligament and facets; and (3) the spinous processes, lamina arcus verte-brae, and interspinous ligaments. The three-column spine theory1 proposed by Francis Denis, MD, which expanded on the Holdsworth two-column theory,2 actually defines the column differently. The correct three-column spine consists of (1) the ante-rior two thirds of the vertebral body, the anterior longitudinal ligament, and the ante-rior annulus fibrosis; (2) posterior third of the vertebral body, posterior longitudinal ligament, and the posterior annulus; and (3) posterior bony complex and ligamen-tous structures. The facet joints are includ-ed in the posterior column of both the two-and three-column theories. ANDREW D. MULLINS, DO Bay St.Louis, Mississippi References 1. Denis F. The three column spine and its signif-icance in the classification of acute thoracolumbar spinal injuries. Spine. 1983;8:817-831. 2. Holdsworth F. Fractures, dislocations, and frac-ture- dislocations of the spine. J Bone Joint Surg Am. 1970;52:1534-1551. Response To the Editor: The comments offered by Andrew D. Mullins, DO, indicate that he thoroughly reviewed our article regarding spine clear-ance in trauma. As Mullin states, Francis Denis, MD, first introduced the three-col-umn theory, which is an expansion of Sir Frank Holdsworth’s initial work.1,2 Denis’ analysis of 412 thoracolumbar injuries in 1983 systematically classified the major types of spinal injuries radiographically and biomechanically. The Denis theory remains the accepted classification. To address Mullin’s point regarding the distinction of halves versus thirds of the vertebral body in delineating columns, I have reviewed several sources. Denis2 describes the three columns as follows: (1) anterior column consists of “anterior lon-gitudinal ligament, anterior annulus fibro-sus, and the anterior part of the vertebral body”; (2) middle column consists of the “posterior longitudinal ligament, posteri-or annulus fibrosus, and the posterior wall of the vertebral body”; and (3) posterior column consists of “posterior bony com-plex (posterior arch) alternating with pos-terior ligaments complex (supraspinous, interspinous, capsule, and ligamentum flavum).” The illustration included with Denis’ article, however, seems to agree with the halves versus thirds breakdown of the vertebral body. The two interpretations of the three-column theory appear in other texts as well. 3,4 I believe the millimeters of difference in anatomic distinction of the three-column theory is less important than the overall concept of three columns and spine insta-bility. However, I appreciate Mullin’s atten-tion to this discrepancy in the literature. MAURIZIO A. MIGLIETTA, DO R Adams Cowley Shock Trauma Center Baltimore, Maryland References 1. Denis F. Spinal instability as defined by the three-column spine concept in acute spinal trau-ma. Clin Orthop. 1984;189:65-76. 2. Denis F. The three-column spine and its signif-icance in the classification of acute thoracolumbar spinal injuries. Spine. 1983;8:817-831. 3. Harris JH Jr, Harris WH, Navelline RA. The Radi-ology of Emergency Medicine, 3rd ed. Baltimore, Md: Williams & Wilkins; 1993;141-142. 4. Vollmer DG, Gegg C. Classification and acute management of thoracolumbar fractures. Neu-rosurg Clin N Am. 1997;8:499-507.
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Transcript | Letters JAOA • Vol 102 • No 4 • April 2002 • 203 LETTERS Follow-up on “Symptoms associated with anthrax exposure: Suspected ‘aborted’ anthrax” To the Editor: Case reports are the front line of evidence in the evolution of medical practice. Despite the obvious weakness of case reports (ie, they deal with a small number of patients, even as low as a single person), they have great value as the starting point of discov-ery. 1 Although we cannot predict whether the ideas presented in our January 2002 case report (JAOA 2002;102:41-43) will be sustained after further study—or after addi-tional evidence is revealed—the clinical observations included in that case report continue to be of interest. The patient we presented, a 37-year-old man with a high level of exposure to the spores of Bacillus anthracis, has improved since publication of the report. On presen-tation, he had a low PO2 level, pleural effu-sions, and abnormal lesions on imaging of the chest. Blood culture results and anti-body tests for exposure to anthrax were negative. After 3 months of triple antibiot-ic treatment, the patient’s PO2 level is now 108; his fevers have subsided, but his strength has not returned. The patient was noted to be anergic to measles and Candida albicans, and the results of histo titers whole complement test have also come back neg-ative. We have received many questions about our decision to relate the patient’s illness to anthrax exposure. Our intention was to present a single case for primary care clin-icians that would begin to explore the expe-riences of clinicians who have patients with similar findings. None of the clinicians at our facility has seen a case of anthrax dis-ease. This patient was cultured for anthrax and tested for antispore antibody and anti-toxin antibody by the Centers for Disease Control and Prevention, and all results were negative. Therefore, the