To the Editor:

The diagnostic evaluation of the post-partum woman with coronary artery dissection in case 28-2010 (1) was inadequately reported.

I suspect the patient’s cardiac catheterization included aortography, or at least a quick aortic “root shot,” that was not disclosed. Coronary dissection mandates such an evaluation, given its association with simultaneous aortic dissection and with the aortic ectasia seen in heritable disorders of connective tissue (as noted in the case’s table 2). Finding aortic disease would likely have altered this patient’s surgical management.

More concerning, the patient’s physical examination omitted pertinent negatives related to connective tissue disorders that cause aorto-coronary dissections, e.g. body habitus, joint hypermobility, skin laxity, visual acuity, and, remarkably, the bifid uvula of Loeys-Dietz syndrome (2).

Aortic diseases have high mortality when untreated (3). They should always be considered when adults, of any age, have chest discomfort, and should remain in the differential diagnosis even after a coronary dissection is found.

To the Editor:

In his letter describing recently-introduced Congressional legislation to establish “healthcare innovation zones” (1), Dr. Kirch of the Association of American Medical Colleges (AAMC) listed his financial disclosures as “none.” I believe this is misleading.

Dr. Kirch did not disclose that the AAMC proposed such zones (2). As a federally registered lobbying organization that has spent $100,000-$400,000 annually on lobbying activities since 1999 (3), common sense dictates that one of the AAMC’s “products” is legislation.

Thus, Dr. Kirch should have disclosed his organization’s role in the product his letter described, just as he would have disclosed if his organization had invented a new drug or device expected to benefit the organization or its affiliates. At the very least, such disclosure would have helped the JAMA editors realize he was hyping something his organization helped create.

To the Editor:

Medical educators I’ve known have often cited the case histories in the Journal’s CPCs as model presentations of clinical information.

Unfortunately, case 2-2010 jeopardizes this reputation by saying the patient experienced “an episode of pain in his left arm … that radiated to his heart” (1).

Medical trainees should not emulate this statement, for three reasons:

First, it is not believable. The complex innervation of thoracic structures prevents localization of pain to any internal organ.

Second, it is ambiguous. Many patients believe pain near the left breast is “heart pain” (2), whereas physicians generally associate retrosternal discomfort with cardiac ischemia.

Third, even if this statement were a direct quote from the patient, it violates the precept to “question [the patient] until sufficient details are obtained to categorize the symptom in medical terms” (3).

No institution of medical education can rest on its laurels. I hope The Journal will re-dedicate itself to maintaining its pre-eminence in this vital field.

To the Editor:

In case 32-2009 (1) I was surprised to see the patient’s height measured with impressive, millimeter precision: 165.1 cm. More likely, of course, this was simply a ludicrously precise conversion to SI units from an imprecise 5-foot 5-inch estimate.

Information, as defined by communications scientists, has been likened to the amount of surprise in a system (2). Thus, to feel surprise when reading about a patient’s unremarkable height indicates that a perturbation of informational content has occurred – surely undesirable in any scientific journal.

To maintain informational aequanimitas, I suggest the Journal report measurements in the units in which they were originally obtained. Converted values – in full misleading precision – could follow in parentheses.

To the Editor:

Desai et al (1) describe a tragic case of panhypopituitarism diagnosed only when the patient developed cardiogenic shock and required two weeks of mechanical and pharmacological inotropic support, plus an implanted defibrillator.

Because they focus chiefly on the final outcome, the authors consider the patient’s management as a success. Instead, they should have used techniques of aviation mishap investigation to question how this patient’s close, 21st-century medical care over the preceding year could have allowed an eminently treatable disease to reach Dickensian severity.

Why did the review of systems upon admission not disclose the patient’s symptoms of hypothyroidism? Why did the admission physical miss the obvious hair and skin signs? Why was the neurological examination deemed “unremarkable” when this patient very likely had markedly delayed relaxation of tendon reflexes (2,3,4)? Evaluating such suspicious findings could have advanced hormone replacement and averted complications.

Aviators live and die by their checklists – literally. Thorough patient histories and physical exams are medicine’s ultimate checklist. We shortcut them at our peril, and at the peril of our patients.