Grand Rounds Presentation Research Articles

Ocular Manifestations of Wegener's Granulomatosis-Reply

In Reply. —Dr Flach raises some important points about ocular manifestations of Wegener's granulomatosis. In my original Grand Rounds presentation at the National Institutes of Health Clinical Center, the various ocular manifestations of Wegener's granulomatosis were discussed. However, because of space limitations, a significant amount of information on the pathophysiology, clinical manifestations, diagnosis, and management of Wegener's granulomatosis could not be included in this published article. For a more complete discussion of Wegener's granulomatosis, including the ocular manifestations, I would refer interested readers to the articles cited in the letter by Flach and to other articles by our group. 1-3

Sydenham's Chorea-Reply

In Reply. —Because of the potential for controversy about the utility of Sydenham's as an etiologic model for childhood-onset obsessive-compulsive disorder and Gilles de la Tourette's syndrome, I was surprised and pleased that the concerns raised did not address this issue, but rather the details of the case report. I appreciate the careful consideration given to the article by Dr Jeret and Dr Jaffe, and I also appreciate the opportunity to clarify the Grand Rounds presentation. As pointed out by Jeret, the EEG findings in the case report were condensed in confusing fashion. The pertinent portion of the original EEG report reads as follows: mildly abnormal and consistent with Sydenham's chorea because of the presence (during wakefulness) of a background consisting of an irregular rhythm bilaterally which has maximum frequency of 9 Hz; intermixed, there are many slow waves of 4-5 Hz frequency and 20-40 microvolts in

Anaesthetic Pharmacology Review

This new-niche journal has three broad purposes: to present recent research and new ideas concerning drugs employed in anesthesiology; to fulfill a continuing education function, particularly for those studying for examinations; and to focus each issue on one subject. The intended audiences are anesthesiologists and researchers in anesthetic pharmacology. Anaesthetic Pharmacology Review for the most part achieves these goals. Reviews offer concise, well-organized summaries of the more recent, generally accepted theories in each research area covered. The majority are authored by well-known experts in the field. The reviews are best suited as first-line sources for preparing a lecture, conference, or grand rounds presentation, or for pursuing further research on topics with a fairly narrow focus. While the subjects covered will be of interest to most practitioners in anesthetic pharmacology, the anesthesiologist in an academic medical center will find this new journal to be especially useful. Clinicians or physicians studying for

Health promotion counseling in residency training.

This report describes health promotion counseling attitudes and practices in a family medicine residency that attempted to encourage such counseling. A patient "Health Habits Questionnaire" and matching patient education booklets were developed and distributed. Six grand rounds presentations on counseling were given. On three occasions, residency physicians completed questionnaires about counseling. Despite good personal health habits and positive attitudes toward counseling, the residency physicians had only moderate confidence in their counseling ability and infrequently documented counseling. The residents reported significant improvement in their ability to counsel patients about smoking cessation. Overall, the curriculum appeared to have a limited effect on health promotion.

Correlates of Psychiatry Grand Rounds Attendance

Although grand rounds is an important educational conference in most medical schools and psychiatry departments, there have been few studies of which variables influence faculty and trainee attendance. The authors hypothesized that psychiatry grand rounds attendance would be affected by content area, the speaker's discipline and geographic origin, and the label of "research" in the presentation title. In 3 years of grand rounds presentations at the Baylor College of Medicine Department of Psychiatry and Behavioral Sciences, fewer residents attended grand rounds when "research" was in the label and attendance was greater when the rounds were cosponsored by another agency, presented in honor of someone, or given by an out-of-town speaker.

Pertussis and Pertussis Vaccines in Adults

Seventy-one years ago John Phillips observed that in adults is often unrecognized, and this is accountable... for the spread of the disease.... The prevalent idea among the laity, and sometimes among physicians and nurses, that adults seldom contract whooping cough is responsible for lack of quarantine. 1 Despite numerous reports to the contrary, 2-18 physicians still embrace the myth that pertussis is a disease affecting only children. To illustrate this point, in a grand rounds presentation on pertussis I asked physicians who had seen adult patients with persistent cough to raise their hands. Not surprisingly, almost everyone had seen such a patient. When asked whether they had included pertussis in the differential diagnosis, only one physician among 200 raised his hand. The worldwide impact of pertussis remains enormous with approximately 60 million cases of pertussis and 600 000 pertussis-related deaths each year. 19 In the United States, 27826 cases