patient presented in the case report does not have anthrax dis-ease. But there should be an explanation as to why a healthy 37-year-old male with no medical problems suddenly has fevers, shortness of breath with a PO2 of 67, pleural effusions, and abnormal lymph nodes. The fact is, thus far, we have failed to produce an explanation for the distress occurring in this patient. The temporal relationship between his exposure to B anthracis and his symp-toms— and the fact that the symptoms were relieved with antibiotic treatment—make an infectious etiology high on our list of possible causes. If anthrax exposure does prove to be the cause of this patient’s distress, our patient would not be the first to have symptoms from an anthrax exposure without being culture- or antibody-positive. A fact sheet on three laboratory occupational deaths includ-ed in a government report, “Report of Demilitarization of Fort Detrick,”2 includes the 1951 case of William Allen Boyles, whose death was classified as caused by anthrax, despite the fact that “the microorganism could not be (and never was) cultivated from blood, sputum, nose and throat, or skin taken at any time during the illness, nor from tissue and fluids taken at autopsy.” The diagnosis was made postmortem be-cause of a small number of gram-positive bacilli resembling B anthracis found only in the pacconian granulations of the brain. Arthur M. Friedlander et al3 reported the findings of a study of 60 rhesus monkeys exposed to B anthracis to test the effectiveness of antibiotics. In that study, one animal given ciprofloxacin died 5 days after exposure, presumably from an aspiration pneumonia diagnosed because of negative blood cul-tures for anthrax. Another monkey died 73 days after antibiotics were stopped; this time the death was attributed to urethral obstruc-tion— again because blood samples were culture-negative for anthrax. A third mon-key died 5 days after antibiotics were dis-continued. Similarly, no cause could be found for that animal’s death.3 The anthrax bacterium causes damage through extensive replication in the blood. Its ability to expand so successfully is helped by proteins it secretes that “intoxicate” the cells it is invading. The proteins are benign until they bind to the surface of the cell where an enzyme trims off its outermost tip. Protective antigen, edema factor, and lethal factor are the proteins involved in cel-lular damage, allowing the spores to enter the cytosol of the cells.4 Without knowing what caused our pa-tient’s illness, we have to take care of him. Granted, the temporal relationship to the exposure does not automatically mean there is a causal relationship. The patient’s con-dition has improved while on triple intra-venous antibiotic therapy and became worse when intravenous antibiotics were discon-tinued. This report gives clinicians an indication as to treatment options. Limited experience with anthrax disease makes all clinical infor-mation, including our patient’s presenta-tion, important to share. TYLER C. CYMET, DO Section Head Department of Family Medicine Sinai Hospital Baltimore, Maryland Assistant Professor Internal Medicine The Johns Hopkins University School of Medicine Baltimore, Maryland GARY J. KERKVLIET, MD Director Residence Practice Office Program of Internal Medicine Sinai Hospital Baltimore, Maryland Assistant Professor Associate Program Director Internal Medicine The Johns Hopkins University School of Medicine Baltimore, Maryland References 1. Vandenbroucke JP. In defense of case reports and case series. Ann Intern Med. 2001;134:330- 334. 2. Report on the Demilitarization of Fort Detrick (MD), including case report of the death of William Boyles. Document of US Government 1977. 3. Friedlander AM, Welkos SL, Pitt ML, Ezzell JW, Worsham PL, Rose KJ, et al. Postexposure pro-phylaxis against experimental inhalation anthrax. J Infect Dis. 1993;167:1239-1243. 4. Young AT, Collier RJ. Attacking anthrax. Sci Am. 2002;286:48-50, 54-59. 204 • JAOA • Vol 102 • No 4 • April 2002 LETTERS Letters Unity between osteopathic and allopathic medicine only answer to preserving osteopathic uniqueness To the Editor: This letter is an addition to the ongoing dialog regarding the uniqueness of osteo-pathic medicine and addresses, in particu-lar, the comments of Brent Hutson, MSII, “DOs must preserve their uniqueness” (The DO 2001;42:15-16). I will discuss the effects of disturbing trends in the current health-care environment that certainly challenge the DO “uniqueness.” Mr. Hutson, while passionate and well-meaning, emphasizes the differences be-tween allopathic and osteopathic medicine, rather than finding their commonalities. He implies that it is impossible to unite the two professions under a single representa-tive body or to test the two professions with a unified testing structure. His arguments on both accounts are neither convincing nor unique. Let us first examine the elements that create the need for unity. Medicine today is under assault on many fronts. Frivolous lawsuits led by lawyers wishing to cash in on the current litigious trend in American culture are driving the cost of malpractice insurance upward, making it nearly impos-sible for small groups of physicians