Evaluating faculty clinical excellence in the academic health sciences center.

Although excellence in the clinical care of patients is the cornerstone of medicine, academic health sciences centers have increasingly given more weight to research and correspondingly less emphasis to patient care. To better recognize and reward clinical excellence, it is first necessary to effectively evaluate physicians' performances in patient care. In addition to addressing the value of faculty clinical excellence in the academic setting, the authors discuss different approaches to clinical assessment, theoretical and practical problems in assessing the performances of clinical faculty, and a system of evaluation being initiated at the University of Virginia School of Medicine.

Anemia in pregnancy.

In evaluating pregnant women with anemia, it is essential to do a complete history and physical examination, as well as a complete blood count with indices and a blood smear examination. Based on these findings, other tests such as ferritin and serum or red cell folate may be ordered. Because of the normal physiologic changes in pregnancy that affect the hematocrit, indices, and some other parameters, diagnosing true anemia, as well as the etiology of anemia, is challenging.

Case report: sickle cell trait and recurrent deep venous thrombosis.

Thromboembolic events are unusual in patients with sickle cell trait, particularly in the absence of hypoxic stresses. A young black man with multiple episodes of lower extremity deep venous thrombosis, the first of which occurred when he was 18 years old, is reported. The only identifiable risk factor for recurrent venous thrombosis was the presence of sickle cell trait.

Fluoxetine and the bleeding time.

Fluoxetine (Prozac) is a nontricyclic serotonin (5-hydroxytryptamine) reuptake inhibitor commonly prescribed for the treatment of depression. Fluoxetine also blocks 5-hydroxytryptamine reuptake in platelets and could potentially lead to clinically significant platelet dysfunction. We describe a patient who developed petechiae and prolongation of the bleeding time while receiving fluoxetine therapy.

Synovitis in angioimmunoblastic lymphadenopathy with dysproteinemia simulating rheumatoid arthritis.

We describe a patient with angioimmunoblastic lymphadenopathy with dysproteinemia who developed a symmetric, rheumatoid-like, peripheral polyarthritis. Radiographs of the involved joints revealed soft tissue swelling without erosions or cartilage loss. Rheumatoid factor and fluorescent antinuclear antibodies were negative, and C-reactive protein and erythrocyte sedimentation rate were normal.

Trisomy 19 in a patient with myelodysplastic syndrome and thrombocytosis.

A patient with refractory anemia with excess blasts, ringed sideroblasts, and thrombocytosis was found on cytogenetic analysis to have trisomy 19 as the sole abnormality. Although trisomy 19 in combination with other chromosomal anomalies has been encountered in association with a variety of hematologic malignancies, many solid tumors, and the myelodysplastic syndrome, its occurrence as the only cytogenetic aberration is rare and has not been reported in association with thrombocythemia.

Hemochromatosis heterozygotes may have significant iron overload when they also have hereditary spherocytosis.

A family is described in which four of six siblings have both hereditary spherocytosis and evidence of abnormal iron metabolism. Three of the four have significant iron overload. HLA typing, which permits the detection of the gene for hemochromatosis, indicates that all family members with hereditary spherocytosis who have abnormal iron metabolism or significant iron overload are heterozygous for the hemochromatosis gene.

Hairy cell leukemia: a case of cryptococcosis appearing as hairy cell meningitis.

Hairy cell leukemia has rarely been shown to involve the central nervous system. We have reported a case of hairy cell leukemia with apparent hairy cell meningitis, later found to be cryptococcal meningitis. Spinal fluid abnormalities, including the hairy cell pleocytosis, resolved with treatment of the cryptococcal infection.

Liver damage in disorders of iron overload. A hypothesis.

The pathogenesis of liver damage in patients with iron loading disorders is not explained. Evidence concerning the following hypothesis is reviewed: Iron, absorbed from the intestinal tract when transferrin saturation is complete or almost so, remains unbound and is lost into the liver on first passage through the portal circulation. By still-to-be-determined molecular events, unbound iron is toxic to liver cells and produces progressive damage when this process occurs repeatedly.

Hemoglobin iron absorption kinetics in the iron-deficient dog.

In the absorption of Hb iron (HbFe), heme is separated from globin in the intestinal lumen and enters mucosal cells where Fe is split off and transported to blood. Previous studies indicated that this final step is the limiting one in absorption of HbFe in normal and Fe loaded animals but not in Fe-deficient animals. The present studies were designed to determine the limiting step in absorption of HbFe in Fe-deficient dogs.

Disseminated intravascular coagulation in pregnancy. The role of heparin therapy.

Treatment of the underlying cause and supportive care constitute the basic principles of management of disseminated intravascular coagulation. The role of anticoagulation with heparin is controversial in the absence of any controlled studies. This case report describes two patients with acute obstetric disseminated intravascular coagulation in whom the use of heparin resulted in marked clinical improvement.

Effect of iron therapy on serum ferritin levels in iron-deficiency anemia.

The level of serum ferritin is a reliable indicator of body iron stores. Exceptions include liver disease, malignant diseases, and treatment of iron-deficiency anemia. The latter was noted in iron-deficient infants who showed a rise of serum ferritin to normal levels in the first week of treatment.

High-fiber diet: its role in the treatment of diabetes mellitus reviewed.

Dietary manipulation has long been a mainstay of treatment of adult-onset diabetes. Weight loss and a diet low in refined carbohydrate have often allowed either reduction or discontinuation of oral hypoglycemic agents or insulin. The evidence presented in this review suggests that complex carbohydrates and high-fiber compounds can play a significant role in this dietary manipulation and merit further study.

Medicinal iron-induced hepatic cirrhosis: reversal by phlebotomy: studies on pathogenesis.

A patient with no underlying hematologic or iron metabolic disorder developed iron induced hepatic cirrhosis as a consequence of long term medicinal iron ingestion. Marked improvement in liver histology followed removal of 28 grams of iron by phlebotomy. Radioautographic studies in rats showed a periportal hepatocyte concentration of radioiron absorbed from the intestine while plasma transferrin was saturated.

Hazards of phlebotomy in polycythemic patients with cardiovascular disease.

Three patients with polycythemia and previous evidence of cardiovascular disease underwent routine phlebotomies. Systolic hypotension followed by ineffective volume replacement with electrolyte solutions developed in all patients after phlebotomy. In two patients acute myocardial infarction and in a third cardiovascular collapse and death were temporally related to the procedure.

Bone marrow necrosis.

The clinical findings of bone marrow necrosis in 13 patients undergoing bone marrow examination to investigate a peripheral blood cytopenia or leukoerythroblastic blood smear were reviewed and compared to those in the literature. Excluding sickle cell disease, all cases of bone marrow necrosis diagnosed during life were associated with a neoplastic process involving the marrow. A myeloproliferative disorder was found in five patients, metastatic carcinoma in five patients, a lymphoma in two patients, and both a myeloproliferative disorder and metastatic carcinoma in one patient.