C1 esterase inhibitor in pregnancy

This patient had multiple diagnoses, including lymphadenopathic mastocytosis with involvement of the spleen, liver, abdominal lymph nodes, skeleton, bone marrow, skin, and gastrointestinal tract. He was also diagnosed with acute nonlymphocytic leukemia predated by the discovery of a biclonal gammopathy. 3 Oligoclonal immunoglobulins have been observed in systemic mastocytosis, but this is the first patient with systemic mastocytosis to our knowledge with a biclonal gammopathy. 20l igoclonal imrnunoglobulins were found to be associated with those patients who had a secondary malignancy as well as a more malignant form of mastocytosis. 2 Biclonal gammopathy most commonly occurs as an IgG/IgA combination, and a significant portion (16%) of these patients are diagnosed with lymphoproliferative disorders such as lymphoma and lymphocytic leukemia, s As a group, patients with systemic mastocytosis have an abnormally increased incidence of hematologic disorders and malignancies including dysmyelopoietic syndromes, myeloproliferative disorders, acute leukemia, and malignant lymphoma. Patients with systemic mastocytosis and coincident hematologic disorders have a significantly decreased survival time compared with the patients with systemic mastocytosis alone. 6 We have presented this brief communication to provide a follow up of our Allergy Grand Rounds presentation on a patient with lymphadenopathic mastocytosis and biclonal gammopathy. 3 Mastocytosis has been suggested to be due to an innate oncogenic aberration in a hematopoietic stem cell resulting in abnormal mast cell proliferation. 2 The development of leukemia could correspond to an increased proliferation of cellular forms that possess this aberration. 2 Perhaps, T-cell derived mast cell interleukin growth factors (IL-3, IL-4, IL-9, IL-10) are partly involved in regulating the expression of neoplasia in a subset of patients with systemic mastocytosis. 3 Finally, this case integrates biclonal gammopathy with systemic mastocytosis and the likelihood of developing malignancy.

Strengthening Your Case Study Approach

A well-written case study has an important place in nursing literature because it describes new problems and techniques in clinical practice and helps identify researchable clinical questions. Do not be deceived into thinking that the case study manuscript is easy to write, because it is not. But, with the application of a few guidelines, the case study can be fun to write, exciting to edit, and enjoyable to read.

Effective Approaches to Treatment Resistant Depression

This month's column features excerpts of a Grand Rounds presentation from the Institute of Living in Hartford, Connecticut given by Harry E. Morgan, MD. Dr. Morgan is Director of the Department of Geriatric Psychiatry at the Institute, a department which actively treats depressive illnesses often of a treatment-resistant type. Dr. Morgan has actively developed geriatric psychiatry clinical and training programs including the Institute's Geriatric Psychiatry Fellowship. Dr. Morgan has special interest in the interface of biologic and interpersonal therapies.

Developing a Holding Environment During the Treatment of the Borderline Patient

This month's column features a Grand Rounds presentation from Sheppard Pratt Hospital in Baltimore, Maryland, coordinated by Miles Quaytman, MD. Dr. Quaytman, Senior Clinician of the Sheppard Pratt Personality Disorders Program, assembled a multidisciplinary panel of staff members to demonstrate and discuss the stages of development of the holding environment during the treatment of a borderline patient. Dr. Quaytman completed his residency training at Sheppard Pratt and joined the staff there in 1978. His special interest is in understanding and treating psychotic and borderline patients and he is presently participating in several current research projects involving borderline patients.

Diagnosis of Cholelithiasis

To the Editor.— I have read with interest the article by Venu et al and the accompanying editorial on ERCP by Drs Craig and Clayman (1983; 249:783). I was surprised that in neither of the articles mention is made of the role of cholescintigraphy using technetium Tc 99m-labeledN-substituted derivatives of iminodiacetic acid (IDA). Since these agents were introduced for clinical use in the mid-1970s, numerous publications in reputable journals of general medicine, gastroenterology, nuclear medicine, and radiology concur that cholescintigraphy is currently the most sensitive and specific noninvasive test in the diagnosis of acute cholecystitis.1-3In addition, cholescintigraphy can be useful in the evaluation of chronic cholecystitis and other biliary disorders.4,5 I recently reviewed the literature on hepatobiliary scintigraphy for a medical grand rounds presentation in our hospital; because of the availability, safety, simplicity, plus sensitivity and specificity of almost 100% in all the series,1-3

Blood Glucose Control

the Editor —The recent GRAND ROUNDS presentation entitled Prevention and Treatment of Diabetic Complications in the MayArchives(1980;140:691-696) is not current with (1) the literature relating to the feasibility of maintaining a euglycemic state, and (2) the reversal correlation of early diabetic retinopathy and the normalization of hemoglobin A lc level. Statements from this article are quoted below, accompanied by recent comments and references. To date, studies using Hb A lc as a measure of diabetic control have failed to show a correlation between the presence or absence of retinopathy or nephropathy and the level of Hb A lc . Retinopathy is now believed to be a continuum that begins with early microvascular leakage of proteins and progresses through the classic stages of exudative and hemorrhagic lesions, proliferation, etc. The modern technique of quantitative vitreous fluorophotometry is capable of measuring excessive capillary leakage in the early stages and