to afford group insurance at reasonable rates. One terrible result of this trend is that a portion of students no longer wish to practice obstetrics-gynecology because of the cost of malpractice insurance. It is unimagin-able that the choice of one’s profession is dictated by insurance malpractice rates, rather than sincere desire! On another front are the problems of insurance reimbursement and Medicare and Medicaid cost cutting. This is our bread and butter, folks; this is how we survive. Reimbursement is guided by Medicare, which is, in turn, set by the government. When the government, in its infinite wis-dom, cuts Medicare reimbursement, pri-vate insurance cuts reimbursement as well. Not only do reimbursement cuts affect pay but affect how a hospital staffs each depart-ment. If General Medical Center receives a cut in Medicare reimbursement, it can no longer fully staff the emergency depart-ment with an adequate number of aides to transport patients to other floors or to the x-ray department in a timely manner. The poor distribution of patients to their next step in care creates a glut in an already-overcrowded department. This is just one example of the effect of reimbursement cuts that occurs every day! A more dangerous example of the effects of reimbursement cuts is the virtual unchecked growth of mid-level practition-ers, so-called “physician extenders.” While Mr. Hutson and others are busy arguing that “OMT [osteopathic manipulative treat-ment] is an art” and “rational treatment is based on an understanding of the basic principles of body unity...,” nurse practi-tioners (NPs) are practicing medicine in primary care offices! To add insult to injury, many nurse practitioners work in the offices of osteopathic physicians. The harm appar-ent in this scenario is that a patient deemed by an NP to have otitis media will not understand the benefit that is possible from receiving lymphatic treatment. Lost also is the possibility of a patient presenting with congestion and cough who is triaged to an NP, who does not see the benefit of thera-py that includes rib-raising. These are the diagnoses that have made osteopathic medicine unique, yet reimbursement drives the diagnosis and treatment of these types of problems. It takes more physician visits to maintain the same income, resulting in health maintenance organizations pushing for the cheaper alternative of physician-extenders. This is what strips osteopathic physicians of their unique identity. So how can we fight back? How can the battle be won? Unity is the answer—the unity of a combined representative body speaking to legislatures demonstrating the strength that can be found when two groups with common issues put aside their differences and acknowledge what really matters to the practice of medicine. Will it be difficult? Yes. Must it occur? Absolutely. Putting together a winning plan is not easy, so it is imperative that we begin by solidifying our common interests and goals. Sharing and teaching OMT to our allopathic peers is only the start. Combining the Unit-ed States Medical Licensing Examination and the Comprehensive Osteopathic Med-ical Licensing Examination is certainly pos-sible. Moreover, the addition of an OMT section to the current USMLE format would further demonstrate that osteopathic physi-cians have treatment options in addition to allopathic medicine, rather than care that is viewed as different. It is my view, and certainly the view of others, that for all branches of medicine to survive in today’s threatening environment, we must unify our voices so they can be heard louder than they have ever been heard before. ETHAN E. WAGNER, MSIV University of Health Services College of Medicine Kansas City, Missouri Herbal medications should undergo rigorous evaluation To the Editor: In his case report, “Digoxin toxicity in a 26- year-old woman taking a herbal dietary supplement” (JAOA 2001;101:444-446), Michael E. Scheinost, DO, points out some of the often-overlooked risks associated with herbal supplements and should be commended for addressing this important public health issue. The following are relat-ed issues that we believe warrant further attention. One of the dangers associated with herbal products is their classification as dietary supplements. Since the Dietary Sup-plement Health and Education Act of 1994 was passed, herbal products (medications) have been exempt from the regulatory over-sight and the safety and efficacy regula-tions established for other biologically active products used in healthcare, namely pre-scription and over-the-counter medica-tions. 