Rejected by the New England Journal of Medicine in late 2010.

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.

(1) Case records of the Massachusetts General Hospital. Case 28-2010. A 32-year-old woman, 3 weeks post partum, with substernal chest pain. Sabatine MS, Jaffer FA, Staats PN, Stone JR. N Engl J Med. 2010 Sep 16;363(12):1164-73.   Pubmed 20843252

(2) Aneurysm syndromes caused by mutations in the TGF-beta receptor. Loeys BL, Schwarze U, Holm T, Callewaert BL, Thomas GH, Pannu H, De Backer JF, Oswald GL, Symoens S, Manouvrier S, Roberts AE, Faravelli F, Greco MA, Pyeritz RE, Milewicz DM, Coucke PJ, Cameron DE, Braverman AC, Byers PH, De Paepe AM, Dietz HC. N Engl J Med. 2006 Aug 24;355(8):788-98.   Pubmed 16928994

(3) Hirst AD, Johns VJ, Kime SW. Dissecting aneurysm of the aorta: a review of 505 cases. Medicine 1958;37:217-279.   Pubmed 13577293

Rejected by JAMA in 2010.

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.

(1) Kirch DG. The Healthcare Innovation Zone: a platform for true reform. JAMA. 2010 Mar 3;303(9):874-875.   Pubmed 20197534

(2) "Rep. Schwartz introduces legislation to establish AAMC-proposed health care innovation zones." Press Release, Association of American Medical Colleges, July 10, 2009. Online at: -- accessed April 4, 2010.

(3) Lobbying Disclosure Act Database: -- Searched on "registrant name" = "association of american medical colleges" on April 4, 2010.

Rejected by the New England Journal of Medicine in February 2010.

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.

(1) Isselbacher EM, Kligerman SJ, Lam KM, Hurtado RM. Case records of the Massachusetts General Hospital. Case 2-2010. A 47-year-old man with abdominal and flank pain. N Engl J Med. 2010 Jan 21;362(3):254-62.   Pubmed 20089976

(2) Wood P. Diseases of the Heart and Circulation. 2nd ed. London: Eyre and Spottiswoode, 1956. Page 4.

(3) DeGowin RL. DeGowin & DeGowin's Bedside Diagnostic Examination. 5th ed. New York: Macmillan, 1987. Page 24.

Rejected by the New England Journal of Medicine in 2009. This topic is a bit of a bugaboo. See   Pubmed 3358592

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.

(1) Tager AM, Sharma A, Mark EJ. Case records of the Massachusetts General Hospital. Case 32-2009. A 27-year-old man with progressive dyspnea. N Engl J Med. 2009 Oct 15;361(16):1585-1593.   Pubmed 19828536

(2) Applebaum D. Probability and Information: An Integrated Approach. 2nd ed. Cambridge, UK: Cambridge University Press, 2008. Pages 105-106.

Rejected by the New England Journal of Medicine in 2009. This case makes me angry.

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.

(1) Desai NR, Ceng S, Nohria A, Halperin F, Giugliano RP. When past is prologue. N Engl J Med. 2009; 360: 1016-1022.   Pubmed 19264691

(2) Jonckheer M, Blockx P, Molter F. Use of the Achilles-tendon reflex in thyroid clinical investigation. Acta Endocrinol (Copenh). 1970; 63: 175-184.   Pubmed 5467016

(3) [No authors listed] The Achilles heel of the ankle jerk. Journal of the American Medical Association. 1967; 199: 39.   Pubmed 6071124

(4) Chaney WE. Tendon reflexes in myxoedema: valuable aid in diagnosis. Journal of the American Medical Association. 1924; 82: 2013-20166.