1,2 As a result, the public, and to a less-er degree, clinicians view herbal med-ications as relatively harmless and may not be aware of their biologic activity. This may explain why patients frequently attribute their physicians’ concerns to anti-herbal sentiments. Herbal medications, similar to some foods and traditional medications, can trigger interactions and allergic reac-tions and should be taken with caution by certain populations. Unknown cardiac gly-coside activity in herbal medications is only JAOA • Vol 102 • No 4 • April 2002 • 205 LETTERS Letters one example of the potential risks and bio-logic activity of these products. The public may not be aware that some herbal companies do not use good manu-facturing practices. As a result, contaminants and unsafe adulterants such as mercury and arsenic may be in some of these products. Although many physicians are inade-quately educated about herbal products and nutritional supplements, it still remains wor-risome that patients follow the “medical” advice of a health store clerk over that of a clinician. Our poison control center held an herbal information day and invited the pub-lic to ask related questions. A random survey of a portion of the callers indicated that fewer than 20% volunteered their use of herbal medications to their clinicians, and fewer than 33% were asked by their clinicians about taking such products. As professionals, we need to become educated about nutriceuticals and under-stand why patients turn to herbal medica-tions and to alternative medicine, then pro-vide a nonjudgmental atmosphere for patients so they feel comfortable discussing their healthcare choices. As there are still rel-atively few well-designed, randomized, con-trolled clinical trials establishing the safety, clinical benefit, or effectiveness of many herbal products, we need to promote rigor-ous evaluation of such products, as well as communicate the message to patients that herbal supplements are not inert, but rather biologically active chemicals that should be considered medications. As osteopathic physicians and students, we may be tempted to automatically accept the use of herbal medicines, as our profession is often considered a complementary modal-ity. This is, however, exactly what we should avoid. It was, in fact, concern about the safe-ty and effectiveness of medications and med-ical practices that served as a major impetus for Andrew Taylor Still, MD, DO, to devel-op osteopathic medicine. ANDREW FARBER, MSII New York College of Osteopathic Medicine Old Westbury, New York ROBIN B. MCFEE, DO Clinical Assistant Professor of Medicine New York College of Osteopathic Medicine Consultant to the LI Regional Poison Control Center Winthrop University Hospital Mineola, New York References 1. Ang-Lee MK, Moss J, Yuan CS. Herbal medicines and perioperative care. JAMA. 2001;286:208-216. 2. Dietary Supplement Health and Education Act, Public Law No. 103-417 (1994). Available at http://www.fda.gov/opacom/laws/dshea.html. To kill, or not to kill... To the Editor: When a physician considers the issue of physician-assisted suicide (PAS), the under-lying question if whether to end another’s life. To many lay people, the question may not seem so difficult to answer. Is the patient’s prognosis “terminal”? Is this per-son’s quality of life unbearable? Is the patient so depressed that he or she has lost the will to live? These questions might seem straightforward, cut-and-dried, or black-and- white, but this could not be farther from the truth. Physicians, patients, and their loved ones know the agony in at-tempting to cope with PAS. Therefore, physicians need to take a stand and be heard as experts on the issue. Medicine is an art, not an exact science—yet lawmakers set exact criteria that enable patients to kill themselves. This demonstrates the degree to which we have allowed our society to dete-riorate. Physician-assisted suicide is an emo-tionally charged, subjective issue that can-not be converted into an objective, exact referendum to be decided at the voting booth. How did we get to this point? What happened to place us in such a difficult sit-uation? The issue of PAS first appeared on the Washington ballot in 1991 and was defeated. California voters considered the issue in 1992, and it was again defeated. In 1994, Oregon’s Death with Dignity Act passed despite the fact that the Oregon Medical Association and the Oregon Osteo-pathic Association were strongly opposed to PAS. The American Medical Associa-tion, the American Osteopathic Associa-tion, and the American Nursing Association continue to maintain strong opposition to PAS. Is anybody listening out there? Osteo-pathic physicians have taken an oath to “first do no harm” and to “give no drugs for deadly purposes.” But these patients are voluntary, terminal patients, right? In 1996, Lee et al1 found that 50% of physicians could not predict confidently that a patient’s condition was terminal. Further, surveyed physicians were unable to definitively rec-ognize depression 33% of the time. So much for the objective criteria to qualify for PAS. The voting public is unaware of that side of the story. To date, only one state—Oregon— has legalized PAS. Michigan and California have had the issue on the ballot, only to be defeated. A poll of California citizens showed that most were in favor of volun-tary PAS for terminally-ill patients. Cali-fornia is expected to again ask its voters to decide this issue, styling the proposed law after the Oregon statute. California’s law would allow the physician to provide, but not administer, the lethal drugs to the ter-minal patient—a hair-splitting point but critical for passage of the proposal. This is, after all, the technicality that got renegade pathologist, [Jack] Kevorkian, convicted of murder in Michigan after he successfully assisted in the killing of nearly 130 human beings. In 1992, D.C. Clark of the Center for Sui-cide Research and Prevention2 stated that patients with terminal illness and intractable pain are usually grateful that no one facil-itated their suicide while they were tem-porarily depressed or having difficulties with pain. Clark also stated that 95% of sui-cide patients suffered from depression, yet only 2% to 4% of suicides were in termi-nally- ill patients. We must concentrate on effectively treat-ing pain and depression in terminally-ill patients. Hospice can provide this service. The suicide rate among hospice patients is generally less than one tenth of 1%. That is because hospice manages pain and pro-vides emotional and spiritual support for the patient and family. Rather than help-ing to facilitate the suicides of terminally-ill patients who are desperate and afraid, we should support the peaceful completion of their journey. JOHN G. HORTON, DO Director of Medical Education Selby General Hospital Marietta, Ohio 206 • JAOA • Vol 102 • No 4 • April 2002 LETTERS Letters References 1. Lee MA, Nelson HD, Tilden VP, Ganzini L, Schmidt TA, et al. Legalizing assisted suicide–views of physicians in Oregon. N Engl J Med. 1996; 334: 310-315. 2. Clark DC. “Rational” suicide and people with terminal conditions or disabilities. Issues Law Med. 1192;8:147-66. Defining the three-column spine To the Editor: The article by Maurizio A. Miglietta, DO, et al, “Evaluation of spine injury in blunt trau-ma” (JAOA 2002;102:87-91) is an excellent discussion of the difficulties physicians face trying to “clear” the spine. In the “Indica-tions for subspecialty consultation” section of the article, however, the authors define the three-column theory as consisting of (1) the anterior half of the vertebral body and anterior longitudinal ligament; (2) the pos-terior half of the vertebral body, posterior longitudinal ligament and facets; and (3) the spinous processes, lamina arcus verte-brae, and interspinous ligaments. The three-column spine theory1 proposed by Francis Denis, MD, which expanded on the Holdsworth two-column theory,2 actually defines the column differently. The correct three-column spine consists of (1) the ante-rior two thirds of the vertebral body, the anterior longitudinal ligament, and the ante-rior annulus fibrosis; (2) posterior third of the vertebral body, posterior longitudinal ligament, and the posterior annulus; and (3) posterior bony complex and ligamen-tous structures. The facet joints are includ-ed in the posterior column of both the two-and three-column theories. ANDREW D. MULLINS, DO Bay St.Louis, Mississippi References 1. Denis F. The three column spine and its signif-icance in the classification of acute thoracolumbar spinal injuries. Spine. 1983;8:817-831. 2. Holdsworth F. Fractures, dislocations, and frac-ture- dislocations of the spine. J Bone Joint Surg Am. 1970;52:1534-1551. Response To the Editor: The comments offered by Andrew D. Mullins, DO, indicate that he thoroughly reviewed our article regarding spine clear-ance in trauma. As Mullin states, Francis Denis, MD, first introduced the three-col-umn theory, which is an expansion of Sir Frank Holdsworth’s initial work.1,2 Denis’ analysis of 412 thoracolumbar injuries in 1983 systematically classified the major types of spinal injuries radiographically and biomechanically. The Denis theory remains the accepted classification. To address Mullin’s point regarding the distinction of halves versus thirds of the vertebral body in delineating columns, I have reviewed several sources. Denis2 describes the three columns as follows: (1) anterior column consists of “anterior lon-gitudinal ligament, anterior annulus fibro-sus, and the anterior part of the vertebral body”; (2) middle column consists of the “posterior longitudinal ligament, posteri-or annulus fibrosus, and the posterior wall of the vertebral body”; and (3) posterior column consists of “posterior bony com-plex (posterior arch) alternating with pos-terior ligaments complex (supraspinous, interspinous, capsule, and ligamentum flavum).” The illustration included with Denis’ article, however, seems to agree with the halves versus thirds breakdown of the vertebral body. The two interpretations of the three-column theory appear in other texts as well. 3,4 I believe the millimeters of difference in anatomic distinction of the three-column theory is less important than the overall concept of three columns and spine insta-bility. However, I appreciate Mullin’s atten-tion to this discrepancy in the literature. MAURIZIO A. MIGLIETTA, DO R Adams Cowley Shock Trauma Center Baltimore, Maryland References 1. Denis F. Spinal instability as defined by the three-column spine concept in acute spinal trau-ma. Clin Orthop. 1984;189:65-76. 2. Denis F. The three-column spine and its signif-icance in the classification of acute thoracolumbar spinal injuries. Spine. 1983;8:817-831. 3. Harris JH Jr, Harris WH, Navelline RA. The Radi-ology of Emergency Medicine, 3rd ed. Baltimore, Md: Williams & Wilkins; 1993;141-142. 4. Vollmer DG, Gegg C. Classification and acute management of thoracolumbar fractures. Neu-rosurg Clin N Am. 1997;8:499-507. |
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